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Full text of "LangeQ&A_Surgery,5th _Ed_www.1aim.net"

SURGERY 



lore than 1 .000 USMLE-styto questions 
Rationales for correct and incorrect answers 

uestions thoroughly updated and reviewed 
New chapter on Pediatrics 



Updated In 

Board- For raV, 



C. Gtfte Cayten * NanakraT Agarwal • Max Goldberg * Simon Wapnick 




FIFTH EDITION 




SURGERY 



C. Gene Cayten, MD, FACS, MPH 

Editor-in-Chief 
Professor of Surgery and Senior Associate Dean 

New York Medical College 

Residency Program Director of General Surgery 

Our Lady of Mercy Medical Center 

Bronx, New York 

Max Goldberg, MBBCh, MD, FRCSI, FACS 

Clinical Assistant Professor of Surgery 

Stonybrook University Hospital and 

Medical Center 

Stonybrook, New York 

Director Emeritus, 

Department of Surgery Long Beach 

Medical Center, 

Long Beach, New York 



Nanakram Agarwal, MD, MPH, FACS 

Professor of Surgery 

New York Medical College 

Chief of Surgical Intensive Care Unit 

Our Lady of Mercy Medical Center 

Bronx, New York 

Simon Wapnick, MBChB, MD, FRCS (Eng), 
FACS (Deceased) 

Director of Postgraduate Clinical 

Anatomy Courses 

Department of Cell Biology and Anatomy 

New York Medical College 

Valhalla, New York 



Medical 



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DOI: 10.1036/0071475664 



15 Professional 




Want to learn more? 

We hope you enjoy this 
McGraw-Hill eBook! If 
you'd like more information about this book, 
its author, or related books and websites, 
please click here. 




Simon Wapnick, MBChB, MD, FRCS (Eng), FACS, 1937-2003 



This book is dedicated to Simon Wapnick, MD, a distinguished and skilled 
surgeon, clinical anatomist, and medical researcher who wrote and edited the 
first four editions of Review of Surgery. He zvas a professional dedicated to 
bringing his scientific excellence to humanity for the common good. Simon 
led a life of profound dedication to the God of his fathers, a life imbued with 
the spirituality and values of the Torah. His students at New York Medical 
College in the dedication of their yearbook to him said, "The spirit, enthusi- 
asm, and commitment of Dr. Simon Wapnick will live on in our lives because 
he played a key role from the very beginning of our professional training. He 
was someone ivith the will of a lion and the heart of a lamb, a teacher who 
zvas always ready to explain anything and a gentleman who was interested 
in so many neat things. He was an avid marathoner and was constantly 
'looking for improved time and efficient stride.' He encouraged us to keep up 
the good race for a good life. He validated our choice of the noble profession 
of medicine." 

James Michener could readily have been thinking about Simon Wapnick 
when he wrote, "The master in the art of living makes little distinction 
between his work and his play, his labor and his leisure, his mind and his 
body, his information and his recreation, his love and his religion. He hard- 
ly knows which is which. He simply pursues his vision of excellence at what- 
ever he does, leaving others to decide whether he is working or playing. To 
him he's always doing both." 

As his wife, Isabelle, I shall always carry within my heart so many loving 
and proud memories of Simon Wapnick. 



This page intentionally left blank 



For more information about this title, click here 



Contents 



Contributors vii 

Preface ix 

Acknowledgments xi 

Introduction xiii 

1. Surgical Critical Care/Pre- and Postoperative Care 1 

Nanakram Agarwal and Akella Chendrasekhar 

Questions 1 

Answers and Explanations 17 

2. Skin, Soft Tissue, and Breast 31 

Aloyious Smith and Andrew Ashikari 

Questions 31 

Answers and Explanations 41 

3. Endocrine, Head, and Neck 47 

Alan S. Berkower and Prakashchandra M. Rao 

Questions 47 

Answers and Explanations 66 

4. Cardiac and Thoracic 79 

Marshall O. Kramer and E. A. Bonfils-Roberts 

Questions 79 

Answers and Explanations 89 

5. Stomach, Duodenum, and Esophagus 97 

Soula Privolous and Max Goldberg 

Questions 97 

Answers and Explanations 114 

6. Small and Large Intestines and Appendix 127 

Evelyn Irizarry and Nicholas A. Balsano 

Questions 127 

Answers and Explanations 144 



vi Contents 



7. Pancreas, Biliary Tract, Liver, and Spleen 157 

Valerie L. Katz and Akella Chendrasekhar 

Questions 157 

Answers and Explanations 174 

8. Hernia 189 

Max Goldberg and Nanakram Agarwal 

Questions 189 

Answers and Explanations 193 

9. Male and Female Genitourinary Systems 197 

Sean Fullerton and Albert Samadi 

Questions 197 

Answers and Explanations 209 

10. Vascular 217 

Nilesh N. Balar and Mayank V. Patel 

Questions 217 

Answers and Explanations 227 

11. Neurosurgery 237 

Kamran Tabaddor 

Questions 237 

Answers and Explanations 250 

12. Trauma 261 

C. Gene Cayten and Rao R. Ivatury 

Questions 261 

Answers and Explanations 281 

13. Pediatric Surgery 293 

Tyr Ohling Wilbanks and Meno Leuders 

Questions 293 

Answers and Explanations 300 

14. Practice Test 307 

James E. Barone and C. Gene Cayten 

Questions 307 

Answers and Explanations 323 



Contributors 



Andrew Ashikari, MD, FACS 

Assistant Professor of Surgery 
New York Medical College 
Westchester Medical Center 
Valhalla, New York 

Nilesh N. Balar, MD, RVT, FACS 

Assistant Professor of Surgery 
New York Medical College 
Chief of Vascular Surgery 
Our Lady of Mercy Medical Center 
Bronx, New York 

Nicholas A. Balsano, MD, FACS 

Clinical Associate Professor of Surgery 
New York Medical College 
Our Lady of Mercy Medical Center 
Bronx, New York 

James E. Barone, MD, FACS, FCCM 

Professor of Clinical Surgery 
Weill Medical College of Cornell University 
Chairman, Department of Surgery 
Lincoln Medical and Mental Health Center 
Bronx, New York 

Alan S. Berkower, MD, PhD 

Assistant Professor of Otolaryngology 
New York Medical College 
Chief of Otolaryngology 
Attending, Department of Surgery 
Our Lady of Mercy Medical Center 
Bronx, New York 

E. A. Bonfils-Roberts, MD, FACS 

Associate Professor of Surgery 
New York Medical College 
Section Chief of Thoracic Surgery 
Lincoln Medical and Mental Health Center 
Bronx, New York 



Akella Chendrasekhar, MD, FACS 

Medical Director, Trauma 
Medical Director, Emergency Department 
Wyckoff Heights Medical Center 
Brooklyn, New York 

Sean Fullerton, MD 

Department of Urology 

Our Lady of Mercy Medical Center 

Bronx, New York 

Evelyn Irizarry, MD, FACS, FACRS 

Assistant Clinical Professor of Surgery 
Weill Medical College of Cornell University 
Bronx, New York 

Rao R. Ivatury, MD, FACS 

Professor of Surgery Physiology, and Emergency 

Medicine 
Chief, Division of Trauma, Critical Care, and 

Emergency Surgery 
Medical College of Virginia 
Virginia Commonwealth University 
Richmond, Virginia 

Valerie L. Katz, MD, FACS 

Assistant Professor of Clinical Surgery 
Weill Medical College of Cornell University 
Section Chief, Department of General Surgery 
Lincoln Medical and Mental Health Center 
Bronx, New York 

Marshall D. Kramer, MD 

Associate Professor of Surgery 
New York Medical College 
Chief, Thoracic Surgery 
Our Lady of Mercy Medical Center 
Bronx, New York 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



VIII 



Contributors 



Meno Lueders, MD, FACS 

Assistant Professor of Clinical Surgery 
Weill Medical College of Cornell University 
Lincoln Medical and Mental Health Center 
Bronx, New York 

Mayank V. Patel, MD 

Department of Surgery 
Our Lady of Mercy Medical Center 
Westchester Square Medical Center 
Bronx, New York 

Soula Priovolos, MD, FACS 

Assistant Professor of Clinical Surgery 
Weill Medical College of Cornell University 
Lincoln Medical and Mental Health Center 
Bronx, New York 

Prakashchandra M. Rao, MD, FACS 

Clinical Associate Professor of Surgery 
New York Medical College 
New York, New York 

Albert Samadi, MD 

Assistant Professor of Urology 
New York Medical College 
Department of Urology 
Our Lady of Mercy Medical Center 
Bronx, New York 



Aloysius Smith, MD 

Assistant Professor of Surgery 
New York Medical College 
Director, Hand and Plastic Surgery 
Lincoln Medical and Mental Health Center 
Our Lady of Mercy Medical Center 
Bronx, New York 

Kamran Tabaddor, MD 

Clinical Professor and Chairman 
Department of Surgery 
Our Lady of Mercy Medical Center 
Clinical Professor of Neurosurgery 
Albert Einstein College of Medicine 
Bronx, New York 

Tyr Ohling Wilbanks, MD, FACS 

Assistant Clinical Professor of Surgery 
Columbia University College of Physicians 

and Surgeons 
Associate Chief of Surgery 
Lincoln Medical and Mental Health Center 
Bronx, New York 



Preface 



The popularity of the previous editions of Appleton 
& Lange Review of Surgery has encouraged this 
revised fifth edition. The questions have been 
selected from the most current pertinent topics, 
facets, and principles of the wide range of general 
surgery and its specialities. 

The main format of question presentation has 
been extensively revised to coincide with that rec- 
ommended by the United States Medical License 
Examination (USMLE) guidelines. The material is 
presented in the form of clinical cases with appro- 
priate answers to mirror the focus of the USMLE 
Step 2. Lange Q&A: Surgery, Fifth Edition, will also 
help equip and familiarize students preparing for 
the Surgery Miniboard Examinations. Surgical resi- 
dents have found both the questions and the anno- 
tated answers useful in preparation for various 
inservice examinations leading to the qualifying 
and certifying exams of the American Board of 
Surgery and equivalent examinations in other parts 
of the world. Surgeons in practice and those prepar- 
ing for recertification in their specialty have found 
this book to be a useful addendum to their arma- 
mentarium of surgical knowledge. 

The types of questions have been arranged into 
two major groupings: one best answer out of five 
possible answers and the selection of one possible 
answers chosen from a given list of seven or more 
items. These question types are explained further in 
the introduction. 



The questions are divided into 14 chapters 
including the practice test. The reader is encouraged 
to tackle each chapter in full before referring to the 
corresponding answer section. Each question should 
be completed in less than 1 minute. When correcting 
a chapter, the reader should review the answer and 
refer back to the question to consolidate knowledge 
gained during test preparation. Incorrect answers 
should be reviewed and attempted at a later date. 

In many questions in the exam there is a lot of 
information in the stem of the question, much of it 
irrelevant. A number of our student consultants 
suggest that it is useful to look at the question and 
possible answers at the bottom of the question 
before reading the question through. This will assist 
you in deciding what information is pertinent. The 
examination developed by the USMLE contains 
100 questions and the persons taking the test are 
given 2 hours to complete the exam. Many of our 
student consultants have indicated that they felt 
rushed with the examination. Another strategy is to 
answer the one best answer matching set of ques- 
tions first. Such questions are usually placed at the 
end of the examination. These are generally done 
more quickly and usually help the test taker to com- 
plete the 100-question exam within the 2 hours of 
the allotted time. 

If you have any comments as to the contents or 
usefulness of this book, e-mail gcayten@olmhs.org. 



IX 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



This page intentionally left blank 



Acknowledgments 



I would like to acknowledge the hard work and 
expertise of our authors. We had considerable input 
by medical students that had taken the USMLE 
Step 2 recently. These medical students helped us in 
assuring the content was pertinent to the exam. 
They also helped us in assuring the format of our 
questions was consistent with the exam. These med- 
ical students include James Wyss, Memba Penn, 
Christina Lemoine, Daniel Morello, William So, Keli 
Mabbott, and Alexandra Stark. We also had several 
young physicians assist in various editorial func- 
tions: Ravi Kumar Pasupuleti, and Cesar A. Mora. Dr. 
Ravikumar was particularly diligent and meticulous 
in his assistance. 



I also would like to acknowledge the contributors 
to the fourth edition: Drs. Kenneth A. Falvo, Jaroslaw 
Bilaniuk, Haroon H. Durrani, John A. Savino, Zahi E. 
Nassoura, Scott I. Zeitlin, Jose A. Torres-Gluck, 
Khawaja Azimuddin, and Virany Huynh Hillard. 

Special acknowledgement goes to Adriane Pratt, 
our Surgical Residency Coordinator at Our Lady of 
Mercy Medical Center. Very special acknowledge- 
ment goes to Marsha Loeb from McGraw-Hill who 
was thorough, patient, and insightful in her editorial 
functions. 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



This page intentionally left blank 



Introduction 



This book has been designed to help you review 
surgery for both examination and patient manage- 
ment. Here in one package is a comprehensive 
review with over 1000 multiple-choice questions 
with paragraph-length discussions of each answer. 
The whole book has been designed to help you 
assess your areas of relative strength and weakness. 

Lange Q&A: Surgery, Fifth Edition, is divided into 
14 chapters. Thirteen chapters provide a review of 
the major areas of surgery. The last chapter, a 
Practice Test, integrates diverse specialities into one 
simulated examination. 

This introduction provides information on 
question types, question-taking strategies, various 
ways you can use this book, and specific informa- 
tion on the USMLE Step 2. 



Questions are stratified into three levels of 
difficulty: (a) rote memory questions; (b) memory 
questions that require more understanding of the 
question; and (c) questions that require understanding 
and judgement. Because the National Board of 
Medical Examiners (NBME) and other examination 
bodies are moving away from the rote memory 
questions, we have tried to emphasize judgement 
cases throughout this text. 

One-Best- Answer-S ingle-Item Question 

This type of question presents a problem or asks a 
question and is followed by five or more choices, 
only one of which is entirely correct. The directions 
preceding this type of question will generally 
appear as follows: 



QUESTIONS 

The USMLE Step 2 now contains only two different 
types of questions. In general, most of these are "one- 
best-answer-single-item" questions; whereas, the 
remainder require selection of one answer from a list 
of seven or more items. "Multiple true-false item" 
and "comparison-matching set" questions have been 
excluded. Questions that are negatively phrased 
("All of the following are correct EXCEPT . . .") have 
been disposed of in accordance with current 
USMLE guidelines. In some cases (in both types of 
questions), a group of two or three questions may 
be related to a situational theme. Certain questions 
have illustrative material (diagrams and x-rays) that 
require understanding and interpretation on your 
part. Some illustrations, however, are included 
mainly for their instructive value in clinical surgical 
practice. 



DIRECTIONS: (Questions 1 through 82): Each of 
the numbered items in this section is followed by 
answer. Select the ONE lettered answer is BEST in 
each case. 

An example for this item type is: 

1. An obese 21-year-old woman reports increased 
growth of coarse hair on her lip, chin, chest, 
and abdomen. She also notes menstrual irreg- 
ularity, with periods of amenorrhea. What is 
the most likely cause? 

(A) Polycystic ovary disease 

(B) An ovarian tumor 

(C) An adrenal tumor 

(D) Cushing's disease 

(E) Familial hirsutism 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



XIV 



Introduction 



In this type of question, choices other than the 
correct answer may be partially correct, but there 
can only be one best answer. In the question above 
the key word is "most." Although ovarian tumors, 
adrenal tumors, and Cushing's disease are causes of 
hirsutism (described in the stem of the question), 
polycystic ovary disease is a much more common 
cause. Familial hirsutism is not associated with the 
menstrual irregularities mentioned. Thus, the most 
likely cause of the manifestations described can only 
be "(A) Polycystic ovary disease." 



TABLE 1. STRATEGIES FOR ANSWERING ONE-BEST- 
ANSWER-SINGLE-ITEM QUESTIONS* 



1 . Remember that only one choice can be the correct answer. 

2. Read the question carefully to be sure that you understand 
what is being asked. 

3. Quickly read each choice for familiarity. (This important step is 
often not done by test takers.) 

4. Go back and consider each choice individually. 

5. If a choice is partially correct, tentatively consider it to be 
incorrect. (This step will help you lessen your choices and 
increase your odds of choosing the correct answer.) 

6. Consider the remaining choices and select the one you think is 
the answer. At this point, you may want to quickly scan the 
stem to be sure you understand the question and your answer. 

7. Select the appropriate answer. (Even if you do not know the 
answer, you should at least guess. Your score is based on the 
number of correct answers, so do not skip any questions.) 

*Note the steps 2 through 7 should take an average of 50 
seconds total. The actual examination is timed for an average of 
50 seconds per question. 



One-Best- Answer-Matching-Set Questions 

These questions are usually accompanied by the fol- 
lowing general directions. 

DIRECTIONS: (Questions 83 through 100): Each 
set of matching questions in this section consists 
of a list of lettered options followed by several 
numbered items. For each numbered item, select 
the appropriate lettered option. Select only one 
answer. 



An example for this item type is: 

Questions 83 through 84 

In each condition listed, select the most appropriate 
antibiotics. 



(A) 


Tetracycline 


(B) 


Chloramphenicol 


(C) 


Clindamycin 


(D) 


Vancoymcin 


(E) 


Fluconazole 


(F) 


Metronidazole 


(Q 


Ciprofloxacin 


(H) 


Chloroquine 


(I) 


Fluconazole 



83. Bone marrow suppression. SELECT ONLY ONE. 

84. A 34-year-old woman complains of lower 
abdominal pain and vaginal discharge due to 
gonorrhea. SELECT ONLY ONE. 

Table 2 lists strategies for answering one-best- 
answer-matching-set questions. 



TABLE 2. STRATEGIES FOR ANSWERING ONE-BEST- 
ANSWER-MATCHING-SET QUESTIONS* 



1 . Remember that the lettered choices are followed by the num- 
bered questions. 

2. Apply steps 2 through 7 in Table 1 but select EXACTLY ONE 
ANSWER as stated. 

3. Consider covering this section first in the beginning of the test, 
you'll likely be less rushed and thus the probability of answer- 
ing these questions correctly when you have time is increased 
vs. answering them at the end when you're rushed and you 
must reuse answer choices A-M. 

'Remember, you only have an average of 60 seconds per 
question. 



ANSWERS, EXPLANATIONS, AND REFERENCES 

In each of the sections of Lange Q&A: Surgery, Fifth 
Edition, the question sections are followed by a section 
containing the answers and explanations for the ques- 
tions. This section: (a) tells you the answer to each 
question; and (b) gives you an explanation and review 
of why the answer is correct, background information 
on the subject matter, and/or why the other answers 



Introduction 



xv 



are incorrect. We encourage you to use this section as 
a basis for further study and understanding. 

If you choose the correct answer to a question, 
you can then read the explanation: (a) for reinforce- 
ment; and (b) to add to your knowledge about the 
subject matter. If you choose the wrong answer to a 
question, you can read the explanation for an 
instructional review of the material in the question. 



PRACTICE TEST 

The 100-question Practice Test at the end of the book 
covers and reviews all the topics covered in 
Chapters 1 through 13. The questions are integrated 
according to question type (one-best-answer-single 
item, one-best-answer-matching sets.) 



HOW TO USE THIS BOOK 

There are two logical ways to get the most value 
from this book. We call them Plan A and Plan B. 

In Plan A, you go straight to the Practice Test 
and complete it. Analyze your areas of strength and 
weakness. This will be a good indicator of your ini- 
tial knowledge of the subject and will help to iden- 
tify specific areas for preparation and review. You 
can now use the first 13 chapters of the book to help 
you improve your relative weak points. 

In Plan B, you go through Chapters 1 through 13 
checking off your answers, and then comparing 
your choices with the answers and discussions in the 
book. Once you have completed this process, you 
can take the Practice Test and see how well prepared 
you are. If you still have a major weakness, it should 
be apparent in time for you to take remedial action. 

In Plan A, by taking the Practice Test first, you 
get quick feedback regarding your initial areas of 
strength and weakness. You may find that you have 
a good command of the material, indicating that 
perhaps only a cursory review of the first 13 chap- 
ters is necessary. This, of course, would be good to 
know early in your examination preparation. On 
the other hand, you may find that you have many 
areas of weakness. In this case, you could focus on 
these areas in your review — not just with this book, 
but also with textbooks. 

However, it is unlikely that you will not do 
some studying before taking the USMLE (especially 
because you have this book). Therefore, it may be 



more realistic to take the Practice Test after you have 
reviewed the first 13 chapters (as in Plan B). This 
will probably give you a more realistic type of test- 
ing situation, because very few of us sit down to a 
test without study. In this case, you will have done 
some reviewing (from superficial to in-depth), and 
your Practice Test will reflect this study time. If, 
after reviewing the first 13 chapters and then taking 
the Practice Test, you still have some weaknesses, 
you can then go back through Chapters 1 through 
13 and supplement your review with your texts. 



SPECIFIC INFORMATION ON THE STEP II 
EXAMINATION 

The official source of all information with respect 
to the USMLE is the NBME, 3750 Market Street, 
Philadelphia, PA 19104. Established in 1915, the NBME 
is a voluntary nonprofit, independent organization 
whose sole function is the design, implementation, 
distribution, and processing of a vast bank of ques- 
tion items, certifying examinations, and evaluative 
services in the professional medical field. 

To be eligible to sit for the USMLE Step 2, a per- 
son must be either officially enrolled in or a gradu- 
ate of a U.S. or Canadian Medical School accredited 
by the Liaison Committee on Medical Education 
(LCME); officially enrolled in or a graduate of a 
US osteopathic medical school accredited by the 
American Osteopathic Association (AOA); or offi- 
cially enrolled in or a graduate of a foreign medical 
school and eligible for examination by the 
Educational Commission for Foreign Medical 
Graduates (ECFMG) for its certificate. It is not nec- 
essary to complete any particular year of medical 
school in order to be a candidate for Step 2; neither 
is it required to take Step 1 before Step 2. 



SCORING 

Because there is no penalty for guessing, you should 
answer every question. Do not skip any questions. 
Each question answered correctly counts as one 
point, and partial credit may be given to partially 
correct answers. 

Information on the USMLE is posted on the 
NBME's web page, www.usmle.org. 



This page intentionally left blank 



CHAPTER 1 



Surgical Critical Care / Pre- and 
Postoperative Care 

Nanakram Agarwal and Akella Chendrasekhar 

Questions 



DIRECTIONS (Questions 1 through 108): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 

1. A 35-year-old man is admitted with systolic 
blood pressure (BP) of 60 mm Hg and a heart 
rate (HR) of 150 bpm following a gunshot 
wound to the liver (Fig. 1-1). What is the effect 
on the kidneys? 

(A) They tolerate satisfactorily ischemia of 
3-A hours duration. 

(B) They undergo further ischemia if 
hypothermia is present. 

(C) They can become damaged, even though 
urine output exceeds 1500 mL/d. 

(D) They are affected and cause an 
increased creatinine clearance. 

(E) They are prevented from further damage 
by a vasopressor. 

2. Twenty-four hours after colon resection, urine 
output in a 70-year-old man is 10 mL/h. Blood 
chemistry analysis reveals sodium, 138 mEq/L; 
potassium, 6 mEq/L; chloride, 100 mEq/L; bicar- 
bonate, 14 mEq/L. His metabolic abnormality 
is characterized by which of the following? 

(A) Abdominal distension 

(B) Peaked T waves 

(C) Narrow QRS complex 

(D) Cardiac arrest in systole 

(E) J wave or Osborne wave 




Figure 1-1. 

Axial image of Computed tomography (CT) scan of abdomen at 
level of both kidneys shows dense nephrogram, which is attributed 
to decrease in renal perfusion. (Reproduced, with permission, from 
Wapnick S et al.: Appleton and Lange Review of Surgery, 4th ed. 31. 
McGraw-Hill, 2003.) 



3. A 24-year-old woman has acute renal failure 
following postpartum hemorrhage. Laboratory 
studies showed serum glucose, 150 mg/dL; 
sodium, 135 mEq/L; potassium, 6.5 mEq/L; 
chloride, 105 mEq/L; and bicarbonate, 15 mEq/L. 
Therapy should include which of the following? 

(A) Decrease potassium chloride to 
10 mEq/L 

(B) Intravenous 0.9% sodium chloride 

(C) 100 mL of 50% glucose water with 
10 U insulin 

(D) Intravenous calcitonin 

(E) Intravenous magnesium sulfate 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



1: Surgical Critical Care I Pre- and Postoperative Care 



4. A 55-year-old man with Crohn's disease had 
undergone resection of small bowel and anas- 
tomosis. Ten days later, he is found to have bil- 
ious drainage of 1 L/d from the drains. He is 
started on total parenteral nutrition (TPN). 
Four days later, his arterial blood gases (ABGs) 
are pH, 7.25; P0 2 , 98 mm Hg; and PC0 2 , 40 mm 
Hg. His anion gap is 10. The most likely cause 
is which of the following? 

(A) Diabetic ketoacidosis 

(B) Renal failure 

(C) Hypovolemic shock 

(D) Small-bowel fistula 

(E) Uncompensated metabolic alkalosis 

5. A 55-year-old man sustains numerous injuries 
involving the abdomen and lower extremities. 
During the intra- and postoperative periods, 
he is resuscitated with 10 L of Ringer's lactate 
and 2 U of packed red blood cells (RBC). After 
initial improvement, he has severe dyspnea on 
the second postoperative day. The most useful 
initial diagnostic test is which of the following? 

(A) Electrocardiogram 

(B) Analysis of arterial blood gas 

(C) Insertion of a central venous line 

(D) Ventilation-perfusion scan 

(E) Computed tomography (CT) scan of 
abdomen 

6. A 20-year-old man involved in a car crash sus- 
tained severe injuries to the chest, abdomen, 
and lower extremities. He is intubated and 
requires increasing concentration of oxygen to 
maintain his P0 2 . The pathologic changes do 
which of the following? 

(A) They cause the alveolar capillary 
membrane to become more 
impermeable. 

(B) They most frequently occur after severe 
injuries. 

(C) They are associated with low compliance. 

(D) They show a characteristic localized 
pattern on x-ray. 

(E) They involve a decrease in dead-space 
ventilation. 



7. A 24-year-old woman is scheduled for an elec- 
tive cholecystectomy. The best method of iden- 
tifying a potential bleeder is which of the 
following? 

(A) Platelet count 

(B) A complete history and physical 
examination 

(C) Bleeding time 

(D) Lee-White clotting time 

(E) Prothrombin time (PT) 

8. A 24-year-old man who is admitted to the 
intensive care unit (ICU) following severe head 
injury develops seizures on the fourth day of 
hospitalization. His urine output is 500 mL 
over 24 hours, sodium is 115 mEq/L, and 
serum and urine osmolality are 250 and 800 
mOsm, respectively. The metabolic abnormal- 
ity is due to which of the following? 

(A) Administration of D 5 W (5% dextrose in 
water) and 0.33 normal saline 

(B) Syndrome of inappropriate secretion of 
antidiuretic hormone (SIADH) 

(C) Decreased antidiuretic hormone (ADH) 
secretion 

(D) Nasogastric suction 

(E) Renal insufficiency 

9. A 40-year-old man who weighs 65 kg is being 
observed in the ICU. Twenty-four hours post- 
operatively, he develops convulsions. His 
serum sodium is 118 mEq/L. Appropriate 
management includes which of the following? 

(A) Administration of normal saline (0.9%) 

(B) Administration of hypertonic saline (3%) 

(C) Emergency hemodialysis 

(D) Administration of vasopressin 

(E) Administration of Lasix, 40 mg 
intravenously (IV) 

10. A 30-year-old man who weighs 60 kg has the fol- 
lowing laboratory values: hemoglobin, 10 g/dL; 
serum sodium, 120 mEq/L; serum potassium, 
4 mEq/L; serum chloride, 90 mEq/L; and serum 
C0 2 content, 30 mEq/L. What is his sodium 
deficit approximately? 



Questions: 4-16 



12. 



(A) 
(B) 
(C) 
(D) 

(E) 



20mEq 
200 mEq 
400 mEq 
720 mEq 
120 mEq 



11. A 65-year-old man has urine output of 10 mL/h 
following abdominal aortic aneurysmectomy. 
Acute tubular necrosis is suggested by the pres- 
ence of which of the following? 

(A) Urine osmolality of more than 
500 mOsm/kg 

(B) Urine sodium of more than 40 mEq/L 

(C) Fractional excretion of sodium of <1% 

(D) Blood urea nitrogen (BUN)-to-serum 
creatinine ratio (SCR) of more than 20 

(E) Urine-to-plasma creatinine ratio (PCR) 
of more than 40 



A 30-year-old man with a history of Crohn's dis- 
ease of the small bowel is admitted with ente- 
rocutaneous fistula. The daily output from the 
fistula is 2 L. The approximate composition of 
the fluids in mEq/L is which of the following? 



Na 



K 



CI 



HCO, 



(A) 


10 


26 


10 


30 


(B) 


60 


10 


130 





(C) 


140 


5 


104 


30 


(D) 


140 


5 


75 


115 


(E) 


60 


30 


40 


40 



13. A 70-year-old woman has a small-bowel fistula 
with output of 1.5 L/d. Replacement of daily 
losses should be handled using the fluid solution 
that has the following composition in mEq/L. 



Na 



K 



CI 



HCO, 



(A) 


130 


4 


109 


28 


(B) 


154 





154 


40 


(C) 


77 





77 





(D) 


167 








167 


(E) 


513 





513 






Questions 14 and 15 

A 70-year-old man has undergone anterior resection 
for carcinoma of the rectum. He is extubated in the 
operating room (OR). In the recovery room, he is 
found to be restless with an HR of 136 bpm and a BP 
of 144/80 mm Hg. ABG analysis on room air reveals 
pH, 7.24; PCO z , 60 mm Hg; P0 2 , 54 mm Hg; HC0 3 , 
25 mEq/L; and Sa0 2 , 90%. 

14. The physiologic status can best be described 
as which of the following? 

(A) Respiratory alkalosis 

(B) Respiratory acidosis 

(C) Metabolic acidosis 

(D) Metabolic alkalosis 

(E) Combined respiratory and metabolic 
acidosis 

1 5. Appropriate management for this patient should 
be which of the following? 

(A) To administer 40% oxygen by mask 

(B) Morphine, 2 mg IV 

(C) Ringer's lactate, 250 mL over 1 hour 

(D) Intubation and ventilatory support 

(E) Deep breathing and coughing 

16. A 60-year-old woman with mild hypertension is 
admitted for elective hysterectomy. On preoper- 
ative evaluation, she is found to have osteoarthri- 
tis; over the previous 6 months, she had noted 
watery diarrhea that was becoming progres- 
sively worse. The serum potassium is 3 mEq/L. 
Which is the most likely cause of hypokalemia? 

(A) Myoglobinemia 

(B) Villous adenoma of colon 

(C) High-output renal failure 

(D) Massive blood transfusion 

(E) Spironolactone (Aldactone) 



1: Surgical Critical Care I Pre- and Postoperative Care 



Questions 17 and 18 

A 64-year-old man underwent major abdominal 
surgery to remove a ruptured aortic aneurysm. Four 
days after the operation, an attempt was made to 
wean him off the ventilator. ABG analysis reveals 
pH, 7.54; PC0 2 , 30 mm Hg; P0 2 , 110 mm Hg; HC0 3/ 
30 mEq/L; and SaO z , 99%. 



17. 



18. 



Blood gas analysis reveals which of the 
following? 

(A) Respiratory acidosis 

(B) Metabolic alkalosis 

(C) Respiratory alkalosis 

(D) Compensated respiratory acidosis 

(E) Combined respiratory and metabolic 
alkalosis 

What will be the most likely complication due 
to the metabolic changes experienced by the 
patient? 

(A) Hypokalemia 

(B) Shift of oxyhemoglobin dissociation to 
the right 

(C) Hyperkalemia 

(D) Hypercalcemia 

(E) Hyperchloremia 

A 42-year-old man with small-bowel fistula has 
been receiving TPN with standard hypertonic 
glucose-amino acid solution for 3 weeks. The 
patient is noticed to have scaly hyperpigmented 
lesions over the acral surfaces of elbows and 
knees, similar to enterohepatic acrodermatitis. 
What is the most likely cause of the condition? 

(A) Copper deficiency 

(B) Essential fatty acid deficiency 

(C) Excess glucose calories 

(D) Hypomagnesemia 

(E) Zinc deficiency 



Questions 20 through 22 

A 27-year-old man is involved in a car crash while 
traveling in excess of 70 mi/h. He sustains an intra- 
abdominal injury and a fracture of the femur. The BP 
is 60/40 mm Hg, and the hematocrit is 16%. 



19. 



20. Which physiologic changes will ensue? 

(A) Peripheral vasodilation 

(B) Inhibition of sympathetic tone 

(C) Temperature rise to 103.8°F 

(D) Eosinophilia 

(E) Lactic acidosis 

21. There is likely to be a proportionately greater 
increase in blood flow to which of the following? 

(A) Kidneys 

(B) Liver 

(C) Heart 

(D) Skin 

(E) Thyroid gland 



22. 



23. 



Initial resuscitation is best done by adminis- 
tration of which of the following? 



D.W 

5 



(A) 

(B) D 5 W and 0.45% normal saline 

(C) Ringer's lactate solution 

(D) 5% plasma protein solution 

(E) 5% hydroxyethyl starch solution 

A 30-year-old man is brought to the emergency 
department following a high-speed car accident. 
He was the driver, and the windshield of the car 
was broken. On examination, he is alert, awake, 
oriented, and in no respiratory distress. He is 
unable to move any of his four extremities; how- 
ever, his extremities are warm and pink. His vital 
signs on admission are HR 54 bpm and BP 
70/40 mm Hg. What is the diagnosis? 

(A) Hemorrhagic shock 

(B) Cardiogenic shock 

(C) Neurogenic shock 

(D) Septic shock 

(E) Irreversible shock 



Questions 24 through 28 

A 48-year-old man with severe vomiting as a result of 
gastric outlet obstruction is admitted to the hospital. 
There is marked dehydration, with urine output 20 
mL/h, and the hematocrit is 48%. 



Questions: 17-31 



24. Clinical confirmation of pyloric obstruction is 
most readily established by which of the 
following? 

(A) Observation of peristalsis from left to 
right 

(B) Observation of peristalsis from right to 
left 

(C) Percussion of the upper abdomen 

(D) Succussion splash 

(E) Auscultation of the upper left abdomen 

2 5. What is the predominant metabolic abnormality? 

(A) Aspiration pneumonia with respiratory 
alkalosis 

(B) Hypochloremic alkalosis 

(C) Salt-losing enteropathy 

(D) Intrinsic renal disease 

(E) Metabolic acidosis 

26. Initial treatment for this patient should include 
which of the following? 

(A) Administration of 10% dextrose (D 10 W) 
in one-third saline solution IV 

(B) Antiemetic 

(C) Hemodialysis to correct azotemia 

(D) Saline fluid replacement with appropriate 
potassium administration 

(E) Ringer's lactate solution 

27. Severe hypochloremic metabolic alkalosis fails 
to respond to standard therapy. His metabolic 
abnormality can be corrected by infusing which 
of the following? 

(A) Normal saline 

(B) Ringer's lactate solution 

(C) Hypertonic saline 

(D) 0.1 N hydrochloric acid 

(E) 1 N hydrochloric acid 

28. In the absence of malignancy further treatment 
after appropriate resuscitation should include 
which of the following? 



(A) Jejunostomy feeding 

(B) Vagotomy and drainage 

(C) Steroids 

(D) No foods given orally (PO) for 6 weeks 

(E) Pyloromyotomy alone 

Questions 29 through 31 

During cholecystectomy in a 67-year-old woman, 
there is severe bleeding from accidental injury to the 
hepatic artery. The patient requires transfusion of 
2000 mL of blood. After the operation, 24-hour urine 
output varies between 1250 and 2700 mL/d. She was 
adequately hydrated, but BUN levels continue to rise 
10-12 mg daily over a 5-day period. 

29. What is the main finding? 

(A) Progressive bleeding 

(B) High-output renal failure 

(C) Postcholecystectomy syndrome 

(D) Glomerulonephritis 

(E) Obstructive jaundice 

30. Metabolic changes likely to occur include which 
of the following? 

(A) Hyperkalemia 

(B) Hyponatremia 

(C) Hypophosphatemia 

(D) Metabolic alkalosis 

(E) Hypomagnesemia 

31. Management includes which of the following? 

(A) Restriction of fluids to 750 mL/d 

(B) 8 L of fluid daily to remove urea 

(C) Replacement of fluid loss plus insensible 
loss 

(D) 80 mEq potassium chloride (KC1) per 
12 hour 

(E) Ammonium chloride IV 



1: Surgical Critical Care I Pre- and Postoperative Care 



Questions 32 and 33 

A 14-year-old boy with a known bleeding tendency 
since infancy has severe epistaxis. Examination 
reveals an equinus contracture of the right leg and a 
large hemarthrosis. 

32. What is the most likely diagnosis? 

(A) Diethylstilbestrol (DES) was taken by 
the mother during pregnancy 

(B) Aplastic anemia 

(C) Henoch-Schonlein purpura 

(D) Hemophilia 

(E) Wilson's disease with cirrhosis 

33. Treatment should include which of the 
following? 

(A) Penicillamine 

(B) Transfusion of factor VIII to 30% of 
normal factor levels 

(C) Transfusion of factor VIII to 10% of 
normal factor levels 

(D) Platelet transfusion 

(E) Exploration of joint 

34. A 10-year-old boy with history of prolonged 
bleeding after minor injury is scheduled for ton- 
sillectomy. The bleeding time, PT, and fibrinogen 
are normal. What would be the most helpful 
investigation? 

(A) Fibrinolysis (euglobulin clot lysis time) 

(B) Platelet count 

(C) Thrombin time 

(D) Partial thromboplastin time (PTT) 

(E) Factor VII assay 

Questions 35 to 37 

A 22 -year-old man is brought into the emergency 
department in profound shock after a fall from the 
fourth floor of a building. After resuscitation, small- 
bowel resection and hepatic segmentectomy are 
performed at laparotomy. He receives 15 U of 
packed RBCs, 4 U of fresh-frozen plasma, and 8 L 
of Ringer's lactate. On closure, diffuse oozing of 
blood is noted. 



35. What is the most likely cause? 

(A) Hepatic failure 

(B) Hypersplenism 

(C) Platelet deficiency 

(D) Factor IX (Christmas factor) deficiency 

(E) Congenital hypoprothrombinemia 

36. Which test is most likely to be helpful in man- 
agement of this patient? 

(A) Platelet count 

(B) Bone marrow biopsy 

(C) Liver-spleen scan 

(D) Factor VIII assay 

(E) Smear for Howell-Jolly bodies 

37. Bleeding persists despite all appropriate blood 
coagulant replacement, and laparotomy reveals 
multiple sites of bleeding from the liver and the 
rest of the abdomen. Treatment should include 
which of the following? 

(A) Hepatic artery ligation 

(B) Packing with laparotomy towels 

(C) Immediate closure 

(D) A large dose of heparin 

(E) Solu-Medrol, 1 g IV 

38. A 50-year-old suffering from chronic alcoholism 
is admitted to the hospital. He has muscle tremors 
and hyperactive tendon reflexes. Serum mag- 
nesium is 1.8 mEq/L (normal 1.5-2.5 mEq/L). 
Concerning magnesium, which of the follow- 
ing statements is true? 

(A) It is mainly extracellular 

(B) Excess may cause a positive Chvostek's 
sign (carpopedal spasm) 

(C) Deficiency is treated with parenteral 
bicarbonate 

(D) Symptoms are due to deficiency of 
magnesium 

(E) It may become elevated in acute 
pancreatitis 

Questions 39 and 40 

A 30-year-old man with multiple injuries has severe 
renal insufficiency. On the third day of hospitalization, 



Questions: 32-46 



he is lethargic with generalized weakness and 
decreased deep tendon reflexes. An electrocardio- 
gram (ECG) reveals a widened QRS complex with 
elevated T waves. 

39. What is the most likely cause of the patient's 
condition? 

(A) Hypokalemia 

(B) Hyponatremia 

(C) Hypermagnesemia 

(D) Hypocalcemia 

(E) Hypophosphatemia 

40. What should be the immediate management 
of the patient? 

(A) Administration of potassium chloride 

(B) Administration of calcium chloride 

(C) Restriction of fluid intake 

(D) Use of Kayexylate enemas 

(E) Administration of hypertonic saline 

41. A 45-year-old male with a known history of 
alcoholism is admitted with acute pancreatitis. 
His serum calcium is 7 mg/dL. Management is 
based upon which of the following? 

(A) One-fourth of calcium in serum is ionized 

(B) Alkalosis increases the ionized calcium 
component 

(C) Hypocalcemia may cause polyuria and 
polydypsia 

(D) Determination of serum albumin is 
necessary 

(E) Treatment should involve intravenous 
administration of calcium chloride 



43. In a 12-year-old boy who sustained severe head 
injury caused by a fall from the third floor of a 
building, the syndrome of diabetes insipidus is 
characterized by which of the following? 

(A) Low serum sodium 

(B) High urinary specific gravity or 
osmolality 

(C) High serum osmolality 

(D) Low urine output 

(E) Expanded extracellular fluid volume 

44. In a 40-year-old woman receiving TPN for 
small-bowel fistula, what finding can be attrib- 
uted to hypophosphatemia? 

(A) Increased cardiac output 

(B) Diarrhea 

(C) Increased energy production 

(D) Rhabdomyolysis 

(E) Increased white blood cells (WBC) 
function 

Questions 45 and 46 

A 60-year-old woman who underwent a mastectomy 
for breast cancer 2 years earlier presents to the emer- 
gency department with headache, backache, and fre- 
quent vomiting. She is extremely thirsty and stuporous. 

45. Which test is most likely to identify the cause? 

(A) CT scan of the head 

(B) X-ray of spine 

(C) Serum sodium determination 

(D) Serum calcium determination 

(E) Serum glucose determination 



42. A 36-year-old diabetic woman develops meta- 
bolic changes following salpingo-oophorectomy 
Serum osmolality of the blood can be calculated 
from serum values of which of the following? 

(A) Sodium, potassium, chloride, and 
bicarbonate 

(B) Sodium, potassium, urea, and 
hemoglobin 

(C) Sodium, potassium, glucose, and urea 

(D) Sodium, albumin, urea, and glucose 

(E) Sodium, potassium, albumin, and glucose 



46. What should be the initial management of the 
patient? 

(A) Restrict fluid intake 

(B) Normal saline infusion 

(C) D 5 W infusion 

(D) Thiazide 

(E) Hemodialysis 



1: Surgical Critical Care I Pre- and Postoperative Care 



47. A 40-year-old man is found to have severe 
metabolic acidosis with a high anion gap. What 
is the most likely cause? 

(A) Diarrhea 

(B) Methanol ingestion 

(C) Proximal renal tubular acidosis 

(D) Distal renal tubular acidosis 

(E) Ureterosigmoidostomy 

48. An 18-month-old boy slipped and hurt his 
right knee while walking. He presents with a 
tender, swollen, warm knee with significant 
hemarthrosis. His PT is 12 (normal, 13 seconds), 
PTT is over 100 (normal, 25 seconds), platelet 
count is 300,000 /mm 3 , and bleeding time is 
normal. Initial management should consist of 
which of the following? 

(A) Fresh-frozen plasma 

(B) Aspiration of knee 

(C) Factor VIII concentrate 

(D) Passive exercise 

(E) Long-leg cast 

49. A 30-year-old woman with a history of an 
uneventful tonsillectomy at age four is sched- 
uled for exploratory laparotomy. Preoperative 
assessment that identifies the risk of intraop- 
erative bleeding is which of the following? 

(A) Bleeding time 

(B) Platelet count 

(C) PT and PTT 

(D) Complete blood cell count 

(E) Obtaining a detailed history 

50. A 43-year-old woman with von Willebrand's 
disease is scheduled for cholecystectomy. It can 
be stated that preoperative evaluation will 
reveal which of the following? 

(A) Normal bleeding time, PT, and PTT 

(B) Platelet aggregate with restocetin 

(C) Increased bleeding time and PTT, and 
normal PT 

(D) Increased bleeding time and PT, and 
normal PTT 

(E) Increased bleeding time, and normal PT 
and PTT 



51. 



52. 



53. 



Following admission to the emergency depart- 
ment, a 26-year-old woman with severe men- 
orrhagia states that both her father and sister 
have a bleeding disorder. The hemostatic dis- 
order transmitted by autosomal-dominant 
mode is which of the following? 

(A) Factor X deficiency 

(B) von Willebrand's disease 

(C) Factor VIII deficiency (true hemophilia) 

(D) Factor IX deficiency (Christmas disease) 

(E) Factor V deficiency (parahemophilia) 

A 75-year-old man is found to have prolonged 
bleeding from intravenous puncture sites. 
Platelet aggregation is inhibited by which of 
the following? 

(A) Adenosine diphosphate (ADP) 

(B) Calcium 

(C) Magnesium 

(D) Aspirin 

(E) Serotonin 

A 45-year-old woman with deep vein throm- 
bosis is taking warfarin (Coumadin), 5 mg/d. 
Seven days after initiation of therapy, she has 
warfarin-induced skin necrosis. Which of the 
following statements regarding this condition 
is true? 

(A) It commonly occurs after warfarin 
therapy. 

(B) It usually involves the upper extremities. 

(C) It improves with an increase in the dose 
of Coumadin. 

(D) It improves with a decrease in the dose 
of Coumadin. 

(E) It requires cessation of Coumadin and 
infusion of heparin. 



54. A 50-year-old man with atrial fibrillation is taking 
warfarin (Coumadin). The effect of Coumadin is 
decreased by which of the following? 

(A) The presence of vitamin K deficiency 

(B) Phenylbutazone 

(C) Quinidine 

(D) Barbiturates 

(E) Thyrotoxicosis 



Questions: 47-61 



55. After undergoing a transurethral resection of the 
prostate, a 65-year-old man experiences excessive 
bleeding attributed to fibrinolysis. It is appro- 
priate to administer which of the following? 

(A) Heparin 

(B) Warfarin (Coumadin) 

(C) Volume expanders and cryoprecipitate 

(D) Aminocaproic acid (Amicar) 

(E) Fresh-frozen plasma and vitamin K 

Questions 56 and 57 

A 64-year-old woman undergoing radical hysterec- 
tomy under general anesthesia is transfused with 2 U 
of packed RBCs. 

56. A hemolytic transfusion reaction during anes- 
thesia will be characterized by which of the 
following? 

(A) Shaking chills and muscle spasms 

(B) Fever and oliguria 

(C) Hyperpyrexia and hypotension 

(D) Tachycardia and cyanosis 

(E) Bleeding and hypotension 

57. The specific test to identify the cause of trans- 
fusion reaction for the patient is which of the 
following? 

(A) PT 

(B) PTT 

(C) Platelet count 

(D) Bleeding time 

(E) Free plasma hemoglobin 

58. A 41-year-old woman has an episode of mild 
right upper quadrant (RUQ) pain associated 
with jaundice that resolves completely with 
antibiotics. Workup reveals numerous large 
stones in the gallbladder. The patient has poly- 
cythemia vera, a hematocrit of 58%, and a 
platelet count of 1.8 million. What is the pre- 
ferred course of treatment for this patient? 

(A) She should be referred to the medical 
clinic for follow-up care and be observed. 

(B) She should undergo phlebotomy and 
then be scheduled for cholecystectomy. 



59. 



(C) She should be treated with chlorambucil 
for 6 weeks and then undergo 
cholecystectomy. 

(D) She should receive miniheparin and 
urgent cholecystectomy. 

(E) She should undergo cholecystectomy. 

A 56-year-old man underwent prostatectomy. 
He bled excessively and urgently required 
blood over and above what had been requested 
before surgery. In deciding on an appropriate 
blood transfusion protocol, what should be 
kept in mind? 

(A) Group AB is the universal donor. 

(B) Serum from the recipient stored for 
1 week is suitable for testing. 

(C) Hypothermia is indicated if cryoglobulin 
is found. 

(D) Cross-matching should be done before 
dextran administration. 

(E) Fresh-frozen plasma can be given 
instead of 4 U of packed cells. 



60. A 60-year-old man with carcinoma of the 
esophagus is admitted with severe malnutri- 
tion. Nutritional support is to be initiated. 
What should be his daily caloric intake? 

(A) 1 kcal/kg body weight/day 

(B) 5 kcal/kg body weight/day 

(C) 15 kcal/kg body weight/day 

(D) 30 kcal/kg body weight/day 

(E) 100 kcal/kg body weight/day 

61. TPN is initiated in a 44-year-old woman with 
Crohn's disease. In parenteral alimentation, 
carbohydrates should be provided in an opti- 
mal ratio of which of the following? 

(A) 1 kcal/g nitrogen 

(B) 5 kcal/g nitrogen 

(C) 10 kcal/g nitrogen 

(D) 100 kcal/g nitrogen 

(E) 1000 kcal/g nitrogen 



10 



1: Surgical Critical Care / Pre- and Postoperative Care 



62. After undergoing subtotal gastrectomy for car- 
cinoma of the stomach, a 64-year-old woman is 
receiving peripheral parenteral nutrition. To 
increase calories by the peripheral route, what 
should be prescribed? 

(A) D 5 W in normal saline 

(B) Multivitamin infusion 

(C) D 25 W (25% dextrose in water) 

(D) Soybean oil 

(E) Lactulose 

63. A 35-year-old man with duodenal stump leak 
after partial gastrectomy is receiving central 
parenteral nutrition containing the standard 
D,_W, 4.25% amino acid solution. Which is 
TRUE of essential fatty acid deficiency seen 
after hyperalimentation? 

(A) It occurs if soybean oil is given only 
once weekly. 

(B) It is usually noted at the end of the first 
week. 

(C) It causes dry scaly skin with loss of hair. 

(D) It is accompanied by 
hypercholesterolemia. 

(E) It is treated with insulin. 



64. 



65. 



In metabolic alkalosis, there is which of the 
following? 

(A) Gain in fixed acid 

(B) Loss of base 

(C) Hyperkalemia 

(D) Rise in base excess 

(E) Hyperchloremia 

Following urinary tract infection associated 
with extraction of a bladder stone, a 64-year-old 
woman developed gram-negative septicemia. 
Which statement is true for gram-negative bac- 
terial septicemia? 

(A) Pseudomonas is the most common 
organism isolated. 

(B) Many of the adverse changes can be 
accounted for endotoxin release. 

(C) The cardiac index is low. 

(D) Central venous pressure (CVP) is high. 

(E) Endotoxin is mainly a long-chain peptide. 



66. In septic shock, which of the following is true? 

(A) The mortality rate is between 10% 
and 20%. 

(B) Gram-negative organisms are involved 
exclusively. 

(C) The majority of patients are elderly. 

(D) The most common source of infection is 
the alimentary tract. 

(E) Two or more organisms are responsible 
in most cases. 

67. A 68-year-old man has a history of myocardial 
infarction. He undergoes uneventful left hemi- 
colectomy for carcinoma of the colon. In the 
recovery room, he is hypotensive and given a 
fluid bolus of 500 mL Ringer's lactate over 
30 minutes. He is intubated, and his neck veins 
are distended. His HR is 130 bpm, his BP is 
80/60 mm Hg, and his urine output is 20 mL 
over the last hour. What should be the next 
step in his management? 

(A) Administration of Ringer's lactate, 
500 mL over 1 hour 

(B) Administration of dopamine 

(C) Insertion of a Swan-Ganz catheter 

(D) Administration of Lasix 

(E) Extubation of the patient 

68. A 75-year-old woman who is in the ICU after 
undergoing cholecystectomy for acute chole- 
cystitis is hypotensive and tachycardic. 
Pulmonary capillary wedge pressure (PCWP) 
is elevated to 18 mm Hg, and cardiac output is 
3 L/min. She is in shock best described as 
which of the following? 

(A) Hypovolemic shock 

(B) Septic shock 

(C) Cardiogenic shock 

(D) Anaphylactic shock 

(E) Neurogenic shock 

69. A 40-year-old woman with deep vein throm- 
bosis is being treated with IV heparin, 1000 
U/h. On the seventh day of treatment, her lab- 
oratory values are hemoglobin, 14 g/dL; WBC 
count, 7600/mm 3 ; platelet count, 30,000 /mm 3 ; 
PT, 13 seconds (control, 12.5 seconds); and PTT, 



Questions: 62-75 



11 



70. 



50 seconds (control, 26 seconds). What man- 
agement would be appropriate? 

(A) Continue with heparin at the same 
dosage 

(B) Increase heparin 

(C) Decrease heparin 

(D) Discontinue heparin 

(E) Continue heparin and start warfarin 
(Coumadin) 

A 55-year-old man involved in an automobile 
accident is unresponsive and is intubated at the 
scene. On arrival in the emergency department, 
he responds to painful stimulation. His systolic 
BP is 60 mm Hg, his HR is 140 bpm, his neck 
veins are distended, and his breath sounds are 
absent on the left side. Immediate management 
should involve which of the following? 

(A) Insertion of a central venous line on the 
right side 

(B) Insertion of an 18-gauge needle in the 
left second intercostal space 

(C) Pericardiocentesis 

(D) Peritoneal lavage 

(E) CT scan of head 

A 25-year-old man sustained laceration of the 
liver and rupture of the spleen in an automo- 
bile accident. He was hypotensive for more 
than 1 hour and received 10 L of crystalloids 
and 10 U of blood. On the second postoperative 
day, he is intubated, his HR is 120 bpm, his BP 
is 110/60 mm Hg, his urine output is 40 mL/h, 
and his CVP is 13 cm H 2 0. His ABGs on 70% 
oxygen reveal a pH of 7.42, a P0 2 of 58 mm Hg, 
and a PCO z of 35 mm Hg. What is the most 
appropriate management? 

(A) Increase the fraction of inspired oxygen 
(Fi0 2 ). 

(B) Increase the tidal volume (VT). 

(C) Administer Lasix, 20 mg IV. 

(D) Institute positive end-expiratory pressure 
(PEEP). 

(E) Decrease Fi0 2 . 



72. A 40-year-old paraplegic is taken to the OR for 
cholecystectomy for acute cholecystitis. She 



71. 



is given succinylcholine before intubation. 
Immediately after induction of anesthesia, she 
develops cardiac arrest. What is the most likely 
cause? 

(A) Esophageal intubation 

(B) Hyperkalemia 

(C) Perforation of gallbladder 

(D) Hypovolemic shock 

(E) Myocardial infarction 

73. A 70-year-old woman has low cardiac output 
with increased PCWP and increased systemic 
vascular resistance. What should be the drug of 
choice? 

(A) Dopamine 

(B) Norepinephrine 

(C) Dobutamine 

(D) Epinephrine 

(E) Phenylephrine 

74. A 60-year-old man had undergone exploratory 
laparotomy for perforated gastric ulcer with 
severe peritoneal contamination. Six hours after 
surgery, he is tachycardic, hypertensive, and 
has shallow respirations. Intubation and insti- 
tution of ventilatory support is indicated in the 
presence of which of the following? 

(A) Respiratory rate of 23 breaths/min 

(B) PaC0 2 of 45 mm Hg 

(C) Pa0 2 of 55 mm Hg on room air 

(D) HR of 140 bpm 

(E) BP of 150/100 mm Hg 

75. A 60-year-old man is being weaned from a ven- 
tilator in the ICU. The likelihood that weaning 
is going to fail is suggested by the presence of 
which of the following? 

(A) A respiratory rate of 24 breaths/min 

(B) A PaO z of 80 mm Hg on Fi0 2 of 40% 

(C) A vital capacity (VC) of 5 mL/kg body 
weight 

(D) A minute ventilation of 8 L/min 

(E) A maximum negative inspiratory 
pressure of -30 cm H z O 



72 1: Surgical Critical Care I Pre- and Postoperative Care 



76. A patient is being weaned from mechanical 
ventilation. Weaning parameters are obtained 
prior to deciding on extubation. Successful 
weaning from a ventilator is suggested by the 
presence of which of the following? 

(A) An alveolar arterial gradient of more 
than 350 mm Hg 

(B) A Pa0 2 /Fi0 2 ratio of <200 

(C) A PaCO z over 55 mm Hg 

(D) A tidal volume of over 5 mL/kg 

(E) A minute ventilation of 12 L/min 

77. A 55-year-old man with oat cell carcinoma of 
the lung is suspected to have SIADH. This is 
characterized by which of the following? 

(A) Decreased total body water (TBW) 

(B) Low serum sodium 

(C) Increased urine output 

(D) Urine sodium of <10 mEq/L 

(E) Low urinary specific gravity 

78. Following surgery for a perforated appendix 
with generalized peritonitis and multiple intra- 
abdominal abscess, a 25-year-old man is admit- 
ted to the ICU. On the third postoperative day he 
continues to be febrile and has a nasogastric tube. 
What is the metabolic characteristic seen in him? 

(A) A decrease in energy expenditure 

(B) Fat as his primary fuel 

(C) Respiratory quotient of 0.6-0.7 

(D) Proteolysis 

(E) Decreased hepatic synthesis of protein 

79. Increase in energy expenditure by 100% over 
normal, or two times greater than normal, is 
seen in a patient with which of the following? 

(A) Pyloric obstruction from chronic 
duodenal ulcer 

(B) Fractured femur 

(C) Perforated diverticulitis of colon 

(D) Severe thermal burns of more than 30% 
total body surface area (BSA) 

(E) Right inguinal herniorrhaphy for 
incarcerated inguinal hernia 



80. A 30-year-old man with a gunshot wound to 
the abdomen has severe injuries involving the 
liver, duodenum, pancreas, and colon. Why is 
parenteral nutrition support preferred over 
enteral nutrition support? 

(A) It is less expensive. 

(B) It preserves gut mucosal mass and 
mucosal immunity. 

(C) It prevents gut permeability and 
translocation. 

(D) It is easy to start and administer nutrient 
requirement rapidly. 

(E) It attenuates hypermetabolic response to 
surgery. 

81. A 24-year-old man with multiple injuries is 
receiving standard TPN. The following is true 
regarding glutamine. 

(A) It is a major fuel for the brain. 

(B) It is an essential amino acid. 

(C) It is a major fuel for the gut. 

(D) It is synthesized de novo in the kidney. 

(E) It is a component of TPN solutions. 

82. A 50-year-old man with small-bowel fistula has 
been receiving TPN for the previous 3 weeks 
through a single-lumen central venous catheter. 
He is scheduled for exploratory laparotomy 
and closure of fistula. On the morning of the 
day of surgery, TPN is discontinued and intra- 
venous infusion with balanced salt solution 
(Ringer's lactate) is started. An hour later, the 
patient is found to be anxious, sweating, and 
tachycardic. What is the most likely cause? 

(A) Anxiety 

(B) Hypoglycemia 

(C) Hypovolemia 

(D) Unexplained hemorrhage 

(E) Hyperglycemia 

83. A 40-year-old woman with inflammatory bowel 
disease has been receiving TPN for over 3 weeks. 
Workup reveals pelvic abscess. She under- 
goes exploratory laparotomy, resection of small 
bowel with anastomosis, and drainage of pelvic 
abscess. During surgery, TPN is maintained at 
the original rate of 125 mL/h. In the recovery 



Questions: 76-89 



13 



room, the patient is found to have a urine output 
of 200 mL/h. CVP is 1, and laboratory results are 
Na, 149; K, 3.5; CI, 110; HC0 3 , 18; BUN, 40; and 
creatinine, 1 mg/dL. Which of the following 
statements is true regarding this condition? 

(A) The patient's urine output is secondary 
to fluid overload during surgery. 

(B) The patient is in high-output renal 
failure. 

(C) Hyperosmolar-nonketotic coma will 
develop if the condition is not 
aggressively treated. 

(D) Diuresis is a normal response to stress 
of surgery. 

(E) Potassium supplementation is not 
indicated. 

84. A 42-year-old man who weighs 60 kg is receiv- 
ing 3 L of standard hypertonic 25% glucose- 
amino acid solution. He has no history of 
smoking or bronchial asthma. In the ICU, he is 
alert, afebrile, and hemodynamically stable, 
but he remains intubated and attempts to wean 
him off the ventilator have been unsuccessful. 
What is the most likely cause? 

(A) Copper deficiency 

(B) Excess fat calories 

(C) Excess glucose calories 

(D) Excess amino acids 

(E) Inadequate glucose calories 

85. An 85-year-old male is admitted to the ICU in 
septic shock. A pulmonary artery (PA) catheter 
is placed. The PA catheter does not directly 
measure which one of the following ? 

(A) PA systolic pressure 

(B) PCWP 

(C) Systemic vascular resistance 

(D) Right ventricular diastolic pressure 

(E) Right atrial pressure 

86. A 50-year-old woman with adult respiratory 
distress syndrome (ARDS) is intubated. The 
oxyhemoglobin curve is shifted to the right 



87. 



with increased oxygen delivery by which of 
the following? 

(A) Metabolic acidosis 

(B) Older age 

(C) Decreased 2,3-diphosphoglycerate (DPG) 

(D) Decreased thyroid hormone level 

(E) Hypothermia 

A 70-year-old man was administered 20,000 U 
of heparin before femoral artery embolectomy 
Following surgery, he is noted to have gener- 
alized bleeding from the wound margins. 
Immediate management should consist of 
administration of which of the following? 

(A) Fresh-frozen plasma 

(B) Cryoprecipitate 

(C) Platelet transfusion 

(D) Intravenous protamine sulfate 

(E) Intravenous sodium bicarbonate 

A 70-year-old female has been admitted to your 
ICU in shock. You determine that a PA catheter 
is needed. Which of the following is not a 
known complication associated with the inser- 
tion of PA catheter? 

(A) Transient arrhythmias such as ventricular 
tachycardia 

(B) Right bundle branch block 

(C) Pneumothorax 

(D) Mural thrombus 

(E) Cardiac perforation 



89. A 34-year-old male has serum sodium of 
114 mEq/L. Correction of hyponatremia can be 
done by raising serum sodium by what amount? 

(A) lmEq/L/h 

(B) 3mEq/L/h 

(C) 5mEq/L/h 

(D) 7mEq/L/h 

(E) lOmEq/L/h 



88. 



14 



1: Surgical Critical Care / Pre- and Postoperative Care 



Questions 90 and 91 

A 47-year-old woman with chronic renal failure has 
been maintained on chronic dialysis for several years. 
She had undergone kidney transplantation but because 
of rejection, she was placed back on dialysis. She had 
repeated bouts of pain in the RUQ and was intolerant 
to fatty meals. Ultrasound showed cholelithiasis. 

90. Following elective cholecystectomy, severe 
bleeding occurred. This was most likely attrib- 
uted to which of the following? 

(A) Elevated PT 

(B) Elevated PTT 

(C) Low platelet count 

(D) Decreased platelet aggregation 

(E) Sepsis 

91. The most appropriate management of this 
patient is the administration of which of the 
following? 

(A) Heparin 

(B) Protamine sulfate 

(C) Fresh-frozen plasma 

(D) Desmopressin 

(E) Factor VIII concentrate 

92. A 70-year-old man, who weighs 70 kg, is admit- 
ted with acute cholecystitis. His calculated 
daily fluid requirement for maintenance is 
approximately which of the following? 

(A) 1L 

(B) 2L 

(C) 2.5 L 

(D) 3L 

(E) 4L 

93. A 90-year-old woman with a fractured neck 
of femur is receiving low-molecular-weight 
heparin (LMWH). Which of the following state- 
ments regarding LMWH is true? 

(A) It has molecular weight below 4000 d. 

(B) Its anticoagulant effect is by binding to 
antithrombin III. 

(C) It should be administered two to three 
times a day. 



(D) It has lower bioavailability than standard 
heparin. 

(E) It has a greater rate of heparin-associated 
thrombocytopenia. 

DIRECTIONS (Questions 94 through 100): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option(s). Each lettered option 
may be selected once, more than once, or not at all. 

Questions 94 through 96 

(A) Copper deficiency 

(B) Chromium deficiency 

(C) Zinc deficiency 

(D) Manganese deficiency 

(E) Vitamin A deficiency 

(F) Vitamin D deficiency 

(G) Vitamin E deficiency 
(H) Vitamin K deficiency 

(I) Vitamin C deficiency 

94. A 45-year-old man receiving TPN has signs of 
retarded wound healing. SELECT ONLY THREE. 

95. A 40-year-old woman with no previous history 
of diabetes is receiving TPN. After 4 weeks, 
she is hyperglycemic, and it is difficult to 
control her glucose despite insulin therapy. 
SELECT ONLY TWO. 

96. A 42-year-old man with small-bowel fistula has 
been receiving TPN with standard hypertonic 
glucose-amino acid solution for the previous 3 
weeks. The patient is noticed to have scaly, 
hyperpigmented lesions over the acral surfaces 
of elbows and knees, similar to enterohepatic 
acrodermatitis. What is the most likely cause of 
this condition? SELECT ONE. 

Questions 97 through 99 

(A) Factor II (prothrombin) 

(B) Factor V 

(C) Factor VII 

(D) Factor VIII 

(E) Factor IX 



Questions: 90-104 



15 



(F) Factor X 

(G) Factor XII 
(H) Calcium 

(I) Fibrin split products 

97. A 72-year-old man requires blood transfusion. 
He was initially given stored plasma. He is 
most likely to show a deficiency of what? 
SELECT TWO. 

98. What is the coagulation factor involved exclu- 
sively in the extrinsic coagulation system? 
SELECT ONE. 

99. A 48-year-old man with severe liver cirrhosis is 
admitted to the hospital with hematemesis. 
What coagulation factors are not synthesized in 
the liver? SELECT TWO. 

Question 100 

A 20-year-old man has undergone appendectomy 
for perforated appendicitis with generalized peri- 
tonitis. Seven days postoperatively, his temperature 
continues to spike to 103. 8°F despite antibiotic ther- 
apy with ampicillin, gentamicin, and metronidazole. 
A CT scan reveals a large pelvic abscess. Soon after- 
ward, he has bleeding from the mouth and nose with 
increasing oozing from the surgical wound and all 
intravenous puncture sites. What is the most likely 
diagnosis? 

(A) Anaphylactoid reaction to intravenous 
dye 

(B) Disseminated intravascular coagulation 
(DIC) 

(C) Antibiotic -induced coagulopathy 

(D) Liver failure 

(E) Congenital bleeding disorder 



101. 



During the treatment of septic shock, a 28-year- 
old male remains hypotensive despite adequate 
volume replacement; PA occlusion pressure is 
18 mm Hg. When dopamine is started , ventric- 
ular tachycardia develops and this is unre- 
sponsive to lidocaine. The V-tach converts back 
to sinus rhythm once the dopamine is stopped. 



At this point, which of the following treatments 
are most appropriate for this hypotensive patient? 

(A) Amrinone 

(B) Dobutamine 

(C) Epinephrine 

(D) Phenylephrine 

(E) Intra-aortic balloon pump 

102. A 65-year-old male is resuscitated using hy- 
droxyethyl starch (hetastarch). Which of the fol- 
lowing is associated with the use of hetastarch ? 

(A) Thrombotic thrombocytopenia 

(B) Elevated levels of factor VIII 

(C) Elevation of serum creatinine 

(D) Hyperbilirubinemia 

(E) Hyperamylasemia 

103. A 28-year-old female several minutes after 
receiving an intravenous dose of ampicillin for 
dental prophylaxis against endocarditis devel- 
ops diffuse pruritis, cutaneous erythema, and 
hypotension (BP = 60/40 mm Hg). All of the 
following hemodynamic parameters are typical 
of this type of shock initially, except 

(A) Increased HR 

(B) Intravascular hypovolemia 

(C) Vasodilation 

(D) Increased cardiac output 

(E) Decreased preload 

104. A 55-year-old male presents to the emergency 
room (ER) with a history suggestive of myocar- 
dial infarction, but without a diagnostic ECG 
pattern of ST-segment elevation. Which of the 
following ECG patterns strongly suggests that 
thrombolytic therapy should be administered. 

(A) Right bundle branch block 

(B) Left bundle branch block 

(C) Second-degree AV block (Wenckebach 
type) 

(D) Complete artrioventricular (AV) block 

(E) Runs of V tachycardia 



16 



1: Surgical Critical Care / Pre- and Postoperative Care 



105. You are called to the emergency department to 
evaluate a 55-year-old woman following motor 
vehicle crash with associated head trauma. She 
withdraws to pain and is intubated for airway 
protection. In order to calculate the Glasgow 
Coma Scale score, which of the following com- 
ponents of the neurologic examination are 
necessary? 

(A) Motor response, verbal response, 
corneal reflexes 

(B) Motor response, eye opening, verbal 
response 

(C) Eye opening, pupillary light reflexes, 
motor response 

(D) Pupillary light reflexes, motor response, 
verbal response 

(E) Corneal reflexes, pupillary light reflexes, 
motor response 

106. A 40-year-old woman is given a routine injection 
of ragweed allergen immunotherapy by her 
family physician. She developed a shortness of 
breath and a sensation of throat swelling. She was 
taken to the emergency department where she 
was noted to be flushed and sweating profusely 
and in moderate distress. She was also noted to 
be wheezing, tachycardic and hypotensive. 
Which of the following interventions is most 
appropriate at this time? 

(A) Ranitidine 50 mg PO 

(B) Diphenhydramine 50 mg PO 

(C) Ringer's lactate, 250 ml over 1 hour 

(D) Methylprednisolone 125 mg PO 

(E) Epinephrine 0.5 mL intramuscular (IM) 

107. A 67-year-old man with severe ARDS is receiv- 
ing pressure assisted control ventilation. He is 
requiring an Fi0 2 of 100% to maintain the fol- 
lowing blood gas levels: pH = 7.26, PC0 2 = 60, 
PO z = 58. You decide to put the patient in prone 
position. Fifteen minutes later, on the same vent 
settings, the patient's tidal volume is now de- 
creased and his blood gas values are pH = 7.09, 
PC0 2 = 76, P0 2 = 89. He is hemodynamically 
unchanged and his chest x-ray (CXR) is also 
unchanged. The most likely cause of his wors- 
ening respiratory acidosis in the prone posi- 
tion is 



(A) Pneumothorax 

(B) Increased dead space 

(C) Decreased cardiac filling 

(D) Reduced chest wall compliance 

(E) Pulmonary edema 

108. You are asked to see a 70-year-old male admitted 
to the ICU with anterior chest pain radiating to 
the back described as "a tearing sensation." The 
pain reached maximum intensity within 30 min- 
utes. The patient has a history of hypertension 
(noncompliant with medications). His BP in the 
ICU is 170/110 mm Hg, HR = 110/min. Physical 
examination reveals a 2/6 diastolic murmur and 
unequal femoral pulses. A CXR of this patient 
was normal and the CT chest, which was 
obtained, is shown in Fig. 1-2. Which of the fol- 
lowing statements regarding his treatment and 
prognosis are correct? 

(A) The patient will require nitroprusside 
and beta blockade, but will not require 
surgical intervention. 

(B) The patient will require only 
nitroprusside but will not require 
surgical intervention. 

(C) The patient will require nitroprusside and 
/3-blockade prior to emergency surgical 
intervention. 

(D) Neither nitroprusside nor /3-blockade is 
required prior to surgical intervention. 

(E) Nitroprusside and /3-blockade are 
required initially, but surgery may be 
done electively within 4-6 weeks. 




Figure 1-2. 

Computed tomography (CT) scan demonstrating aortic dissection. 
(Reproduced, with permission, from Brunicardi FC et al: Schwartz's 
Principles of Surgery, 8th ed. 706. McGraw-Hill, 2005.) 



Answers and Explanations 



1. (C) High-output renal failure should be sus- 
pected if the BUN continues to rise with urine 
output >1000-1500 mL/d. It is associated 
with mild-to-moderate renal insufficiency; in 
comparison, severe renal injury results in olig- 
uric renal failure. The kidneys do not tolerate 
ischemia for more than 30-90 minutes. Hypo- 
thermia is protective. There is a decrease in cre- 
atinine clearance. Vasopressors aggravate the 
deleterious effects of shock. 

2. (B) Hyperkalemia can manifest by GI or 
cardiovascular signs. GI symptoms include 
nausea, vomiting, intestinal colic, and diarrhea. 
Abdominal distension as a result of paralytic 
ileus is due to hypokalemia. An ECG is useful 
to monitor potassium levels. Hyperkalemia 
is characterized by peaked T waves. ECG 
changes also include ST-segment depression, 
widened QRS complex, and heart block. 
Cardiac arrest occurs in diastole with increas- 
ing levels of potassium. Osborne (J) wave is 
seen in hypothermia. 

3. (C) In hyperkalemia, all oral and intravenous 
potassium must be withheld. Sodium chloride 
worsens the metabolic acidosis. Sodium bicar- 
bonate intravenously is given to divert potas- 
sium intracellularly by causing alkalosis. 
Calcium gluconate (1 g [10 mL of 10% solu- 
tion]) is given to counteract the effect of potas- 
sium on the myocardium. The hypertonic 
glucose solution stimulates the synthesis of 
glycogen, which causes cellular uptake of 
potassium. Small amounts of insulin (1 U/5 g 
of glucose) is helpful. The usual recommen- 
ded dose is 100 mL of 50% glucose with 10 U 
of insulin. Calcitonin is used for treating 



hypercalcemia. Serum magnesium is also ele- 
vated in renal failure. 

4. (D) This patient has metabolic acidosis with 
normal anion gap. The normal value of anion 
gap is 10-15. Loss of bicarbonate (e.g., small- 
bowel fistula, pancreatic fistula, or diarrhea) and 
gain of chloride (e.g., administration of ammo- 
nium chloride or HC1 and decreased excretion as 
in distal renal tubular acidosis) result in meta- 
bolic acidosis with normal anion gap. In con- 
trast, in acidosis due to increased production of 
an organic acid (e.g., ketoacids in diabetes, sulfur 
and phosphoric acid in renal failure, and lactic 
acid in shock), the anion gap is increased. 

5. (B) The patient has acute respiratory distress 
syndrome (ARDS). Measurement of ABGs pro- 
vides initial evaluation of pulmonary function 
in terms of oxygenation and ventilation. ECG is 
valuable for diagnosing myocardial ischemia 
or cardiac arrhythmias. Ventilation perfusion 
scanning is used for diagnosing pulmonary 
embolism. A central venous line provides infor- 
mation regarding the volume status of the 
patient, which may be low to normal in ARDS. 

6. (C) Increased airway resistance (stiff lung) 
may be noted early in shock lung. The alveo- 
lar capillary membrane becomes more per- 
meable. There is a leak of a high-protein fluid 
from the capillary to the interstitial tissues 
and then into the alveoli. This is commonly 
called ARDS. Sepsis syndrome is the most 
frequent cause of ARDS (39%), followed by 
aspiration, multiple transfusion, massive soft- 
tissue injury, multiple trauma, near drown- 
ing, fat embolism, DIC, and pancreatitis. 



77 



18 



1: Surgical Critical Care / Pre- and Postoperative Care 



ARDS is associated with ventilation-perfusion 
imbalance. In some areas of lung, there is ven- 
tilation with no perfusion, whereas, in other 
areas, nonventilated alveoli are being per- 
fused. The net result is decrease in functional 
residual capacity, shunting, and increased 
dead space ventilation. Chest x-ray reveals 
diffuse alveolar infiltration, and findings are 
normal in the initial stage. 

7. (B) A history of bleeding should alert the clini- 
cian to evaluate the underlying cause. The bleed- 
ing time is influenced by those factors affecting 
platelet and capillary integrity. Prolongation of 
the PT may be attributed to decreased absorption 
of fat-soluble vitamin K, liver impairment, or 
decrease in the blood components because of 
consumption. 

8. (B) Possible causes of this syndrome include 
head injury, central nervous system (CNS) dis- 
orders, neoplastic diseases, pulmonary dis- 
eases, drugs, and idiopathic. It results in 
impaired water excretion characterized by olig- 
uria, hyponatremia, significantly decreased 
serum osmolality, and increased urinary osmo- 
lality. Administration of a hypotonic solu- 
tion(D5/0.33 NS) would not result in decreased 
urine output. Decreased ADH secretion would 
result in an increased urine output as opposed 
to a decreased urine output. Naso-gastric suc- 
tion while it can result in a hypo-kalemia, 
hyponatremia is less likely. Renal insufficiency 
would likely result in a decreased urine 
osmolality. 

9. (B) Hyponatremia occurs because of overhydra- 
tion and/or inadequate sodium replacement. 
When serum sodium is <130 mEq/L, acute 
symptomatic hyponatremia is manifested by 
CNS symptoms due to increased intracranial 
pressure. Muscle twitching and increased tendon 
reflexes seen in moderate hyponatremia progress 
to convulsions, loss of reflexes, and hyperten- 
sion with severe hyponatremia. Oliguric renal 
failure may become irreversible if not immedi- 
ately treated. Mild asymptomatic hyponatremia 
is treated with fluid restrictions. In the presence 
of CNS symptoms, the patient should be given 
hypertonic saline. 



10. (D) Sodium deficit is estimated by multiplying 
the decrease in serum sodium times the total 
body water, which is 60% of body weight: 

(normal serum sodium - observed serum 
sodium) x 0.6 x (total body weight) 
= (140 - 120) x 0.6 x 60 = 720 mEq 

Half of this amount should be administered 
over 12-18 hours. 

11. (B) Oliguria may be prerenal or renal. The fol- 
lowing table characterizes findings in prerenal 
failure versus those observed in intrinsic renal 
failure (acute tubular necrosis). 

TABLE 1-1. PRERENAL VS. INTRINSIC RENAL FAILURE 





Prerenal 


Intrinsic Renal 




Failures 


Failures 


Urine osmolality 


>500 


<350 


(mOsm/kg) 






Urine sodium 


<20 


>40 


(mEq/L) 






Fractional excretion 


<1% 


>2% 


of sodium 






BUN/SCR 


>20 


<10 


Urine/PCR 


>40 


<20 



12. (C) The composition of various GI secretions is 
different. They are as follows: A, saliva; B, gas- 
tric; C, ileal; D, pancreatic; and E, colonic. The 
composition of intestinal fluid is the closest to 
that of plasma. 

13. (A) The composition of small intestinal fluid is 
sodium, 140 mEq/L; potassium, 5 mEq/L; chlo- 
ride, 104 mEq/L; and bicarbonate, 30 mEq/L. 
Daily losses are best replaced by administra- 
tion of balanced salt solution (Ringer's lactate) 
whose composition is depicted in A. B repre- 
sents normal saline (0.9%), C is half normal 
saline (0.45%), D is M/6 sodium lactate, and E 
is 3% sodium chloride. 

14. (B) A decrease in pH below 7.4 indicates acido- 
sis. PCO z is increased over 40 mm Hg, suggest- 
ing respiratory acidosis. To differentiate pure 
from combined acidosis, pH is calculated based 
on changes in C0 2 . A change of 10 mm Hg from 
40 mm Hg changes pH by 0.08 from 7.4. In this 



Answers: 7-23 



19 



case, there is a 20 mm Hg increase in PC0 2 , 
which would decrease pH by 2 x 0.08 = 0.16 
from 7.4 or 7.24. The measured pH is 7.24. 
Therefore, the patient has pure respiratory 
acidosis. 

15. (D) Respiratory acidosis in the immediate post- 
operative period is due to inadequate ventila- 
tion. Adequate ventilation needs to be restored 
by prompt intubation and ventilatory support. 
Use of morphine will further depress the 
respiration. 

16. (B) Villous adenoma of colon can result in watery 
diarrhea and hypokalemia. Massive tissue injury 
producing myoglobinemia is associated with 
significant release of intracellular potassium. 
Massive blood transfusion results in release 
of large amounts of potassium. The ability to 
excrete potassium is impaired in high-output 
renal failure. Spironolactone is a potassium- 
sparing diuretic. 

17. (E) A change in PC0 2 of 10 mm Hg from the 
normal value of 40 mm Hg produces a 0.08 
change in pH (from 7.4). A PC0 2 of 30 mm Hg, 
representing a decrease of 10 mm Hg, can 
account for an increase in pH by 0.08 (i.e., 
7.4-7.48). The patient's measured pH is 7.54. 
The additional increase in pH is due to meta- 
bolic alkalosis. 

18. (A) Alkalosis is associated with hypokalemia. 
Hypokalemia can be sudden and severe. It is 
related to (a) intracellular shift of potassium in 
exchange for hydrogen and (b) excessive uri- 
nary potassium loss. The oxyhemoglobin dis- 
sociation curve is shifted to left, and a decrease 
in levels of ionized calcium can result in tetany 
and convulsions. 

19. (E) Zinc is one of the metalloenzymes involved 
in lipid, carbohydrate, protein, and nucleic acid 
metabolism. Skin lesions similar to enterohep- 
atic acrodermatitis are the most common sign 
seen in zinc deficiency. Other manifestations 
include hypogonadism, diminished wound 
healing, and immunodeficiencies. Copper defi- 
ciency is characterized by microcytic hypo- 
chromic anemia. 



20. (E) The fall in pressure will signal changes via 
baroreceptors located in the arch of the aorta 
and carotid sinus and will cause sympathetic 
stimulation with tachycardia, peripheral vaso- 
constriction, and hypothermia. Eosinopenia 
rather than eosinophilia is more likely to be 
present. There is a switch from aerobic to anaer- 
obic metabolism. Lactic acid accumulation indi- 
cates an adverse prognosis in shock. There is a 
progressive deterioration in prognosis as the 
blood lactate level increases from 1 to above 
3 mm/L. 

21. (C) The fall in cardiac output results in a rela- 
tively larger proportion of blood to be distrib- 
uted to the heart. The changes are mediated 
mainly by sympathetic stimulation. There is 
increased arteriolar and precapillary sphincter 
tone in the skin and in the renal and splanchnic 
circulation. In the heart, coronary artery vasodi- 
lation occurs, which is brought about partly by 
local release of vasodilator substances (due to 
hypoxemia and acidosis). 

22. (C) Initial resuscitation of a trauma patient is 
best done by administering Ringer's lactate, 
because it is isotonic, and it is similar to plasma 
in electrolyte composition. There is no conclu- 
sive evidence that colloid solutions (albumin, 
plasma protein solution, or hydroxy ethyl starch 
solution) improve the rate of resuscitation or 
eventual outcome. D 5 W and D 5 W and 0.45% 
normal saline are hypotonic. Use of crystalloid 
solutions also aids in the resuscitation of the 
interstitial compartment. 

23. (C) Neurogenic shock (not to be confused with 
spinal shock, which is defined by loss of reflexes 
below the area of spinal cord injury, a neurologic 
phenomena) is secondary to high spinal cord 
injury as evidenced by inability to move all four 
extremities. Neurogenic shock is clinically man- 
ifested by warm skin, bradycardia, and hypoten- 
sion. In septic shock, while the skin is warm, the 
patient usually has tachycardia. In all other types 
of shock, the skin is cold. Treatment consists of 
volume replacement with balanced salt solution 
(lactated Ringer's solution). On rare occasions, 
some patients may need vasoconstrictors (e.g., 
phenylephrine hydrochloride). 



20 1: Surgical Critical Care I Pre- and Postoperative Care 



24. (D ) Succussion splash is elicited by placing one 
hand behind and the other in front of the left 
abdomen and rib cage and rocking the patient 
gently between the two hands. In pyloric 
obstruction, one can feel the fluid hitting the 
fingers (succussion). Peristalsis is likely to be 
observed in infants with congenital pyloric 
stenosis. 

25. (B) Duodenal ulcer and gastric carcinoma are the 
most likely causes of pyloric obstruction in 
adults. Metabolic alkalosis results from loss of 
fixed acids from the stomach. The bicarbonate 
content of the blood accompanies the elevation 
in pH. In severe metabolic alkalosis, paradoxical 
loss of acid (hydrogen) in the urine occurs in an 
attempt to conserve potassium. Hypokalemia 
worsens the metabolic consequences of meta- 
bolic alkalosis. 

26. (D) Potassium should not be given initially 
until moderate hydration has been achieved, 
and urine flow is adequate. Normal saline is 
required initially to correct the hypochloremia. 

27. (D) Initial management of hypochloremic meta- 
bolic alkalosis includes administration of isotonic 
sodium chloride solution with replacement of 
potassium chloride. In patients refractory to stan- 
dard therapy use of O.l N and 0.2 N hydrochlo- 
ric acid has been shown to be safe and effective 
therapy. Ammonium chloride solution has also 
been used, but this can lead to ammonia toxicity, 
especially in patients with hepatic insufficiency. 

28. (B) The actual surgical treatment for obstruc- 
tion caused by peptic ulcer is controversial. 
Appropriate gastric surgery with drainage usu- 
ally is required if pyloric stenosis is severe. 
Drainage procedures include pyloroplasty, gas- 
trojejunostomy, or antrectomy. An alternative to 
vagotomy and drainage would be vagotomy, 
antrectomy with gastrojejunostomy, or a Billroth 
II subtotal gastrectomy with gastrojejunal anas- 
tomosis. It is important to be certain that a gas- 
tric carcinoma is not the cause of the pyloric 
outlet obstruction. 

29. (B) The presence of an adequate urine output 
does not preclude a diagnosis of high-output 



renal failure. The mechanism is based in part on 
prior ischemia to the nephron structure of the 
kidneys. There may be an initial period of olig- 
uria. Urea, potassium, and acids are still partly 
excreted in the urine, and lactate or bicarbonate 
is given to avoid development of acidosis. 

30. (A) Potassium should not be given, and potas- 
sium levels must be monitored carefully to 
avoid hyperkalemia. Phosphorous and mag- 
nesium levels may be increased, and hyperna- 
tremia is likely to occur when fluid is restricted 
and a solute-poor urine is excreted. Autopsy in 
patients dying early shows that the distal 
nephron is affected more than the proximal 
nephron. Although mortality figures are high, 
if the patient survives the postoperative period, 
satisfactory renal function can be anticipated. 

31. (C) Marked fluid restriction may result in 
hypernatremia. If the condition is treated appro- 
priately, urea nitrogen usually falls after 1 or 
2 weeks. In elderly and cardiac patients, pul- 
monary edema occurs more readily, and diuret- 
ics may be contraindicated because azotemia 
may be made more severe. Ammonium chlo- 
ride would make the acidosis worse. Potassium 
has to be monitored carefully, because severe 
hyperkalemia is readily induced. 

32. (D) Hemophilia (factor VIII deficiency) usually 
occurs during infancy. It is sex-linked, recessive, 
and affects males almost exclusively. DES 
administered during the mother's pregnancy 
has not been incriminated in coagulation disor- 
ders but is associated with vaginal carcinoma in 
adolescent girls. Henoch-Schonlein purpura 
usually occurs about 3 weeks after a streptococ- 
cal infection and includes joint pain, purpura, 
and nephritis. Wilson's disease is associated 
with a disturbance in copper metabolism. 

33. (B) Spontaneous bleeding occurs when factor 
VIII is reduced below 2-3%. Once serious 
bleeding occurs, a higher factor VIII activity — 
probably approaching 30% — is required for 
adequate hemostasis. The half-life of factor VIII 
is 8-12 hours. In minor lesions, 10 U/kg body 
weight of factor VIII is administered. For severe 
lesions, the dosage is 40-50 U/kg body weight 



/Answers: 24-41 



21 



of factor VIII. After major surgical procedures, 
factor VIII must be given daily for 7-10 days. 
Penicillamine is used to inhibit excess copper 
deposition (e.g., in Wilson's disease). 

34. (D) The clinical picture is suggestive of hemo- 
philia. The normal bleeding time excludes cap- 
illary fragility or platelet deficiency. If fibrinolysis 
was evident, the fibrinogen level would be 
reduced. In the presence of a normal PT, a pro- 
longed PTT indicates a deficiency of factor VIII, 
IX, XI, or XII. The PT evaluates the extrinsic 
coagulation pathway. The normal PT excludes 
factor VII deficiency. The thrombin time eval- 
uates fibrinogen to fibrin conversion with an 
external source of thrombin and will be normal 
as fibrinogen levels are normal. 

35. (C) Thrombocytopenia is the major hemostatic 
disorder in massive blood transfusion. Platelet 
transfusion usually is indicated when more than 
6-8 U of blood is transfused rapidly. There is 
the risk of causing hepatitis. Stored blood is defi- 
cient in factors V and VIII; as such, PT and PTT 
may be slightly prolonged after massive blood 
transfusion. Fresh-frozen plasma is the source of 
factors V and VII, which would be deficient in 
banked blood. Unless there is previous liver cir- 
rhosis, the procedures enumerated are unlikely 
to lead to liver failure. Hypersplenism occurs 
in patients with enlarged spleens. 

36. (A) Platelet deficiency is likely to be evident, 
but tests to exclude other causes of bleeding are 
indicated. The possibility of defibrinogenation, 
intravascular coagulopathy, or fibrinolysis 
must be excluded by appropriate coagulation 
studies. Bleeding from a vein or artery, incom- 
patible blood transfusion, DIC, acidosis, and 
hypothermia are other considerations to explain 
any unusual bleeding after a major surgical 
procedure. 

37. (B) In desperate cases where bleeding persists 
despite all other measures, packing the abdomen 
with laparotomy packs may offer temporary 
control. The patient is taken to the OR 24^8 
hours later for removal of packing after stabi- 
lization of hemodynamic status and correction 
of coagulopathy. 



38. (D) Symptoms are due to magnesium deficiency. 
Magnesium is mainly intracellular. Magnesium 
deficiency occurs in the presence of starvation, 
malabsorption syndrome, acute pancreatitis, 
and chronic alcoholism. Symptoms are charac- 
terized by neuromuscular and CNS hyperactiv- 
ity, such as muscle tremors, hyperactive tendon 
reflexes, and tetany with a positive Chvostek 
sign. The syndrome of magnesium deficiency 
can exist in the presence of normal serum mag- 
nesium levels. Magnesium deficiency is treated 
with parenteral magnesium sulfate or magne- 
sium chloride. 

39. (C) Symptomatic hypermagnesemia is seen 
after early thermal injury, massive trauma, 
surgical stress, and in the presence of severe 
renal insufficiency. ECG changes resemble 
those seen with hyperkalemia. Hypokalemia 
and hypophosphatemia can cause symptoms 
of generalized weakness, but potassium and 
phosphorus are increased in renal failure. 
Hypokalemia is characterized by flattening 
of T waves and U waves. Hypocalcemia is 
characterized by hyperactive tendon reflexes. 
Hyponatremia is characterized by nervous irri- 
tation as restlessness and convulsions with no 
specific ECG changes. 

40. (B) Administer calcium chloride. Management 
of hypermagnesemia involves correction of 
extracellular volume deficit and acidosis and 
withholding exogenous magnesium. Calcium 
chloride should be administered to reverse the 
ECG changes temporarily. Peritoneal dialysis 
or hemodialysis is necessary for persistent 
symptoms or toxicity. Calcium chloride stabi- 
lizes the cardiac cell membrane and thereby 
reduces the risk of dysrhythmias. 

41. (D) Determination of serum albumin or protein 
level is necessary for proper determination of 
serum calcium level. For every 1 g decrease of 
serum albumin, the serum calcium level is cor- 
rected by 0.8. Intravenous administration of 
calcium chloride is indicated in the presence of 
symptoms. Approximately 45% of serum cal- 
cium is ionized and responsible for neuromus- 
cular stability. Half of the calcium in the blood 
is bound to protein, and an additional 5% is 



22 1: Surgical Critical Care I Pre- and Postoperative Care 



attached to substances other than protein. 
Alkalosis decreases the ionized component. 
Hypercalcemia causes polydypsia and polyuria. 

42. (C) Serum osmolality is calculated from serum 
values of sodium, potassium, glucose, and BUN 
by using the formula 2 (Na + K) + BUN/2.8 + 
glucose/18. 

43. (C) Injury to the pituitary stalk in major skull 
fractures involving the base of the skull can result 
in decreased secretion of vasopressin (ADH). 
There is increased urine output that is diluted 
(osmolality <270 mOsm/kg). The extracellular 
fluid volume is contracted, resulting in high 
serum osmolality (>300 mOsm/kg) and increased 
serum sodium. 

44. (D) Hypophosphatemia results in decreased syn- 
thesis of phosphorylated intermediate metabo- 
lites such as adenosine triphosphate (ATP), 2, 
3-DPG, and cyclic adenosine monophosphate 
(cAMP). Deficiency can result in erythrocyte 
membrane instability, WBC dysfunction, platelet 
dysfunction, congestive heart failure, arrhyth- 
mias, weakening of respiration muscles, hemol- 
ysis, and rhabdomyolysis. 

45. (D) The symptoms are suggestive of hypercal- 
cemia. Major causes of hypercalcemia are cancer 
with bony metastasis and hyperparathyroidism. 
Symptoms involve the GI, renal, musculoskele- 
tal, and CNS. 

46. (B) Patients with hypercalcemia have decreased 
extracellular fluid volume due to vomiting and 
polyuria. Vigorous resuscitation with salt solu- 
tion will lower the serum calcium by dilution 
and increased renal excretion. Furosemide and 
not thiazides increase renal excretion of calcium. 
Additional therapy includes administration of 
oral or intravenous inorganic phosphates, corti- 
costeroid, mithramycin, and calcitonin. 

47. (B) Methanol ingestion results in increased pro- 
duction of lactic acid causing an increased anion 
gap. The other conditions listed are associated 
with normal anion gap. Diarrhea, proximal renal 
tubular acidosis, and ureterosigmoidostomy 
result in loss of bicarbonate, while distal renal 



tubular acidosis is associated with decreased 
acid excretion. 

48. (C) The boy has hemophilia. Management con- 
sists of infusion of factor VIII concentrate. Bed 
rest and local cold packs are helpful. Aspiration 
of the knee to remove blood and passive exer- 
cise are not recommended for fear of recurrent 
bleeding. In contrast, active exercise is benefi- 
cial because movement beyond the point when 
bleeding can recur is limited owing to pain. 
Fresh-frozen plasma has a low level of factor 
VIII (0.6 U/mL) and is not useful because the 
required volume is excessive. Patients can use 
long leg splint. 

49. (E) Obtaining a detailed history is the most 
important preoperative information that pre- 
dicts the risk of unexpected intraoperative 
bleeding complication. It is even more reliable 
than laboratory tests. 

50. (C) von Willebrand disease is characterized by 
decreased level of factor VIIIc (procoagulant). 
It has autosomal-dominant inheritance. These 
patients have prolonged bleeding times and 
PTT, with normal PTs. In contrast to platelets 
of normal patients that aggregate when resto- 
cetin is added, in von Willebrand's resease, 
platelets fail to aggregate in presence of 
restocetin. 

51. (B) von Willebrand disease is the most common 
hemostatic disorder transmitted by autosomal- 
dominant mode. Other disorders transmitted 
by this mode are hereditary hemorrhagic 
telangiectasia and factor XI deficiency. Diseases 
transmitted by an autosomal-recessive mode 
are factor X, factor V, factor VII, and factor I 
deficiencies. Factor VIII (true hemophilia) and 
factor IX (Christmas disease) deficiencies are 
sex-liked recessive. 

52. (D) ADP, serotonin, and thromboxane A 2 are 
important mediators of platelet aggregation. 
In the presence of calcium, magnesium, and 
platelet factor 4, they cause release of platelet 
content and their granules resulting in the for- 
mation of a platelet plug. This process is inhib- 
ited by aspirin. 



/Answers: 42-61 



23 



53. (E) Requires cessation of Coumadin and infu- 
sion of heparin. Warfarin (Coumadin)-induced 
skin necrosis is a rare complication with high 
morbidity and mortality. It usually occurs 3-10 
days after initiation of therapy, affects women 
more commonly than men, and most often 
involves the skin of thighs, buttocks, abdomen, 
and breast. The exact mechanism is unknown 
but may be related to depression of protein C 
levels in some patients. Management involves 
immediate cessation of Coumadin and admin- 
istration of heparin IV. 

54. (D) Patients receiving barbiturates, oral contra- 
ceptive agents, and corticosteroids often require 
larger amounts of Coumadin to maintain ade- 
quate anticoagulation. In patients with vitamin K 
deficiency or impaired liver function and in those 
with thyrotoxicosis, there is increased effect of 
Coumadin. Also, the cholesterol-lowering agent 
clofibrate, D-thyroxine, and certain antibiotics 
given concomitantly with Coumadin enhance 
its anticoagulant effect. It is important to adjust 
the dose of Coumadin when initiating anticoag- 
ulation therapy in such patients. 

55. (D) Fibrinolysis may be primary or acquired. 
Primary fibrinolysis is seen after fibrinolytic ther- 
apy with streptokinase or urokinase; surgical 
procedures on the prostate gland (which is rich 
in urokinase) and severe liver failure. Secondary 
fibrinolysis is most commonly seen in DIC. If 
the PT, PTT, and platelet count are normal, DIC 
is unlikely to be present. Aminocaproic acid 
inhibits plasminogen activation to plasmin and 
can be used if there is excessive fibrinolysis. It 
must not be given in DIC, because serious 
intravascular clotting may occur. 

56. (E) In the anesthetized patient, the classic signs 
of transfusion reaction are masked. The sudden 
unexplained onset of bleeding and hypoten- 
sion should include transfusion reaction in the 
differential diagnosis. In the conscious patient, 
chills, fever, pain in the lumbar region, a tight 
sensation over the chest, flushing of the face, 
and dark-colored urine may be evident. 

57. (E) Acute hemolytic transfusion reaction due to 
transfusion of incompatible blood in a patient 



under general anesthesia usually presents as gen- 
eralized bleeding due to DIC. PT, PTT, and bleed- 
ing time will be abnormally high, and platelets 
may be decreased because of DIC. The most spe- 
cific tests to determine hemolysis are free plasma 
hemoglobin and hemoglobinuria. The labora- 
tory criteria are hemoglobinuria with a con- 
centration of free hemoglobin over 5 mg/dL, a 
serum hepatoglobin level below 50 mg/dL, and 
serological criteria to show antigen incompati- 
bility of the donor and recipient blood. 

58. (C) Patients with polycythemia vera do poorly 
in general surgery if they have not had appro- 
priate treatment to reduce the RBC and platelet 
count. With chlorambucil treatment, elective 
cholecystectomy should be performed to avoid 
the possible need to perform the operation on 
an emergency basis when the patient is not 
fully prepared. 

59. (D) Cross-matching should be done before dex- 
tran administration. Group O is the universal 
donor, and if there is insufficient time to do 
appropriate cross-matching of blood, this type of 
blood should be used. Serum of the recipient 
should be <24 hours old, because antigenicity 
may be altered in blood stored for a longer time. 
Before hypothermia is undertaken, the patient's 
(recipient's) blood should be tested for cold 
agglutinin titer. Cryoglobulin may be present in 
patients with lymphoma or leukemia. Blood must 
be given at room temperature to such patients. 

60. (D) In general, total caloric needs for the 
majority of patients ranges between 25 and 
35 kcal/kg/d. An alternative formula for calcu- 
lating daily caloric requirements is the Harris- 
Benedict equation, which is based on sex, age, 
weight, and height. The caloric requirements of 
humans also varies by amount of activity, degree 
of stress of surgery, trauma, sepsis, or burns. 

61. (D) The baseline protein requirements are cal- 
culated as 1 g/kg/d. Following stress, there is 
an increased protein requirement, and protein 
intake should be 1.5 g/kg/d after surgery, 
2 g/kg/d after polytrauma, and after sepsis. 
Glucose and amino acids must be infused 
simultaneously to appropriately utilize nitrogen. 



24 1: Surgical Critical Care I Pre- and Postoperative Care 



The ideal ratio is 100 nonprotein kcal/g of 
nitrogen. In starvation, the nonprotein calorie- 
to-nitrogen ratio of 150 kcal/g is adequate. 

62. (D) Lipid emulsions derived from soybean or 
safflower oils are widely used. One of the real 
advantages of lipid emulsion is that a large 
amount of calories can be provided through a 
peripheral vein. The 10% solution provides 
4.62 kJ/mL and the 20% solution, 9.24 kJ/mL. 
Dextrose concentration in peripheral route is 
10%. Concentrations >10% require administra- 
tion into a central vein to prevent phlebitis owing 
to hypertonicity of the solutions. Lactulose is 
used to treat hepatic encephalopathy. 

63. (C) Essential fatty acid deficiency usually 
occurs if hyperalimentation is extended for 
more than 1 month and when soybean oil is not 
administered at least twice a week. There is a 
decrease in linolenic, linoleic, and arachidonic 
acids and an increase in oleic and palmitoleic 
acid. In addition to the skin changes, there may 
be poor wound healing, increased susceptibil- 
ity to infection, lethargy, and thrombocytope- 
nia. It is characterized by a triene-to-tetraene 
ratio >0.4. 

64. (D) In metabolic alkalosis, there may be a loss 
of fixed acids or excess of base. It is associated 
with hypokalemia because of renal conser- 
vation of H + ions and urinary potassium loss. 
Loss of hydrochloric acid as seen in vomiting 
in patients with pyloric obstruction results 
in hypochloremic, hypokalemic, metabolic 
alkalosis. 

65. (B) Many of the adverse changes can be 
accounted for by endotoxin release. Escherichia 
coli is the most common organism involved in 
gram-negative septicemia, followed by Klebsiella, 
Aerobacter, Proteus, and Pseiidomonas. The car- 
diac index is high, peripheral resistance is 
decreased, and C VP is low to normal. The most 
common conditions leading to gram-negative 
sepsis are those of the urinary tract, followed 
by respiratory and biliary tract and abdominal 
visceral infections. Endotoxins are lipopolysac- 
charide complexes. The lipid A portion is prob- 
ably responsible for the toxicity. 



66. (C) Most patients are elderly. The underlying 
conditions leading to septic shock occur more 
commonly in elderly patients. The mortality is 
higher in this patient population. The overall 
mortality rate exceeds 40-50%. Gram-positive 
organisms, parasites, or fungi also may be 
responsible. The genitourinary and respiratory 
tracts are more common sources for initiating 
sepsis. Two or more organisms are found in 
10-20% of cases. 

67. (C) The patient's clinical picture is suggestive of 
cardiogenic shock. However, he may still be 
hypovolemic, because distension of neck veins 
does not accurately reflect the filling pressures of 
the heart. A Swan-Ganz catheter should be 
inserted for appropriate assessment of hemody- 
namic status and institution of appropriate ther- 
apy. Fluid therapy will worsen cardiogenic 
shock, and Lasix will make the patient hypov- 
olemic. Dopamine will increase BP but is delete- 
rious to the heart. The patient should not be 
extubated until he is stable. 

68. (C) Low cardiac output in the presence of ele- 
vated filling pressures is characteristic of cardio- 
genic shock. PCWP is decreased in all the other 
types of shock. 

69. (D) Thrombocytopenia is a common complica- 
tion of heparin therapy. The most common 
form, type I (seen in up to 30% of patients), is a 
milder form that occurs after 2-3 days of 
heparin therapy. The platelet count remains over 
50,000 /mm 3 and has no clinical significance. 
Type II, seen in 1-2%, usually occurs 7-10 days 
after heparin treatment. It is immune mediated 
and can be caused by heparin therapy in any 
form, in any dose, including heparin flushes and 
heparin-bonded intravenous catheters. Treat- 
ment consists of immediate cessation of heparin 
administration in any form. 

70. (B) The patient has tension pneumothorax, as 
evidenced by distended neck veins and absent 
breath sounds. Increased intrathoracic pressure 
interferes with venous return to the heart, 
resulting in shock. Immediate management 
should be insertion of a large-bore needle in 
the left second intercostal space, followed by 



Answers: 62-79 



25 



insertion of a chest tube. In a trauma patient, 
venous access should be achieved by inserting 
two large-bore (16-gauge) angiocatheters in the 
cubital veins. Insertion of a central venous line 
on the right side should not be done, because it 
carries the risk of producing pneumothorax in 
the opposite side. 

71. (D) Institute positive end-expiratory pressure 
(PEEP). This patient has developed ARDS, 
which is associated with a significant decrease 
in functional residual capacity (FCR) of the 
lungs from collapse of alveoli and increased 
shunt from perfusion of unventilated alveoli. 
The most appropriate way to improve his oxy- 
genation is by instituting PEEP. 

72. (B) Administration of a depolarizing anesthetic 
agent such as succinylcholine in quadriplegics, 
in paraplegics, or after burns and severe 
trauma can result in life-threatening hyper- 
kalemia from release of intracellular potassium. 

73. (C) Dobutamine is the drug of choice for 
improving cardiac function. It is a P 1 -receptor 
agonist and increases myocardial contractibil- 
ity and also reduces afterload by f$ 2 effect. 
Dopamine at low doses (1-3 mg/kg/min) stim- 
ulates dopaminergic receptors and increases 
renal blood flow. At moderate doses (3-10 
mg/kg/min), it stimulates preceptors, resulting 
in a positive inotropic and chronotropic effect. 
Systolic and mean BP are increased; whereas, 
diastolic BP is usually unchanged. At higher 
doses (10-20 mg/kg/min), stimulation of a- 
receptors occurs and it significantly increases 
systemic vascular resistance. Norepinephrine, 
epinephrine, and phe-nylephrine are powerful 
vasoconstrictors. 

74. (C) The criteria for need for ventilatory support 
are apnea, respiratory rate >30 breaths/min, 
Pa0 2 <60 mm Hg on room air, and PaC0 2 
>55 mm Hg (except in patients with chronic 
obstructive pulmonary disease [COPD]). 

75. (C) Vital capacity (VC) of 5 mL/kg body 
weight. See Answer 76. 



76. (D) Successful weaning from the ventilator is 
suggested by the presence of 

(a) Pa0 2 of 70 mm Hg or more with an FiO z 
of 0.35 or less 

(b) An alveolar arterial gradient of 
<350 mm Hg 

(c) A Pa0 2 -to-Fi0 2 ratio of >200 

(d) A PaCO z of over 30 mm Hg and 
<55 mm Hg 

(e) A VC of more than 10-15 mL/kg 

(f) A maximum negative inspiratory force 
of more than -25 cm H z O 

(g) A minute ventilation of <10 L/min 
(h) A tidal volume of over 5 mL/kg 

(i) A respiratory rate of <30 breaths/min 

77. (B) Patients with SIADH have low urinary 
output with hyponatremia. Urine-specific grav- 
ity or osmolality is increased, urinary excretion 
of sodium is increased (>20 mEq/L), and TBW 
is increased as manifested by low serum osmo- 
lality. SIADH is seen after various CNS disor- 
ders, in neoplastic disease, pulmonary diseases, 
and with some drugs and may be idiopathic. 

78. (D) The metabolic response to stress is different 
to that seen following starvation, as illustrated 
in Table 1-2. 

TABLE 1-2. 





Starvation 


Stress 


Resting energy expenditure 


Decreased 


Increased 


Respiratory quotient 


(0.6-0.7) 


(0.8-0.9) 


Mediator activation 


NA 


+++ 


Primary fuels 


Fat 


Mixed 


Proteolysis 


+ 


+++ 


Branched-chain oxidation 


+ 


+++ 


Hepatic protein synthesis 


+ 


+++ 


Ureagenesis 


+ 


+++ 


Urinary nitrogen loss 


+ 


+++ 


Glucogenesis 


+ 


+++ 


Kelone body production 


++++ 


+ 



(Reproduced, with permission, from Brunicardi FC et a/.: Schwartz's 
Principles of Surgery, 8th ed. 31. McGraw-Hill, 2005.) 



79. (D) Resting energy expenditure is decreased fol- 
lowing starvation (e.g., in the patient with pyloric 
obstruction) and increased after the stress of sur- 
gery, trauma, or sepsis. The increase in energy 



26 1: Surgical Critical Care I Pre- and Postoperative Care 



expenditure correlates with the severity of insult 
being 1.2 times greater after minor operation 
(e.g., right inguinal herniorrhaphy), 1.35 times 
greater after skeletal trauma (e.g., fractured 
femur), 1.6 times greater after major sepsis (e.g., 
perforated diverticulitis), and 2 times greater 
after severe thermal burns. 

80. (D) It is easy to start and administer nutrient 
requirements rapidly. Parenteral nutrition should 
be administered when enteral access cannot be 
obtained, when enteral nutrition support fails to 
meet nutritional requirements, or when feeding 
into the GI tract is contraindicated. Current evi- 
dence suggests that in addition to safety, con- 
venience, and cost, enteral feeding is well 
tolerated, preserves gut mucosal mass and 
normal gut flora, prevents increased gut per- 
meability to bacteria and other toxins, main- 
tains mucosal immunity, and attenuates the 
hypermetabolic response to surgery. As com- 
pared to parenteral nutrition, enteral nutri- 
tion is also associated with significantly 
reduced septic complications. Therefore, enteral 
feeding is preferred over TPN when feasible. 

81. (C) It is a major fuel for the gut. It is readily syn- 
thesized de novo in skeletal muscle, lung, and 
liver. Glutamine is a nonessential amino acid. It 
is not a component of presently available 
TPN solutions because of its lack of stability. 
Glutamine is a major fuel for the small intes- 
tinal mucosa and other replicating cells such as 
lymphocytes, macrophages, fibroblasts, and 
endothelial cells. Glucose is the primary source 
of fuel for the brain. 

82. (B) Patients on TPN with hypertonic glucose 
solutions have elevated islet-cell production of 
insulin. Sudden cessation of TPN can lead to 
rebound hypoglycemia, because pancreatic 
islet-cell insulin secretion is not immediately 
downregulated. Symptoms are attrbutable to 
high catecholamine release secondary to hypo- 
glycemia. In general, the TPN rate should be 
reduced to 50 mL/h during surgery. This pre- 
vents both hypoglycemia and the hyper- 
glycemia seen with higher infusion rates. 
Weaning from TPN should be done gradually 
over 24^8 hours. In instances where TPN is 



discontinued suddenly, a solution of D 10 W 
should be administered in the interim. 

83. (C) Hyperosmolar-nonketotic coma is a seri- 
ous complication seen when an excessive 
amount of glucose is given, especially in the 
presence of sepsis, steroids, or inadequate 
insulin. Furthermore, the combination of sur- 
gery and sepsis results in an increased insulin- 
resistant state. The increased urine output is 
secondary to osmolar load from blood glu- 
cose. Low CVP, hypernatremia, and BUN-to- 
creatinine ratio over 20 suggest hypovolemia 
and not fluid overload. Normal creatinine level 
and BUN-to-creatinine ratio over 20 rules out 
high-output renal failure. The stress of surgery 
is characterized by water retention and not 
diuresis. Management consists of aggressive 
hydration, discontinuation of TPN, and insulin 
drip. Insulin drives the potassium intracellu- 
larly and potassium must be replaced. 

84. (C) Glucose infusion should not exceed 
4-5 mg/kg/min, equivalent to 365^32 g for 
this patient. The patient is receiving 750 g of 
glucose. Glucose has a respiratory quotient of 
1. Excess glucose results in increased produc- 
tion of C0 2 , making it difficult to wean the 
patient off ventilator. Treatment consists of 
reducing glucose load and providing fat calo- 
ries (up to 40% of total calories). Fat has a res- 
piratory quotient of 0.7, resulting in decreased 
production of CO z . 

85. (C) Systemic vascular resistance (an approxi- 
mation of afterload) is a calculated value. All 
the other choices are directly measured. 

86. (A) The oxyhemoglobin dissociation curve is a 
convenient method to study the affinity of 
hemoglobin for oxygen. It is S-shaped, which 
provides an efficient method of uptake and 
release of oxygen. It holds on to the oxygen at 
high concentrations and as the blood enters the 
lower pressures encountered in the capillaries, it 
releases the oxygen. Hemoglobin is 75% satu- 
rated at a P0 2 of 40 mm Hg and 50% saturated 
at a P0 2 of 27 mm Hg. At the peripheral tissues, 
a right or left shift does have a real impact on the 
affinity of hemoglobin for oxygen. If the S-curve 



/Answers: 80-96 



27 



is shifted to the right, there is a decreased affin- 
ity of hemoglobin for oxygen (more oxygen is 
released). A right shift occurs with increase in 
2,3-DPG, acidosis, increase in temperature, and 
increase in hormones (Cortisol, thyroid, or aldos- 
terone). A left shift occurs with a decrease in 
temperature, alkalosis, low DPG, carboxyhemo- 
globinemia, and old age. 

87. (D) Intravenous protamine sulfate. The cause 
of bleeding is circulating heparin. The antico- 
agulative effect of heparin can be immediately 
neutralized by intravenous protamine sulfate. 
One milligram of protamine sulfate usually 
neutralizes 100 U of heparin. Fresh-frozen 
plasma is given to counteract the effect of war- 
farin (Coumadin). Cryoprecipitate is useful in 
treating patients with hemophilia. Intravenous 
sodium bicarbonate is indicated after mis- 
matched blood transfusion to alkalinize the 
urine. Platelet transfusions are necessary to cor- 
rect dilutional thrombocytopenia seen after 
massive blood transfusion. 

88. (D) Transient arrhythmias and right bundle 
branch block are seen during the insertion of 
the PA catheter as it may hit the wall of the 
right ventricle causing these electrical distur- 
bances. Pneumothorax is a risk associated with 
the insertion of the introducer for the PA 
catheter. Cardiac perforation is certainly a risk 
anytime a catheter is being placed through 
the heart. Mural thrombus is not a known 
complication. 

89. (A) Rapid correction of hyponatremia >l-2 
mEq/L/h can lead to central pontine myeli- 
nolysis. Serum sodium level should not be 
raised >25 mEq/L within 48 hours of starting 
therapy. Only symptomatic hyponatremia 
requires treatment with hypertonic saline, oth- 
erwise fluid restriction is sufficient. 

90. (D) Abnormal hemostasis, common in chronic 
renal failure, is characterized by prolonga- 
tion of bleeding time, decreased activity of 
platelet factor 3, abnormal platelet aggrega- 
tion, and adhesiveness. The prolonged bleeding 
time is related to failure of platelet interaction 
with von Willibrand's factor (factor 8-VWF) 



This interaction can be corrected by using 
desmopressin or by transfusing cryoprecipitate. 

91. (D) The coagulation changes can be reversed 
with desmopressin or cryoprecipitate. 

92. (C) Daily maintenance fluid requirements are 
calculated on the basis of 100 mL/kg for the 
first 10 kg of body weight, 50 mL/kg for the 
second 10 kg of body weight, and 20 mL/kg for 
each additional kg of body weight (i.e., 100 x 
10 + 50 x 10 + 20 x 50 = 2500 mL). Hourly fluid 
requirement can be calculated using the 4, 2, 1 
rule as follows: 4 mL/kg, for the first 10 kg, 2 
mL/kg for second 10 kg, and 1 mL/kg for each 
additional kg of body weight (i.e., 4 x 10 + 2 x 
10 + 1 ( 50 = 110 mL/h). 

93. (B) Low molecular weight heparins (LMWH) 
are fragments of unfractionated standard 
heparin with mean molecular weights between 
4000 and 64,000 d. They bind to and accelerate 
the activity of antithrombin III. LMWH has 
greater bioavailability, more effective antico- 
agulant effect, lower incidence of heparin- 
associated thrombocytopenia, and can be 
administered once daily. 

94. (C, E, I) Zinc deficiency, vitamin A deficiency, 
and vitamin C deficiency. Zinc is a metalloen- 
zyme involved in protein and nucleic acid 
metabolism. Deficiency results in diminished 
wound strength and healing rates. Vitamin A 
deficiency results in delayed wound healing, 
specifically epithelization. Vitamin C deficiency 
results in defective sulfonated mucopolysac- 
charides and chondroitin sulfate with retarded 
wound healing. 

95. (B, D) Chromium is an insulin cof actor. Defi- 
ciency state results in hyperglycemia. Manganese 
is a cofactor of enzyme of energy and protein 
metabolism and also of fat synthesis. Besides 
causing glucose intolerance, manganese defi- 
ciency also causes hypocholesterolemia. 

96. (C) Zinc is one of the metalloenzymes involved 
in lipid, carbohydrate, protein, and nucleic acid 
metabolism. Skin lesions similar to enterohepatic 
acrodermatitis are the most common signs seen 



28 1: Surgical Critical Care I Pre- and Postoperative Care 



in zinc deficiency. Other manifestations include 
hypogonadism, diminished wound healing, 
and immunodeficiencies. Copper deficiency 
is characterized by microcytic hypochromic 
anemia. 

97. (B, D) Factor V and VIII are deficient in stored 
plasma. In contrast, fresh-frozen plasma con- 
tains all the coagulation factors. The major dis- 
advantage of plasma administration, however, 
is the risk of hepatitis. 

98. (C) There are two coagulation pathways — 
extrinsic and intrinsic. In the extrinsic system, 
tissue thromboplastin (a lipoprotein) interacts 
with factor VII. The intrinsic pathway requires 
factors XII, XI, IX, and VIII. Factor XII is the ini- 
tial step in the coagulation cascade. Factor XII, 
activated by contact with a nonendothelial sub- 
stance, will activate factor XI (plasma throm- 
boplastin antecedent). However, factor XI can 
be activated even when factor XII is deficient. 
Calcium is required for nearly all of the enzyme 
reactions in both the intrinsic and extrinsic sys- 
tems. The amount of ionized calcium required 
for these reactions is extremely small, and clin- 
ical hypocalcemia itself is not a cause of abnor- 
mal bleeding. Fibrin split products are not part 
of the normal pathway in either the intrinsic or 
extrinsic system. The excessive breakdown of 
fibrinogen results in measurable amounts of 
the breakdown products of fibrinogen in the 
blood. Their presence may signal DIC if the PT 
and platelet count are deranged. In pure fibri- 
nolysis, fibrinogen breakdown product levels 
also may be increased. 

99. (D, H) All the coagulation factors except throm- 
boplastin, calcium, and factor VIII are synthe- 
sized in the liver. Factors II, VII, IX, and X are 
vitamin K dependent. 

100. (B) Disseminated intravascular coagulation is 
characterized by diffuse intravascular coagu- 
lation, thrombosis, and fibrinolysis. It results in 
thrombocytopenia, hypofibrinogenemia, pro- 
longation of PT and PTT, and increased con- 
centration of fibrin degradation products in 
plasma. Sepsis is a major factor that can trigger 
DIC. 



101. (D) Dopamine activates /^-receptors and this 
was probably the reason for the arrhythmia. 
Amrinone will inhibit phosphodiesterase and 
result in an increased cyclic AMP level, pro- 
ducing the same result as /3-receptor stimu- 
lation. Dobutamine and epinephrine also 
stimulate the /3- receptors. The only choice 
which stimulates only a-adrenergic receptors 
is phenylephrine. Intra-aortic balloon pump 
is invasive, therefore, less appropriate as a 
choice. 

102. (E) Hetastarch is a synthetic colloid that is 
metabolically inert and can be infused IV A 
6% solution of hetastarch has the same osmotic 
properties as 5% albumin. Relatively few com- 
plications are associated with hetastarch. Large 
volumes do cause dilution of plasma proteins 
as well as coagulation and platelet function 
disorders. Hetastarch binds to amylase and 
impairs renal excretion of amylase causing 
hyperamylasemia. 

103. (D) In anaphylactic shock, which this patient is 
showing, the HR would reflexively increase due 
to the drop in BP The intravascular hypovolemia 
and decreased preload are clearly present along 
with the vasodilation; however, the cardiac 
output is initially decreased not increased. 

104. (B) The only ECG rhythm, which can obscure 
ST-segment changes seen in acute myocardial 
infarction, is left bundle branch block. All the 
other rhythms would allow visualization of the 
ST-segment changes. 

105. (B) The Glasgow Coma Score scale is made up 
of eye opening, verbal response, and motor 
response. 

106. (E) The patient is suffering from anaphylaxis, 
and the treatment of choice is epinephrine. 
Epinephrine IM has been shown to be more 
effective than SC for the treatment of anaphy- 
laxis. 

107. (D) The prone positioning reduces the dispar- 

ity in mechanics between the dependent 
and nondependent regions of the lungs. This 
reduces the collapsing of the alveoli in the 



Answers: 97-108 



29 



dependent portions of the lungs and overdis- 
tention in the nondependent portions of the 
lungs. The prone position also has other 
effects — it allows a more normal curvature of 
the diaphragm and allows better function. It 
also stiffens the chest wall allowing a more 
even distribution of ventilation and reduction 
in overventilation of nondependent alveoli. 



108. (C) The patient has a diagnosis of dissecting 
aortic aneurysm. This requires emergent med- 
ical as well as surgical intervention. The BP 
needs to be lowered by using nitroprusside as 
well as a /3-blocker to reduce dp/dt (the force 
with which the heart is pumping). Once BP is 
controlled the surgical intervention is needed to 
correct the problem. 



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CHAPTER 2 



Skin, Soft Tissue, and Breast 

Aloyious Smith and Andrew Ashikari 



Questions 



DIRECTIONS (Questions 1 through 50): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 

Questions 1 through 6 

1. A 75-year-old farmer complained of a scaly, 
plaque like skin lesion on his forearm with 
recent development of ulceration. Biopsy reveals 
invasive squamous carcinomas within actinic 
keratosis negative examination of axillary 
nodes. Definitive treatment is: 

(A) Local wound care until the ulcer heals; 
then wide excision and repair 

(B) Excision of the lesion with frozen section 
determined free margins and repair 

(C) Wide excision; split-thickness skin graft 
and axillary node dissection 

(D) Wide excision; split-thickness graft and 
radiation therapy 

(E) Wide excision; split-thickness graft and 
chemotherapy 

2. A 65-year-old light-complexioned male presents 
with a solitary scaly plaque like lesion on his 
forearm present for many years. The lesion is 



0.5 cm in diameter. Shave biopsy reveals intraep- 
ithelial squamous cell carcinoma. (Bowen's dis- 
ease) incompletely excised. Further treatment 
includes: 

(A) Wide excision of the lesions and sentinel 
node biopsy 

(B) Referral for local radiation therapy 

(C) Excision and repair of this area, ensuring 
clear surgical margins 

(D) No further treatment indicated 

(E) Local application of 5-fluorouracil(5-FU) 
cream 

A 45-year-old soccer player presents with a 
6-month history of an ulcerative nodular lesion, 
1.5 cm in diameter in the region of the right oral 
comunissure. Biospy reveals basal cell carci- 
noma. The preferred treatment is: 

(A) Mohs micrographic surgery and 
subsequent reconstruction 

(B) Excision with a clinical margin and local 
flap repair 

(C) Topical 5-FU 

(D) Local radiation therapy 

(E) Cryotherapy 



31 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



32 



2: Skin, Soft Tissue, and Breast 



Questions 4 and 5 

4. A 43-year-old window cleaner fell off a scaffold. 
He sustained an open wound on the right leg. 
Debridement was carried out in the emergency 
department, and the edges of the wound were 
left open. The wound measures 4 cm x 6 cm. 
What is TRUE of wound contraction? 

(A) It occurs within 12 hours of injury. 

(B) It is more prominent over the tibia than 
gluteal region. 

(C) It is accelerated if wound is excised 
3 days after injury. 

(D) It accounts for excessive fibrous tissue 
formation and fixation of tissue around 
a joint. 

(E) It is experimentally less affected by 
excision of tissue from center of wound 
rather than at the periphery. 

5. Which factor is least likely to inhibit wound 
contraction? 

(A) Radiation 

(B) Cytolytic drug 

(C) Transformation growth factor fi 

(D) Full-thickness skin graft 

(E) External splints 

6. A 43-year-old male undergoes a total procto- 
colectomy for ulcerative colitis. The terminal 
ileum is brought out on the anterior abdominal 
wall as an end (Brooks) ileostomy. What is nec- 
essary to obtain optimal healing? 

(A) The ileostomy should be circular rather 
than square. 

(B) The seromuscular layer is sutured to the 
epithelium of the skin to avoid 
inflammatory changes. 

(C) The ileostomy must be constructed to 
avoid fixing the mesentery. 

(D) The mesentery of the ileal loop should 
be widely cut to increase its mobility. 

(E) The ileostomy must be constructed on 
the right side. 



Questions 7 and 8 

A 64-year-old male is to undergo an elective laparo- 
tomy procedure. The proposed wound is considered 
clean-contaminated." 



as 



7. This term implies an infection rate of which of 
the following? 

(A) 1% 

(B) 2% 

(C) 9% 

(D) 15% 

(E) 30% 

8. The wound characteristic indicates which of 
the following? 

(A) Entry of intestinal or urinary tract 
without significant spillage 

(B) Gross spillage from intestinal tract 

(C) No entry of intestinal tract 

(D) Entry into infected tissue 

(E) Drainage of an abscess 

Questions 9 and 10 

A 56-year-old male is burned while sleeping in his 
home. His right upper and lower extremity and the 
anterior aspect of the upper chest have extensive 
second-degree burns. 

9. A second-degree burn is characterized by 
which of the following? 

(A) Coagulative necrosis extending to 
subcutaneous fat 

(B) Pearly white appearance 

(C) Anaesthetic 

(D) Erythema and bullae formation 

(E) Requires immediate skin grafting 

10. The extent of the burn is calculated to represent 
what percentage of body surface area (Fig. 2-1)? 



(A) 
(B) 



10% 
20% 



Questions: 4-12 



33 





Relative Percentages of Areas Affected by 


Growth 








Age 




Area 


10 


15 


Adult 


A = half of head 
B = half of one thigh 


5 1 /2 
4 1 /4 


4 1 /2 
4 1 /2 


3 1 /2 
4 3 /4 





Relative Percentages of Areas Affected by Growth 



Area 

A = half of head 
B = half of one thigh 



9 1 /2 
2 3 /4 



Age 



1 

8 1 /2 
3 1 /4 



6 1 /2 



Figure 2-1. 

Table for estimating extent of burns. In adults, a reasonable system for calculating the percentage of body surface burned is the "rule 
of nines" — Each arm equals 9%, the head equals 9%, the anterior and posterior trunk each equals 18%, and each leg equals 18%; 
the sum of these percentages is 99%. (Reproduced, with permission, from Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 247. McGraw-Hill, 2006.) 



(C) 30% 

(D) 40% 

(E) 50% 

11. Following initial resuscitation, based upon the 
Parkland formula, the patient was resuscitated 
with Ringer's lactate solution at 800 mL/h. 
Further assessment after 6 hours reveals olig- 
uria. What should the next step in manage- 
ment be? 

(A) Continue with increased amount of 
lactated Ringer's solution 

(B) Give Plasma 

(C) Give Diuretics to improve urine flow 

(D) Colloid solution 

(E) Continue initial resuscitation with normal 
saline 



12. After a period of resuscitation, management 
of this patient should include which of the 
following? 

(A) Tangential excision of all eschar until 
bleeding is encountered 

(B) Split-thickness graft (Fig. 2-2) if wound 
grows /3-hemolytic streptococci 

(C) Use of cadaver allograft when required 

(D) Avoid use of porcine xenograft 

(E) Chest x-ray useful for diagnosis of 
inhalation injury 



34 



2: Skin, Soft Tissue, and Breast 




Figure 2-2. 

Typical appearance of meshed split-thickness skin graft secured with 
staples, (Reproduced, with permission, from Brunicardi FC et al.: 
Schwartz's Principles of Surgery, 8th ed. 206. McGraw-Hill, 2005.) 



13. A 12-year-old boy has multiple skin lesions that 
are diagnosed as von Recklinghausen's syn- 
drome (NF-1). What is TRUE of this condition? 

(A) It does not show other malignant lesions. 

(B) It is autosomal recessive. 

(C) It is associated with optic nerve gliomas. 

(D) It is characterized by atrioventricular 
(AV) malformation. 

(E) It is associated with dermoid. 

14. A 29-year-old female swimmer develops a pig- 
mented lesion on the right thigh. With reference 
to a pigmented lesion, there is an increased risk 
of developing melanoma if it is identified with 
which of the following? 

(A) Hutchinson freckle (lentigo maligna) 

(B) Freckle involving basal layer of skin 

(C) Congenital nevocellular nevi 

(D) Hemangioma 

(E) Tophi 

15. A 67-year-old business executive and tennis 
player has a basal cell carcinoma removed from 
the right cheek. What is TRUE of basal cell car- 
cinoma (Fig. 2-3)? 

(A) It may show a flat ulcer. 

(B) It may metastasize to lymph nodes. 

(C) It may metastasize to remote skin areas. 




Figure 2-3. 

Basal cell carcinoma with rolled, pearly borders. (Reproduced, with 
permission, from Brunicardi FC et al.: Schwartz's Principles of 
Surgery, 8th ed. 440. McGraw-Hill, 2005.) 



(D) It is found exclusively in the head and 
neck. 

(E) It is best treated by topical 5-FU. 



16. 



17. 



A 38-year-old female undergoes removal of a 
2 x 1-cm skin lesion shown to be a melanoma. It 
is reported as Clark level 1, which implies what? 

(A) It is superficial to the basement 
membrane. 

(B) It is 1 mm in thickness. 

(C) It has nodal involvement. 

(D) It involves the papillary layer. 

(E) It involves the reticular dermis. 

A 49-year-old male postman had undergone 
several operations to excise recurrent infections 
in both axillary lesions and perianal region. The 
lesions are hydradenitis supperativa (Fig. 2-4). 
Which is TRUE of these? 

(A) They arise from stratum corneum of 
skin. 

(B) They are noninflammatory conditions. 



Questions: 13-21 



35 




19. 



Figure 2-4. 

Active hydradenitis suppurative of the axilla. (Reproduced, with per- 
mission, from Brunicardi FC et al. : Schwartz's Principles of Surgery, 
8th ed. 435. McGraw-Hill, 2005.) 



(C) They always require surgical 
intervention. 

(D) They frequently involve the scalp. 

(E) They are usually caused by staphylococci 
and streptococci. 



18. 



List the layers of skin from the most superficial 
to the deepest layer adjacent to the dermis (a) 
basal layer, (b) granular layer, (c) prickle layer, 
and (d) stratum corneum. 

(A) abed 

(B) dbac 

(C) deb a 

(D) cabd 

(E) cadb 



20. 



21. 



A 12-year-old boy has multiple skin lesions that 
are diagnosed as von Recklinghausen's syn- 
drome (NF 1). What is TRUE of this condition? 

(A) It does not show other malignant lesions. 

(B) It is autosomal recessive. 

(C) It is associated with optic nerve 
gliomas. 

(D) It is characterized by AV malformation. 

(E) It is assocated with dermoid. 

A 35-year-old White male previously diag- 
nosed with basal cell nevus syndrome (Gorlin's 
syndrome) presents with a new lesion for treat- 
ment. Apart from mulitple basal cell lesions 
other features of this disorder may include: 

(A) The disorder is genetically determined 
and transmitted as an autosomal 
dominant. 

(B) Rib abnormalities such as splayed or 
bifid ribs. 

(C) Skin ribs on the palms and soles. 

(D) A benign clinical course before puberty. 

(E) Normal mental development. 

A 35-year-old professional dancer presents 
with a well-defined, tense, smooth mass in the 
upper outer quadrant of the left breast. She 
states that the mass becomes larger just before 
onset of her periods. Aspiration yields a clear 
yellow fluid and the mass disappears. The most 
likely diagnosis is: 

(A) Fibroadenoma is a cyst. 

(B) Fibrocystic disease of the breast. 

(C) Carcinoma in a cyst. 

(D) Lipoma. 

(E) Galactocele. 



36 



2: Skin, Soft Tissue, and Breast 



11. An 18-year-old presents with a well- 
circumscribed 2-cm mass in her right breast. 
The mass is painless and has a rubbery consis- 
tency and discrete borders. It appears to move 
freely through the breast tissue. What is the 
likeliest diagnosis? 

(A) Carcinoma 

(B) Cyst 

(C) Fibroadenoma 

(D) Cystosarcoma phyllodes 

(E) Intramammary lymph node 

23. Galactorrhea, a milky discharge from the nipple 
in nonpregnant women, is most likely to be 
associated with which of the following? 

(A) Fibroadenoma 

(B) Tubular adenoma 

(C) Pituitary adenoma 

(D) Hyperparathyroidism 

(E) Breast abscess 

24. A 28-year-old female figure skater presents sev- 
eral weeks after having sustained an injury to 
her left breast. She has a painful mass in the 
upper outer quadrant. Skin retraction is noticed, 
and a hard mass, 3-^ cm in diameter, can easily 
be palpated. What is the most likely diagnosis? 

(A) Infiltrating carcinoma 

(B) Breast abscess 

(C) Hematoma 

(D) Fat necrosis 

(E) Sclerosing adenosis 

25. A 35-year-old patient presents to your office 
with chronic draining subcutaneous periareolar 
abscesses, which have been incised and drained 
many times in the past 5 years but keep recur- 
ring. What is the best treatment of choice? 

(A) Repeat incision and drainage (I and D) 
since the previous procedures were 
inadequate 

(B) Long-term antibiotics 

(C) Major duct excision 

(D) Complete excision of the drainage tract 

(E) Tell the patient there is nothing to do and 
that this will eventually resolve with age 



26. A patient presents 1 month after a benign right 
breast biopsy with a lateral subcutaneous cord 
felt just under the skin and causing pain. The 
etiology of this condition is? 

(A) Fat necrosis 

(B) Infection 

(C) Superficial thrombophlebitis 

(D) Suture granuloma 

(E) Misdiagnosed breast cancer 

27. A 36-year-old woman complains of a 3-month 
history of bloody discharge from the nipple. 
At examination, a small nodule is found, deep 
to the areola. Careful palpation of the nipple- 
areolar complex results in blood arrearing at 
the 3 O'clock position. Mammogram findings 
are normal. What is the likeliest diagnosis? 

(A) Intraductal papilloma 

(B) Breast cyst 

(C) Intraductal carcinoma 

(D) Carcinoma in situ 

(E) Fat necrosis 

28. A 35-year-old premenopausal woman whose 
mother had breast cancer comes into your office 
and has been told that she has fibrocystic breasts. 
On examination she has multiple areas of thick- 
ening but no discrete mass. Of the following 
diagnostic tests, which should be performed? 

(A) Re-examination in 6 months 

(B) Bilateral breast ultrasound 

(C) Thermography 

(D) Bilateral breast magnetic resonance 
imaging (MRI) with gadolinium 

(E) Spot compression views if an area of 
discrete asymmetry or concerning 
calcifications is seen 

29. During a routine screening mammography, a 
62-year-old teacher is informed that she has 
changes on her mammography, and she should 
consult her physician. She can be reassured 
that the findings that indicate a benign condi- 
tion are which of the following? 

(A) Discrete, stellate mass 

(B) Fine, clustered calcifictions 



Questions: 22-34 



37 



(C) Coarse calcifications 

(D) Solid, clearly defined mass with irregular 
edges 

(E) Discrete, nonpalpable mass that has 
enlarged when compared with a mass 
shown on a mammogram taken 1 year 
previously 

30. A 40-year-old lawyer comes into your office after 
seeing some information on the Internet relating 
to breast cancer. Which of the following factors 
has not shown to increase a woman's risk for 
breast cancer? 

(A) Smoking 

(B) Previous history of benign breast 
biopsies 

(C) Atypia seen on pathology from previous 
breast biopsy 

(D) First-degree relative with history of 
breast cancer 

(E) Increasing age 

Questions 31 and 32 

A 53-year-old waitress inquires about the implica- 
tions of positive estrogen receptors (ER+) in an inva- 
sive carcinoma that is excised from her left breast. 

31. She should be informed of what? 

(A) They are more often positive in patients 
under 50 years of age. 

(B) If the receptors are positive, antiestrogen 
therapy is not indicated. 

(C) If the receptors are positive, the prognosis 
is more unfavorable. 

(D) ER and progesterone receptor (PR) status 
should be determined in all cases of 
breast carcinoma. 

(E) ER are usually negative when PR are 
positive. 



32. The patient is postmenopausal. She should be 
informed that which of the following hormonal 
therapy has been shown to be most effective? 

(A) Tamoxifen 

(B) Raloxifene 

(C) Toremifene 

(D) Megace 

(E) Aromotase inhibitors 

33. A 52-year-old undergoes a left modified radical 
mastectomy for a 2-cm breast cancer. She should 
be informed that the factor which has the great- 
est impact on her prognosis is? 

(A) The size of the primary tumor 

(B) The histological type of the carcinoma 

(C) The number of axillary nodes positive 
for metastasis 

(D) Hormonal receptor status of the primary 
tumor 

(E) Positive findings on tests for the presence 
of the BRCA(breast cancer)l gene 

34. A 46-year-old woman presents with a mam- 
mogram that shows a 1-cm cluster of fine 
calcification in the right breast. Following mam- 
mographic wire localization, the lesion is 
excised and the pathology reported as ductal 
carcinoma in situ (DCIS) with comedo features 
and free margins. What advice should be given 
to the patient? 

(A) If untreated, about 30% of such lesions 
become invasive over a 10-year period. 

(B) Comedo DCIS is less aggressive than 
noncomedo DCIS. 

(C) Bilateral mastectomy and radiotherapy 
are the preferred treatments. 

(D) Axillary node dissection is always 
indicated. 

(E) Total mastectomy carries a high (50%) 
risk of carcinoma recurrence. 



38 



2: Skin, Soft Tissue, and Breast 



35. 



36. 



37. 



38. 



A 43-year-old premenopausal patient has a 
biopsy showing focal lobular carcinoma in situ 
(LCIS) in the area of calcification. With regard 
to the LCIS, you should tell the patient which 
of the following? 



(A) 
(B) 

(C) 



(D) 



(E) 



She needs a simple mastectomy. 

She must be placed on tamoxifen and 

chemotherapy. 

This is a premalignant lesion, and she 

requires additional lumpectomy and 

radiotherapy. 

She is at increased risk of breast cancer, 

and she should just be observed closely. 

LCIS often presents with a mass. 



A partially blind 65-year-old mother presents 
with a slight change in color of the areola of her 
left breast. An eczematous rash of the left areola 
has persisted for the last 3 months. Biopsy of the 
nipple reveals Paget's disease. In Paget's disease 
of the nipple which of the following is TRUE? 

(A) Carcinoma of the breast is rarely found. 

(B) Surgical therapy often fails to cure 
Paget's disease. 

(C) The diagnosis should be made by nipple 
biopsy when suspected. 

(D) The underlying carcinoma when present 
is very large. 

(E) Paget's disease of the bone is commonly 
encountered. 

A 39-year-old patient presents to your office 
with a left 3.5-cm breast tumor, which on core 
needle biopsy, is shown to be an invasive ductal 
cancer. On left axillary examination, she has a 
hard nonfixed lymph node. A biopsy of a left 
supraclavicular node is positive for malig- 
nancy. Her stage is currently classified as? 

(A) IIIC 

(B) IV 

(C) IIB 

(D) IIIB 

(E) IIA 

A 40-year-old patient is diagnosed with a local- 
ized 1-cm infiltrating ductal cancer after a needle 
core biopsy of the lesion. She is clinical node 



39. 



40. 



41. 



negative; a lumpectomy and sentinel lymph 
node biopsy are performed. The patient devel- 
ops an anaphylactic response during the case. 
Which of the following substances was the 
likely causative agent? 

(A) Fluorescein 

(B) 99 Tc radiolabeled colloid 

(C) Isosulfan blue dye 

(D) Methylene blue dye 

(E) Indigo carmine 

A 65-year-old woman undergoes a lumpectomy 
and sentinel lymph node biopsy and is found to 
have a 5-mm tubular cancer ER and PR positive 
and a negative sentinel lymph node. What adju- 
vant treatment should be recommended? 

(A) Chemotherapy and radiation 

(B) Radiation treatment only 

(C) Hormonal therapy only 

(D) Radiotherapy and hormonal therapy 

(E) Partial breast irradiation 

A 41-year-old patient presents to your office 
with a biopsy proven invasive ductal cancer in 
the upper outer aspect of her left breast, a sus- 
picious palpable left axillary lymph node, and 
diffuse calcifications throughout the rest of the 
breast proven to be DCIS on stereotactic biopsy. 
The best surgical option is: 

(A) Modified radical mastectomy 

(B) Simple mastectomy 

(C) Lumpectomy with sentinel lymph node 
biopsy 

(D) Radical mastectomy 

(E) Total mastectomy with sentinel lymph 
node biopsy 

A premenopausal 44-year-old woman under- 
goes a quadrantectomy and node dissection for 
a 2-cm infiltrating carcinoma of the left breast. 
The margins are clear, and 5 out of 15 lymph 
nodes are involved. ER and PR are positive. 
Recommended adjuvant therapy should include 
which of the following? 

(A) Radiotherapy alone 

(B) Estrogen therapy alone 



Questions: 35-46 



39 



(C) Modified radical mastectomy 

(D) Chemotherapy alone 

(E) Chemotherapy, radiotherapy, and 
tamoxifen 

42. An 18-week pregnant, 35-year-old woman 
presents after undergoing a modified radical 
mastectomy for a 2-cm ductal cancer with one 
out of fifteen positive axillary lymph nodes. 
What should she be informed of regarding 
breast cancer during pregnancy? 

(A) She cannot undergo chemotherapy until 
after she delivers. 

(B) She should have a therapeutic abortion 
in order to proceed with radiotherapy. 

(C) Breast cancer is the most common cancer 
during pregnancy. 

(D) Radiotherapy is indicated. 

(E) Most of these cancers are ER+. 

43. After undergoing modified radical mastectomy 
for cancer of the right breast, a 52-year-old female 
teacher becomes aware that the medial end of 
her scapula becomes prominent in protraction 
movements at the shoulder. She also complains 
of some weakness in complete abduction of the 
same shoulder. What nerve was injured? 

(A) Long thoracic 

(B) Thoracodorsal 

(C) Ulnar 

(D) Median 

(E) Intercostobrachial 

44. A 50-year-old patient has recently undergone a 
mastectomy for a 2.5-cm multicentric breast 
cancer with three positive axillary lymph nodes 
(stage IIB). A metastatic survey is done, and is 
negative, and she receives adjuvant chemother- 
apy. The most common site for distant metas- 
tasis would be: 

(A) Brain 

(B) Bone 



(C) Lung 

(D) Gastrointestinal tract 

(E) Liver 

45. A 45-year-old premenopausal woman undergoes 
a left breast lumpectomy for a 1.5-cm, lymph 
node positive, hormone sensitive invasive breast 
cancer. She receives chemotherapy, radiotherapy, 
and is on tamoxifen. Recommended follow-up 
after therapy should always include: 

(A) Blood tumor markers drawn every 
3-6 months after treatment. 

(B) Routine monitoring of liver function 
tests (LFTs) every 3-6 months after 
treatment. 

(C) Yearly bone scans. 

(D) Routine clinical examination every 
3-6 months for the first 5 years after 
treatment as well as continued yearly 
mammography. 

(E) Yearly breast MRI with gadolinium. 

46. A 43-year-old female requests breast augmen- 
tation surgery. She has no family history of 
breast cancer and her clinical examination fails 
to reveal any evidence of pathology. What 
should she be informed about the procedure? 

(A) In the United States only silicone 
gel-filled and not saline-filled implants 
are performed. 

(B) Breast implants increase the incidence of 
malignancy of the breast. 

(C) The occurrence of subsequent breast 
cancer occurs at a later stage than those 
without implants. 

(D) Saline implants have a more natural 
appearance than silicone gel-filled 
implants. 

(E) Implants in the submuscular plane 
allow better mammographic findings 
than those placed in the subglandular 
position. 



40 



2: Skin, Soft Tissue, and Breast 



47. 



48. 



49. 



50. 



A 56-year-old male patient develops an accen- 
tric hard breast lump over the past few months 
and a biopsy proves this to be breast carcinoma. 
Of all breast cancers, the rate of occurrence in 
males is which of the following? 

(A) <1% 

(B) 4% 

(C) 7% 

(D) 10% 

(E) >10% 

A 25-year-old nonalcoholic man has noticeable 
right gynecomastia since age 20. He is most 
uncomfortable and reluctant to swim or exer- 
cise at a gym for fear of being an object of deri- 
sion. He should be advised to have which of 
the following? 

(A) Right mastectomy 

(B) Observation 

(C) Needle biopsy of the breast 

(D) Endocrine workup and right 
subcutaneous mastectomy 

(E) Testosterone therapy by transdermal 
patch 

A 36-year-old woman presents with a substantial 
unilateral breast enlargement. She had presumed 
that this was normal, but on examination, a large, 
firm tumor is palpated by the attending physi- 
cian. There is early erosion on the skin. A favor- 
able outlook can be anticipated if the lesion is 
which of the following? 

(A) Sarcoma 

(B) Cystosarcoma phyllodes 

(C) Colloid carcinoma 

(D) Infiltrating carcinoma 

(E) Inflammatory carcinoma 

A 55-year-old postmenopausal woman under- 
goes a left axillary lymph node biopsy, which 
turns out to be an adenocarcinoma. Breast 
examination fails to show any abnormality 
and mammography, ultrasound, and metasta- 
tic workups are all negative. The tumor is 
ER+/PR+. The following statements are true 
EXCEPT for which of the following? 



(A) Recurrence and survival results for this 
patient are worse than those identified 
with primary tumor in the breast. 

(B) This is most likely a lesion from the 
larynx or pharynx. 

(C) This is a common site for papillary 
carcinoma of the thyroid to metastasize. 

(D) The treatment should be a left axillary 
dissection followed by chemotherapy 
and radiation therapy. 

(E) A primary breast cancer is only found in 
10-20% of mastectomy specimens. 

DIRECTIONS (Questions 51 through 54): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. Each lettered option 
may be selected once. 

Questions 51 to 54 

(A) Tubular 

(B) Medullary 

(C) Colloid 

(D) Inflammatory carcinoma 

(E) Infiltrating ductal carcinoma 

(F) Infiltrating lobular carcinoma 

(G) DCIS 
(H) LCIS 

(I) Paget's disease 

51. The histology that shows an intense lympho- 
plasmacytic reaction around and within the 
tumor, which is usually poorly differentiated 
with a high mitotic rate. SELECT ONE. 

52. Microscopic examination of this malignancy 
shows large vacuolated cells. SELECT ONE. 

53. Clinical findings of this breast cancer typically 
includes a rash-like erythema, which spreads 
throughout the skin of the breast. SELECT ONE. 

54. This histologic variant is characterized by a 
linear ("indian-file") arrangement of tumor 
cells and a tendency to grow circumferentially 
around ducts and lobules. SELECT ONE. 



Answers and Explanations 



1. (B) Actinic (solar) keratosis is the most common 6. 
premalignant lesion usually seen in older, light- 
complexioned individuals. The incidence of 
degeneration to invasive squamous carcinoma 

is 20-25%. These carcinomas, arising from 
actinic keratosis, metastasize suggesting con- 
servative excision in treating them. 

2. (C) Bowen's disease represents an intraepithe- 
lial squamous cell carcinoma (carcinoma in 7. 
situ) and is seen in older patients. These lesions 

tend to have a long clinical course. Adequate 
excision is the recommended treatment as these 
lesions can become invasive squamous cell car- 8. 

cinomas and metastatasize. 

3. (A) Basal cell carcinoma is the most common 
malignancy in Caucasians. The lesion is cured by 
complete excision and reconstruction (Moh's) 9. 
surgery. 

4. (E) Wound contraction refers to the decrease 
in diameter of an open wound. It commences 
on about the fourth day after injury and con- 
tinues at a relatively rapid rate (1/2-1 mm/d). 
It is maximal in areas where tissue laxity 

exists. Wound contraction should not be con- 10. 

fused with wound contracture where scar for- 
mation over a joint interferes with mobility. 
Experimentally, it less affected by excision of 
tissue from the center of the wound, rather than 
at the periphery. 

5. (D) Following the application of a full-thickness 11. 
graft, contraction at the site of the recipient 

site is maximally inhibited by a full- thickness 
and to a lesser extent by the partial-thickness 
graft. 



(A) The ileostomy should be circular rather than 
square to avoid excessive stenosis of the stoma. 
Wound healing by a square incision results in a 
greater degree of stenosis than by an equivalent 
circular stoma. Failure to close the gap between 
the ileal loop on the abdominal wall may lead to 
subsequent internal herniation. It is critical to 
ensure that the ileal stump is not devascularized. 

(C) In a clean wound, the anticipated infection 
rate should be 1.5-5%, in a contaminated wound, 
15%, and a dirty wound, 30^0%. 

(A) If spillage is substantial or infected tissue 
has entered, the wound is classified as contam- 
inated. Dirty wounds are used for drainage of 
an abscess or debridement of infected tissue. 

(D) In a second-degree burn, the skin appen- 
dages in the dermis are minimally destroyed 
(superficial partial thickness) or more extensively 
destroyed (deep partial thickness). In a third- 
degree(full-thickness) burn, all of the dermis, 
with skin appendages, are destroyed, and the 
lesion extends to the subcutaneous fat layer. 

(D) In calculating burn surface area, the rule of 
"9's" assigns 9% to each upper extremity, 18% 
to each lower extremity, and 9% to the head 
and neck. The trunk and abdomen (36%) is 
divided into four equal parts (9% each). Thus, 
upper trunk anteriorly would be 9%. 

(A) Continue with increased amount of lactated 
Ringer solution. Urine flow should be 0.5-1.0 
mL/kg/h. Patients exposed to inhalation on 
burns, and those admitted following alcoholic 
intoxication require additional fluids. In general, 



41 



42 



2: Skin, Soft Tissue, and Breast 



for second- and third-degree burns, the Parkland 
formula is used to administer 4 mL/kg weight of 
patient x percentage of area of burn. Half of the 
calculated amount is given within 8 hours and 
the remainder during the subsequent 16 hours. 

12. (C) Use cadaver allograft when required. Tan- 
gential excision of the skin (to secure a bleeding 
surface) is done with a guarded dermatome. 
However, because of possible extensive blood 
loss, it should be limited to an area <20% of the 
total body surface area. The presence of bacte- 
ria growth >10 5 organisms/cm 2 or growth of 
/3-hemolytic streptococci should contraindicate 
split-skin-thickness grafting. 

13. (C) It is inherited as a autosomal dominant dis- 
order and noted in nearly 1/5000 births. The 
NF-1 gene encodes a protein neurofibromin 
that plays a role in neuroectodermal differen- 
tiation and cardiac development. 

14. (C) Most melanoma arise from nondysplastic 
nevi. Congenital nevocellular nevi found in 
about 1/100 births have a 3-5% lifetime risk of 
undergoing malignant change. Dysplastic (a 
typical) nevi may be familial and predisposed 
to malignancy. Hutchinson freckle occurs mainly 
in older patients. 

15. (A) The surface of a basal cell carcinoma has a 
shiny appearance with telangiectasia. Ulcer for- 
mation may occur; hence, are named rodent ulcer. 
Although treatments with 5 FU, cryosurgery, or 
electrodessication are effective in treatment, sur- 
gical excision offers the best results and ensures 
an accurate diagnosis. 

16. (A) Level II involves papillary layer III between 
papillar and reticular layer, IV the reticular 
layer, and V the subcutaneous fat. The Breslow 
classification utilizes differences in the thick- 
ness of the tumor. 

17. (E) Usually caused by staphylococci and strep- 
tococci. Hydradenitis supperativa is an infec- 
tion of the apocrine glands and surrounding 
subcutaneous tissue and fascia, which most 
commonly involves the axilla, groin, perineum, 
and perianal region. The periumbilical and 



areola region may be involved. In milder cases, 
local hygienic measures and tetracycline may 
be adequate; in more severe cases, wide exci- 
sion is indicated. 

18. (C) The stratum corneum consists mainly of 
dead cells and keratin. 

19. (C) It is inherited as a autosomal dominant dis- 
order and noted in nearly 1 /5,000 births. The 
NF-1 gene encodes a protein neurofibromin 
that plays a role in neuroectodermal differen- 
tiation and cardiac development. 

20. (E) Gorlin's syndrome is genetically determined, 
a disorder of childhood onset. Along with mul- 
tiple basal cell carcinomas, other abnormalities 
include skin ribs on the palms and soles, epithe- 
lial jaw line cysts, rib abnormalities, ectopic cal- 
cifictions in the dura, and mental retardation. 
The disease is transmitted as autosomal domi- 
nant with no sex linkage. Generally the tumors 
have a benign clinical course until after puberty. 

21. (B) Breast cysts are often well demarcated and 
tend to get larger and contain nonbloody fluid, 
which is usually acellular and cytology is rarely 
indicated. Galactoceles present in pregnant and 
nursing women are filled with milky fluid. 

22. (C) Fibroadenomas are most often found in 
teenage girls. They are firm in consistency, 
clearly defined , and very mobile. The typical 
feature on palpation is that they appear to 
move freely through the breast tissue ("breast 
mouse"). 

23. (C) Galactorrhea is fairly common up to old 
age. The discharge may vary in color from 
brown to milky. Hormonal causes are associ- 
ated with elevated prolactin levels or with pitu- 
itary or thyroid disorders. Tranquilizers have 
also been implicated. Simple abscesses do not 
cause galactorrhea. 

24. (D) Fat necrosis is a rare condition that follows 
injury. Diagnosis may be difficult, and mam- 
mography and exicision may be necessary to 
rule out carcinoma. Sclerosing adenosis is a 
variant of fibrocystic disease and may present 



/Answers: 12-36 



43 



with a hard mass. In a hematoma, evidence of 
resolving ecchymosis may be present. 

25. (D) Mammary fistula also known as Zuska's 
disease is felt to represent dilated laciferous 
ducts, which develop chronic inflammation 
presenting with these periareolar draining 
sinuses. They will continue to recur until com- 
pletely excised, which may require removal of 
the terminal duct into the nipple, leaving the 
wound open. 

26. (C) This entity is known as Mondor's disease 
and is caused by superficial thrombophlebitis 
usually induced by surgery, infection, or trauma. 
The process is self-limiting and resolves within 
2-10 weeks. 

27. (A) Intraductal papilloma is the most common 
cause of bloody discharge from the nipple. The 
lesion is treated by excision and is benign in 
most cases. Cancer is present in 5% of cases. 
Preoperative ductography can be used to help 
locate the offending duct . 

28. (D) Patients who present with fibrocystic mas- 
topathy at this age should undergo routine 
screening mammography, either regular film 
or digital, and ultrasound if no obvious benign 
etiology is seen on mammography. Spot com- 
pression mammography is done for any ques- 
tionable abnormality. Routine use of screening 
MRI is not indicated at this time. 

29. (C) Coarse calicifications are usually benign. 
Fine, clustered califications are often milignant 
and require biopsy. Solid tumors of the breast, 
especially those that have increased in size or 
have changed in appearance, are suspicious for 
carcinoma and require biopsy. 

30. (A) Any history of previous breast biopsy, even 
benign, does show an increase risk of breast 
cancer. Atypia, family history, and increasing 
age also increase a woman's risk. Smoking has 
not shown an increase risk for breast cancer. 

31. (D) ER and PR status should be determined in 
all cases of breast carcinoma. Positive ER and 
PR are indicative of an improved outlook and 



likelihood of response with antiestrogen med- 
ication. PR+ do not predict negative ER status. 

32. (E) Recent studies are showing aromatase 
inhibitors to be more beneficial than tamoxifen 
in preventing breast cancer recurrence in post- 
menopausal women. Tamoxifen, raloxifene, 
and toremifene are all selective ER modulators 
(SERMS), which act by competitively blocking 
estrogen binding sites and thus reducing esto- 
gen stimulation of breast tissue. Megace (mege- 
strol acetate) has been used for metastatic 
breast cancer. 

33. (C) The number of positive axillary nodes 
remains one of the best prognostic indicators in 
breast carcinoma. The current American Joint 
Committee on Cancer (AJCC) staging classifi- 
cation now defines patients with 1-3 positive 
nodes (Nl), 4-9 positive nodes (N2), and 10 or 
more positive nodes (N3) due to their different 
prognosis. 

34. (A) DCIS is a noninvasive lesion. Comedo 
DCIS is more aggressive than noncomedo DCIS. 
Axillary disease in uncommon is DCIS, and 
lymph node staging is generally not required. 
Breast conserving procedures can be performed 
as long as extensive or multicentric disease is not 
present. Radiation therapy is generally indicated 
after breast conserving therapy for DCIS. 

35. (D) She is at increased risk for breast cancer and 
should be followed closely. LCIS is usually in 
incidental finding. Although multifocal through- 
out both breasts, it is thought not to be precan- 
cerous itself but rather an indicator of increased 
cancer risk. Therefore, wide resection is not indi- 
cated. Careful examinations, every 6 months and 
yearly mammograms are done to detect inva- 
sive carcinoma at the earliest time. Lifetime 
breast cancer risk is about 30%. 

36. (C) The diagnosis should be made by nipple 
biopsy when suspected. Paget's disease repre- 
sents a ductal carcinoma that has grown along 
the ducts into the nipple /areolar region. The 
lesion often presents with an eczematous rash, 
which does not resolve and can be diagnosed 
with a small incisional biopsy. Typically swollen 



44 



2: Skin, Soft Tissue, and Breast 



vacuolated Paget's cells are found on histolog- 
icl examination. Many cases involve small 
breast cancers, which are missed on clinical 
examination and mammogram. Surgical ther- 
apy is often curative. This is unrelated to 
Paget's disease of the bone. 

37. (A) Ipsilateral supraclavicular lymph node dis- 
ease is stage IIIC in breast cancer. The new 
AJCC staging system includes ipsilateral supr- 
aclavicular nodes as IIIC and not IV. These 
patients require appropriate metastatic workup 
and often get neoadjuvant chemotherapy. 

38. (C) Both methylene blue or isosulfan (lymp- 
hazurin) blue dye can be used for sentinel 
lymph node identification and have been asso- 
ciated with some allergic reactions. Isosulfan 
blue has been associated with rare anaphylac- 
tic reactions in <1% of patients. Methylene blue 
can cause skin necrosis if injected too superfi- 
cially. Fluorenscein and indigo carmine are not 
given in these surgeries. 99 Tc is given for the 
lymphoscintigraphy and gamma probe isola- 
tion of the sentinel node and has no known 
anaphylactic reactions. 

39. (D) Generally patients with small (<1 cm) breast 
cancers, which are pathologically node nega- 
tive, are spared from chemotherapy. Radiation 
and hormonal therapy is indicated. Partial breast 
irradiation can be offered though there is no 
current randomized data to show the best 
modality of treatment (currently an ongoing 
NSABP/RTOG trial). 

40. (A) This patient has a palpable axillary lymph 
node making sentinel node biopsy contraindi- 
cated. The multicentricity of the disease also 
makes the use of sentinel lymph node biopsy 
relatively contraindicated. Radical mastectomies 
are no longer performed unless gross tumor 
invasion into the pectoralis muscle is found. 

41. (E) Current National Institute of Health (NIH) 
consensus conference advises chemotherapy 
for all invasive cancers >1 cm as well as for 
node-positive cancers. Radiotherapy is required 
whenever breast conserving surgery is under- 
taken and tamoxifen should be given for all 



ER+ and/or PR+ invasive tumors whose patients 
are premenopausal. 

42. (C) Breast cancer is the most common cancer 
during pregnancy. It is usually ER-/PR-. Patients 
can undergo chemotherapy (nonmethotrexate 
regimens) starting after the first trimester and 
continue on with the pregnancy. Radiotherapy 
cannot be given during pregnancy, so mastec- 
tomy is often indicated unless the patient is 
toward the end of the pregnancy, and the radio- 
therpy can be given postpartum. 

43. (A) Axillary dissection during modified radical 
mastectomy requires exposing the long tho- 
racic and thoracodorsal nerves. Injury to the 
long thoracic nerve that supplies the serratus 
anterior muscle causes "winging of the scapula". 
The intercostobrachial nerve supplies sensory 
innervation to the skin in the axilla and proxi- 
mal upper extremity. The medial and ulnar 
nerves are outside of the usually axillary dis- 
section field. 

44. (B) Bone metastasis is the most common distant 
metastatic site for breast cancer. They are typi- 
cally osteolytic lesions and can be treated by 
biphosphonates, which inhibit bone deminer- 
alization and have been shown to reduce the 
pathologic fracture frequency and need of 
radiation. 

45. (D) Follow-up after breast cancer treatment is 
very variable. There is no consensus and no 
follow-up test has shown a survival advantage. 
Routine 3-6 month clinical examinations and 
yearly mammography should always be per- 
formed. The use of tumor markers such as a 
CA 15-3 has not shown any proven significant 
value and may lead to unnecessary worry. 

46. (E) There is no evidence that long-term insertion 
of breast implants leads to an increased inci- 
dence of breast cancer or detection of the cancer 
at an inappropriate late stage. Although the use 
of silicone gel implants is still confined by the 
Food and Drug Administration (FDA) to select 
circumstances (e.g., breast reconstruction fol- 
lowing mastectomy), retrospective studies to 
date have failed to demonstrate a significant 



/Answers: 37-54 



45 



increase in the incidence of collagen disease in 
patients who have had a silicone breast implant. 

47. (A) Cancer of the breast in males constitutes 
<1% of total cases. It tends to present at a more 
advanced stage in men than in women, because 

it is often overlooked. It may easily be confused 51. 

with the more commonly occurring condition 
of gynecomastia. Careful clinical radiological 
follow-up studies are indicated. 

48. (D) In general, persistent gynecomastia should 

be evaluated to rule out endocrine abnormalities. 52. 

In most cases, none are found. Subcutaneous 
astectomy is indicated if the patient is self- 
conscious. 

49. (B) Cystosarcoma phyllodes is a tumor that is 53. 
very slow growing and has a good prognosis if 
treated by mastectomy. It is characterized by 

large polygonal cells with abundant cytoplasm 

and lymphoid infiltration. 54. 

50. (D) Occult primary breast cancer is a rare but 
well-known entity. Stage for stage these patients 
have a similar prognosis as other patients with 
node-positive breast cancer. The primary tumor 



is often found in the breast (60-70% of mastec- 
tomy specimens). Either modified radical mas- 
tectomy and chemotherapy or just axillary 
dissection with radiation and chemotherapy are 
accepted treatment choices. 

(B) Medullary tumors have an intense sur- 
rounding lymphoid reaction and though poorly 
differentiated, have a favorable prognosis com- 
pared to other invasive cancers. They tend to be 
hormone receptor negative. 

(I) Paget's disease is characterized by these 
large vacuolated intradermoid cells usually 
arising from a ductal carcinoma that is thought 
to have grown along the duct to the nipple. 

(D) Inflammatory breast cancer is a very aggres- 
sive form of breast cancer characterized by 
intradermal lymphatic spread of tumor. 

(F) Infiltrating lobular cancers have this typical 
linear ("indian-file") arrangement of cells. There 
is a higher incidence of multifocality and bilat- 
erality with lobular cancers. These cancers have 
a greater tendency to be hormone sensitive. 



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CHAPTER 3 



Endocrine, Head, and Neck 

Alan S. Berkower and Prakashchandra M. Rao 



Questions 



DIRECTIONS (Questions 1 through 92): Each of 
the numbered items in this section is followed by 
five answers or by completions of the statement. 
Select the ONE lettered answer that is BEST in 
each case. 

1. An 85-year-old ventilator-dependent male 
was endotracheally intubated 10 days ago. He 
remains unresponsive and is not a candidate 
for early extubation. The intensive care unit 
(ICU) attending elects to perform tracheotomy 
at the bedside. During the procedure, copious 
dark blood is encountered. This is most likely 
due to transection of which of the following: 

(A) Anterior jugular vein 

(B) External jugular vein 

(C) Internal jugular vein 

(D) Middle thyroid vein 

(E) Inferior thyroid vein 

2 . A 43-year-old teacher underwent left parotidec- 
tomy. Upon awakening from surgery paralysis 
of the left lower lip was observed. This com- 
plication was most likely due to injury to which 
of the following: 

(A) Parotid duct 

(B) Facial nerve - temporal branch 

(C) Facial nerve - cervical branch 

(D) Facial nerve - main trunk 

(E) Platysma muscle 



3. A 70-year-old male complains of progressive 
weight loss and hoarseness. Ear, nose, and 
throat (ENT) evaluation reveals right vocal cord 
paralysis and several right neck masses, which 
fine needle aspiration reveals to be squamous 
cell carcinoma. The patient undergoes right 
hemilaryngectomy and right radical neck dis- 
section. Postoperatively, right hemidiaphragm 
paralysis is noted. This is due to injury of which 
of the following: 

(A) Vagus nerve 

(B) Brachial plexus 

(C) Cervical plexus 

(D) Spinal accessory nerve 

(E) Phrenic nerve 

4. A 65-year-old woman complains of severe, 
acute onset left temporal headache and changes 
in left eye vision. She presents to her physician 
with sweating, malaise, and temperature of 
99°F. Medical evaluation reveals: 

(A) Myocardial infarction (MI) 

(B) Pneumonia 

(C) Diabetes 

(D) Cerebral vascular accident 

(E) Temporal arteritis 



47 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



48 



3: Endocrine, Head, and Neck 



5. Tracheotomy is performed uneventfully in a 
79-year-old ventilator-dependent encephalo- 
pathy male. After several spontaneous breaths, 
however, the patient stops breathing. The anes- 
thesiologist continues to assist the patient's 
breathing for several minutes, after which the 
patient again breathes spontaneously. The most 
likely cause of apnea is: 

(A) A mucus plug blocked the tracheotomy 
tube. 

(B) Bleeding in the trachea. 

(C) Preoperative respiration was driven by 
hypoxia. 

(D) The patient was allergic to Latex. 

(E) Surgery created a tracheoesophageal 
fistula. 

6. While conversing with admirers at a postcon- 
cert cocktail party, a trumpet player complains 
of acute onset intermittent hoarseness and non- 
productive cough. Subsequent medical evalu- 
ation reveals: 

(A) MI 

(B) Vocal cord paralysis 

(C) Pneumonia 

(D) Vocal cord polyp 

(E) Supraglottic prolapse 

7. While lecturing to her advanced psychology 
students, a 55-year-old college professor com- 
plains of acute onset strained, raspy fluctuat- 
ing voice, forcing her to discontinue her 
lecture and seek urgent ear, nose, and throat 
(ENT) evaluation. Which diagnosis is most 
likely: 

(A) Vocal cord paralysis 

(B) Vocal cord hematoma 

(C) Vocal cord polyp 

(D) Vocal cord spasm 

(E) Vocal cord cancer 

8. A 16-year-old high school wrestler complains 
of difficulty breathing after being held in a tight 
choke hold. He is rushed to the nearest emer- 
gency room, where the ENT consultant per- 
forms a fiberoptic laryngoscopy. Most likely 
finding is: 



9. 



10. 



(A) Unilateral vocal cord paralysis 

(B) Thyroid cartilage fracture 

(C) Thyroid gland bleeding 

(D) Parathyroid gland bleeding 

(E) Laryngeal tumor 

A 60-year-old veteran with a 40-pack year 
smoking history underwent supraglottic laryn- 
gectomy and right radical neck dissection for 
laryngeal squamous cell cancer. Postoperatively, 
he complained of difficulty swallowing. The 
most likely cause of his symptom was which of 
the following: 

(A) Recurrent cancer 

(B) Recurrent laryngeal nerve injury 

(C) Superior laryngeal nerve injury 

(D) Sternocleidomastoid muscle injury 

(E) Brain metastasis 

A 3-year-old child presented to the emergency 
room with thin, gray pus dripping from her 
left nostril. Her foster mother stated that the 
child "always had a cold" for as long as she 
knew her during the past year. Prior treatment 
with oral antibiotics failed to relieve the symp- 
toms. What was the most likely source of the 
chronic discharge? 

(A) Sinusitis 

(B) Tumor 

(C) Foreign body 

(D) Polyp 

(E) Trauma 

While shaving, a 45-year-old teacher notices a 
marble-sized mass beneath his left ear. The 
mass is eventually excised, revealing which of 
the following benign parotid gland lesions? 

(A) Glandular hypertrophy, secondary to 
vitamin A deficiency 

(B) Cystic dilation 

(C) Mikulicz's disease 

(D) Pleomorphic adenoma 

(E) Papillary cystadenoma (Warthin's tumor) 



12. Following a vacation in Florida, a 43-year- 
old man notes shortness of breath. He is a 



11. 



Questions: 5-17 



49 



nonsmoker. His wife points out that his face 
has become slightly swollen. On examination, 
his blood pressure is normal. His pupils are 
equal and respond to light. Dilated veins are 
noted around the shoulders, upper chest, and 
face. An x-ray of the chest reveals an opacity in 
the superior mediastinum. What is the most 
likely diagnosis? 

(A) Thymoma 

(B) Neurogenic tumor 

(C) Lymphoma 

(D) Teratodermoid tumor 

(E) Pheochromocytoma 

13. A 64-year-old assistant hair stylist undergoes a 
vaginal hysterectomy under spinal anesthesia. 
Bleeding occurs when an attempt is made to 
separate and exclude the right ureter from the 
operating field. After a short interval, respira- 
tory arrest occurs and intubation must be 
instituted. What is the most likely cause of res- 
piratory arrest during this procedure under 
spinal anesthesia? 

(A) Paralysis of the intercostal muscle 

(B) Paralysis of the diaphragm (phrenic 
nerves) 

(C) Centrally induced mechanism secondary 
to decreased cardiac output 

(D) Diffusion of anesthetic to the level of the 
pons 

(E) Diffusion of anesthetic to the level of the 
medulla 

14. In the evaluation of a 64-year-old woman 
with fluctuating neurological signs of ptosis, 
eleventh and twelfth cranial nerve palsy, and 
generalized extremity weakness are noted. 
Edrophonium (Tensilon) given intravenously 
results in clinical improvement. A computed 
tomography (CT) scan shows a lesion in the 
anterior mediastinum, and a biopsy confirms 
the presence of a thymoma. She should undergo 
which of the following? 

(A) High-dose steroid administration 

(B) Irradiation of the anterior mediastinum 



(C) Calcium administration 

(D) Thymectomy 

(E) Pneumococcal vaccination 

15. A 54-year-old construction worker has smoked 
two packs of cigarettes daily for the past 25 
years. He notes swelling in his upper extremity 
and face, along with dilated veins in this 
region. A computerized tomography (CT) scan 
and venogram of the neck are performed. What 
is the most likely cause of the obstruction? 

(A) Aortic aneurysm 

(B) Metastasis 

(C) Bronchogenic carcinoma 

(D) Chronic fibrosing mediastinitis 

(E) Granulomatous disease 

16. During a routine chest x-ray offered by a 
department store to all its employees, a 42- 
year-old business manager is found to have a 
1.5-cm nodule in the upper lobe of the lung 
with a central core of calcium. He has no symp- 
toms. The management of this lesion should 
involve which of the following? 

(A) Transbronchial biopsy 

(B) Percutaneous needle biopsy 

(C) Thoracotomy 

(D) Periodic x-ray, follow-up evaluation 

(E) Mediastinoscopy 

17. A 54-year-old manager of a bank is noted to 
have a solitary 1.5-cm nodule on a routine chest 
x-ray. He is asymptomatic. The most suggestive 
feature of malignancy would be the finding of 
which of the following? 

(A) A lesion in the lingula lobe 

(B) Central calcification 

(C) A laminated calcium pattern 

(D) Indistinct margins 

(E) A lesion in the left lobe 



50 



3: Endocrine, Head, and Neck 



18. An asymptomatic 56-year-old man is found on 
routine chest x-ray to have a 2-cm nodule-cen- 
tral tumor in the upper lobe of the right lung. 
The lesion is not calcified. No previous x-rays 
exist. What is the most appropriate initial step 
toward making a diagnosis? 



(A) Fiberoptic bronchoscopy 


(A) 


(B) Bone scan 


(B) 


(C) Thoracotomy 


(C) 


(D) Observation at follow-up examination 




in 6 months 


(D) 


(E) Mediastinoscopy 


(E) 



19. At the age of 46, an accountant has developed 
hoarseness due to an inoperable cancer of the 
left upper lung lobe. He has smoked heavily 
since the age of 14. Which of the following fea- 
tures of cancer of the lung indicates distant 
spread? 

(A) Hypercalcemia 

(B) Cushing-like syndrome 

(C) Gynecomastia 

(D) Syndrome of inappropriate secretion of 
antidiuretic hormone (SIADH) 

(E) Brachial plexus lesion (Pancoast's 
syndrome) 

20. Surgery is indicated in the initial management 
of lung cancer in the presence of which of the 
following? 

(A) Hypercalcemia 

(B) Vocal cord paralysis 

(C) Superior vena cava syndrome 

(D) Small-cell anaplastic carcinoma 

(E) Chest wall and anterior abdominal wall 
metastasis 

21. Pneumonectomy for carcinoma of the lung is 
contraindicated with which of the following? 

(A) Total atelectasis of the involved lung 

(B) PC0 2 over 60 mm Hg 

(C) Cardiac index (CI) of 3 L/min 

(D) PO 2 of80mmHg 

(E) Maximal breathing capacity of 75% of 
predicted value 



22 . After undergoing a percutaneous needle biopsy 
a 49-year-old electrical engineer is found to have 
small-cell carcinoma. The chest x-ray shows a 
lesion in the peripheral part of the right middle 
lobe. The patient should be advised to undergo 
which of the following? 

Right lobectomy 

Right pneumonectomy 

Excision of lesion and postoperative 

radiotherapy 

Combination chemotherapy 

Radiotherapy 

23. While walking to the train station from college, 
a sophomore is accosted and stabbed in the 
chest immediately above the second rib. On 
admission to the hospital, he is bleeding from 
the wound and the blade of the knife is pro- 
truding from the skin. A chest x-ray reveals 
that the knife is at the level of the inferior 
margin of the fourth thoracic vertebra. The 
patient has a blood pressure of 100/60 mm Hg. 
Which structure is the most likely cause of 
bleeding? 

(A) Arch of the aorta 

(B) Left ventricle 

(C) Hemizygous vein 

(D) Vertebral artery 

(E) Right subclavian artery 

24. Four years previously, a 56-year-old fisherman 
underwent thyroidectomy for cancer of the thy- 
roid gland. He is now noted to have a single 
4-cm lesion in the upper lobe of the left lung. 
There is no other evidence of disease, and he is 
in excellent health. Endobronchial biopsy con- 
firms that the lesion is malignant but the organ 
of origin cannot be determined. What should 
he be given? 

(A) Radiotherapy 

(B) Combination chemotherapy 

(C) Attempted curative lung resection 

(D) Exploration of the neck for thyroid 
recurrence 

(E) Androgen therapy 



Questions: 18-30 



51 



25. A 72-year-old retired miner complains of pro- 
gressive dyspnea, chest pain, and a 20-lb 
weight loss. He is a nonsmoker. Examination 
reveals clubbing of the fingers. CT scan shows 
a pleural effusion and nodular, irregular thick- 
ening of the right lung and involvement of the 
celiac lymph nodes. Cytology repeated on sev- 
eral occasions, is not helpful. Which test will 
most likely establish the diagnosis? 

(A) Laparoscopy 

(B) Bronchoscopy 

(C) Open pleural biopsy 

(D) Repeat cytology 

(E) Gastroscopy 

26. A 28-year-old bank employee undergoes inves- 
tigation for infertility that revealed oligosper- 
mia. On further inquiry, it is found that he has 
suffered from repeated bouts of coughing since 
childhood and episodes of recurrent pancre- 
atitis. Clubbing of the fingers is evident. Which 
test is most likely to reveal the cause of his 
chronic lung disease? 



27. 



(A) 


Chest x-ray 


(B) 


X-ray of the humerus 


(C) 


Sweat chloride elevated to over 




80 mEq/L 


(D) 


Sweat chloride reduced to less than 




50 mEq/L 


(E) 


Aspergillus in the sputum 



A 58-year-old male factory worker scheduled 
to undergo a left inguinal hernia repair is noted 
to have a severe chronic cough. Further pul- 
monary function tests revealed reduction of 
forced expiratory volume in 1 second (FEV 1 ) 
and reduction of FEVj/FVC (forced vital capac- 
ity) ratio associated with emphysema. Before 
rescheduling surgery, which of the following 
would improve residual function? 

(A) Trial of ipratropium bromide 
bronchodilator therapy 

(B) Cromolyn 

(C) Cough suppressants 

(D) Bilateral carotid body resection 

(E) Intermittent positive-pressure breathing 
(IPPB) 



28. The chest x-ray of a 62-year-old woman who 
complains of weakness, dyspnea, and hemop- 
tysis shows multiple nodules in the right lung. 
She states that the dyspnea is worse in the 
supine position (platypnea) and improves on 
sitting up. On examination, the physician notes 
multiple hemorrhagic telangiectasia in the 
mouth and in the skin of the upper chest wall. 
There is a mild increase in the erythrocyte 
count, and the P0 2 is 90. An angiogram shows 
multiple pulmonary arteriovenous (AV) fistula 
in both lungs. What should be the next step in 
treatment? 

(A) Needle biopsy of lesion 

(B) Irradiation 

(C) Therapeutic embolization 

(D) Endobronchial biopsy 

(E) Sympathomimetic inhalation therapy 

29. A 32-year-old male janitor complains of a 
swollen face during the past week. A CT scan 
reveals an expanding hematoma in the superior 
mediastinum. Mediastinal tamponade is most 
likely to manifest as which of the following? 

(A) Hypertension 

(B) Increased pulse pressure during 
inspiration 

(C) Paresis of the right arm 

(D) Venous congestion in the upper extremity 

(E) Hyperhidrosis 

30. After returning from vacation, a 67-year-old 
retired judge is admitted to the emergency 
department with severe dyspnea. On exami- 
nation, an inspiratory stridor, ecchymosis in 
his neck, and swelling of soft tissue and veins 
in his face and upper extremity veins are evi- 
dent. The CT scan shows an expanding supe- 
rior mediastinal hematoma. What is the most 
common source of mediastinal hemorrhage? 

(A) Parotid gland surgery 

(B) Trauma 

(C) Dissecting thoracic aneurysm 

(D) Mediastinal tumor 

(E) Hemorrhagic diathesis 



52 



3: Endocrine, Head, and Neck 



31. 



32. 



A 42-year-old man known to have Marfan's 
syndrome is admitted to the emergency depart- 
ment with severe chest pain radiating to the 
back. His blood pressure is 190/130 mm Hg. An 
electrocardiogram (ECG) shows no evidence of 
myocardial infarction. A type I (ascending aorta) 
dissecting aneurysm is detected on angiogra- 
phy. What should he undergo? 

(A) Percutaneous transluminal coronary 
angioplasty (PTCA) 

(B) Nitroprusside and attempted resection 
of the ascending aorta 

(C) Intra-aortic balloon pumping (IABP) 

(D) Immediate thoracotomy 

(E) Steroid administration 

In interpreting a follow-up x-ray to exclude 
metastatic disease in an elderly man with pro- 
static cancer, the radiologist reports sclerotic 
metastasis to all floating rib(s). Floating rib refers 
to ribs: 

(A) 1 

(B) 2 

(C) 3-7 

(D) 8-10 

(E) 11 and 12 



Questions 33 and 34 

A 36-year-old man is crossing a bridge when he is 
suddenly swept by a torrent into the river. After 
rescue and resuscitation, he is admitted to the ICU 
of the local hospital with adult respiratory distress 
syndrome (ARDS). 

33. Which of the following associated features 
would suggest a diagnosis of ARDS? 

(A) High lung compliance 

(B) Activation of surfactant 

(C) Consolidation confined to the lingula 

(D) Interstitial edema with normal 
pulmonary capillary wedge pressure 
(PCWP) 

(E) Hypoxia responding rapidly to oxygen 
therapy 



34. Which is one of the most important principles 
of treatment of ARDS? 

(A) Steroid use 

(B) Avoidance of positive end-expiratory 
pressure (PEEP) 

(C) Tracheobronchial toilet 

(D) Use of large amount of fluids 

(E) Early and vigorous use of PEEP and 
highest Fi0 2 



35. 



On his return from a 3-year visit to India, a 
United Nations research worker complains of 
night sweats, cough, weight loss, and tired- 
ness. An x-ray shows an apical radiopaque 
lesion (Fig. 3-1). Several enlarged glands are 
palpable in the posterior triangle of the neck. 
The next step toward establishing the diagno- 
sis should involve which of the following? 






Figure 3-1. 

Cavity lesion of the right upper lobe. 



(A) Determination of antitrypsin 3 level 

(B) Kveim skin test 

(C) Examination of sputum for cytology 

(D) Thoracotomy and open-lung biopsy 

(E) Sputum culture for mycobacterium 



Questions: 31-41 



53 



36. A student with known human immunodefi- 
ciency syndrome (HIV) infection has lost 6 lb in 
weight and his sedimentation rate is increased 
to 40. He has no other symptoms. The Mantoux 
(tuberculin) test results show a change of 7 mm 
(positive), and x-ray findings reveal a small 
lesion in the apex of the right lobe of the lung. 
How should this patient be managed? 

(A) Hospitalized in a public ward 

(B) Hospitalized in an isolated hospital room 

(C) Treated as an outpatient with triple 
antituberculous drug therapy for 2 weeks 

(D) Treated as an outpatient with multiple 
antituberculous drug therapy for 

2 months and then appropriate 
antituberculous drugs for 4 more months 

(E) Observed and should undergo repeat 
skin test after 8 weeks 

37. A 12-year-old girl with leukemia develops a 
lower respiratory tract infection with hemopt- 
ysis that is shown to be due to right-sided 
bronchiectasis. In addition to treatment for the 
underlying leukemia, the patient should receive 
which of the following? 

(A) Undergo right pneumonectomy 

(B) Receive selective antibiotics, 
physiotherapy, and bronchodilator 
therapy 

(C) Undergo tracheostomy 

(D) Have cough-suppressant medication 

(E) Undergo weekly suction by endotracheal 
intubation 

38. An 18-year-old man develops a severe cough 
with productive sputum due to Psendomonas 
aeruginosa. He has had similar episodes in the 
past, and previous studies revealed bronchiec- 
tasis. Which of the following will help eluci- 
date the most likely underlying cause of 
bronchiectasis? 

(A) Small-intestinal obstruction successfully 
treated at birth 

(B) Low concentration of deoxyribonucleic 
acid (DNA) in the bronchial sputum 



(C) Mycobacterium culture from sputum 

(D) Fungus grown from sputum 

(E) Immunodeficiency studies 

39. After suffering an episode of hemoptysis, a 
14-year-old boy is found, on chest x-ray, to have 
a well-circumscribed mass that contains both 
fluid and air. Surgical excision is carried out, 
and a localized mass adjacent to the carina is 
excised. What is the most likely diagnosis? 

(A) Tuberculosis 

(B) Bronchogenic carcinoma 

(C) Bronchogenic cyst 

(D) Chronic obstructive pulmonary disease 
(COPD) 

(E) AV fistula 

40. Following thoracotomy, in a 20-year-old man a 
lesion is detected in the right lower lung lobe 
and is found to be nonfunctioning lung tissue 
that is served by vessels separate from those of 
the adjacent lung tissue. What is the most likely 
diagnosis? 

(A) Mesothelioma 

(B) Hiatal hernia 

(C) Glomus tumor 

(D) Bronchopulmonary sequestration 

(E) Cystic hygroma 

41. A 64-year-old man complains of pain in the 
lower chest. A CT scan confirms the presence of 
a tumor of the lung at T10 level to the left of the 
midline and invading the surrounding left 
lung base. Because of the structure most likely 
involved and penetrating the diaphragm at this 
level, what could be associated? 

(A) Hoarseness 

(B) Latissimus dorsi palsy 

(C) Budd-Chiari syndrome (hepatic venous 
outlet obstruction) 

(D) Dysphagia 

(E) Tracheobronchial fistula 



54 



3: Endocrine, Head, and Neck 



42. An 8-year-old girl with a prominent chest wall 
deformity that pushes the sternum inward (i.e., 
in a posterior direction) is asymptomatic, and 
she participates fully in athletic activities at 
school. Surgical correction is recommended. 
What is the most likely cause of the deformity? 

(A) Funnel chest (pectus excavatum) 

(B) Pectus carinatum (protrusion at the 
sternum) 

(C) Flail chest 

(D) Cystic hygroma 

(E) Rickets 

43. After suffering a respiratory tract infection, a 
64-year-old female biochemist develops chronic 
lung disease requiring intubation in the ICU for 
an 8-week period. Tracheal stenosis is noted. 
What is the most likely cause of tracheal stenosis? 

(A) Prolonged intubation 

(B) Tuberculosis 

(C) Scleroderma 

(D) Riedel struma (fibrous thyroiditis) 

(E) Achalasia 

44. In evaluating the chest x-ray findings in a 
60-year-old man with pleural effusion, which 
of the following constitutes an abnormal find- 
ing of the pleural cavity? 

(A) Communication between the right and 
left pleural cavities 

(B) Intersection of the twelfth rib posteriorly 

(C) Existence of both a parietal and visceral 
layer in the upper parts 

(D) Existence of different attachments on the 
right and left sides 

(E) Extension of the cavity above the levels 
of the clavicles 

45. Because of his involvement in a motor vehicle 
accident, a 23-year-old football player has a 



chest wall injury. The only abnormal findings 
on clinical and radiologic examination are a 
fracture of the left fifth to seventh ribs and a 
small hemothorax. What should treatment 
include? 

(A) Insertion of an intercostal drain to avoid 
pneumothorax 

(B) Thoracotomy to treat a small hemothorax 
in the left base 

(C) Insertion of a metal plate to fix the 
fracture 

(D) Administration of analgesic medication 

(E) Administration of cortisone to prevent 
callus formation 

46. In chest surgery, which is true regarding a tho- 
racoabdominal incision? 

(A) It should be used for most abdominal 
and thoracic procedures. 

(B) It enters the third to fifth intercostal 
space. 

(C) It causes less postoperative pain. 

(D) It allows division of the costal margin 
and the diaphragm. 

(E) It causes severe denervation of the 
anterior abdominal wall. 

47. A rope used to elevate a heavy metal object 
breaks causing the object to fall on a 55-year-old 
factory worker and producing chest wall injury. 
Which is true of associated sternal injury? 

(A) It occurs most commonly at the work site. 

(B) It usually involves the body of the 
sternum. 

(C) It usually is vertical. 

(D) It involves the hemizygous system. 

(E) It causes miosis of the pupil owing to 
sympathetic injury. 



Questions: 42-52 



55 



48. 



49. 



50. 



After undergoing an emergency operation for 
dehiscence of a colon suture line, a 62-year- 
old patient requires endotracheal intubation. 
Following prolonged intubation, it is noted that 
she has tracheal stenosis. What is the most 
appropriate treatment? 



(A) 
(B) 
(C) 
(D) 



(E) 



Administration of steroids 

Resection of segment of tracheal stenosis 

Irradiation 

Treatment with an intrathoracic 

underwater drain if a tracheoesophageal 

fistula is present 

Dilatation of the stenotic area 



A 22-year-old student is scheduled to under 
go parathyroidectomy for hyperparathryoi- 
dism associated with familial multiglandular 
syndrome. His sister developed peptic ulcer 
disease secondary to a Zollinger-Ellison (hyper- 
gastrinemia) tumor of the pancreas. On exami- 
nation, a swelling was noted over the posterior 
aspect of the patient's fifth rib. What is the most 
likely finding? 



(A) 
(B) 



(C) 
(D) 

(E) 



Metastasis from a parathyroid carcinoma 

Osteitis fibrosa cystica (brown tumor) 

and subperiosteal resorption of the 

phalanges 

Dermoid cyst 

Eosinophilic granuloma 

Chondroma 



51. 



After suffering a severe bout of pneumonia, a 
46-year-old renal transplantation patient devel- 
ops a lung abscess. She has been receiving 
immunosuppression therapy since her last 
kidney transplantation 3 years ago. What is the 
most appropriate treatment? 

(A) Needle aspiration 

(B) Urgent thoracotomy 

(C) Antituberculous therapy 

(D) Antibiotics and vigorous attempts to 
obtain bronchial drainage 

(E) Insertion of an intercostal pleural drain 

An 18-year-old girl developed a neck mass 
anterior to the right sternum mastoid muscle 



following a upper respiratory tract infection 
(URTI). What is most characteristic of branchial 
cleft cysts? 

(A) They usually appear in the axilla. 

(B) They may become infected after an 
URTI. 

(C) They may be traced to the stomach. 

(D) They arise from endodermal tissue. 

(E) They frequently cause brachial plexus 
lesions. 

52. A 9-year-old boy complains of a swelling on the 
left side of his neck in the supraclavicular 
region. The swelling is translucent; a diagnosis 
of cystic hygroma (Fig. 3-2) is established. 
What is true of cystic hygroma? 




Figure 3-2. 

Left cervical cystic hygroma in a 2-day-old baby. (Reproduced, with 
permission, from Brunicardi FC et al.: Schwartz's Principles of 
Surgery, 8th ed. 1476. McGraw-Hill, 2005.) 



(A) It arises from sweat glands in the neck. 

(B) It is usually an anterior midline structure. 

(C) It may occur in the mediastinum. 

(D) Its lesions are usually easy to enucleate. 

(E) It is premalignant. 



56 



3: Endocrine, Head, and Neck 



53. A 48-year-old woman presents with a 6-month 
history of intermittent cranial nerve palsy that 
has become progressively worse in the past 
2 weeks. On examination, ptosis and diplopia 
are evident. Her condition shows a favorable 
response to the anticholinesterase inhibitory 
drug prostigmin (neostigmine). What is the 
most likely diagnosis? 

(A) Cerebral palsy 

(B) Pineal gland tumor 

(C) Adenoma of the pituitary 

(D) Myasthenia gravis 

(E) Tetany 

54. Squamous cell carcinoma of the lip is least 
likely to develop in which of the following? 

(A) Scandinavian fisherman 

(B) Redheaded pornographic actress with a 
gorgeous year-round tan 

(C) Man from Lohatchie, AL, who smokes a 
clay pipe 

(D) Brunette secretary who constantly 
drinks tea 

(E) Mentally defective man who smokes 

40 cigarettes a day and keeps the butt in 
his mouth 

55. A 43-year-old male tennis champion develops 
cancer of the lip. What is true of this condition? 

(A) It involves the upper lip in 90% of 
patients. 

(B) It is more common at the lateral 
commissure than in the middle. 

(C) It usually occurs beyond the vermilion 
border. 

(D) It results in cure in about 60% of cases. 

(E) It requires radical neck dissection. 

56. A 58-year-old fisherman has been heavily 
exposed to the sun for more than 30 years. He 
develops a thickened, scaly lesion extending 
over two-thirds of the lower lip. There is no 
ulceration. Histology reveals hyperkeratosis. 
What should he undergo? 



(A) Steroid ointment application three times 
daily 

(B) Antihistaminic medications 

(C) Lip stripping and resurfacing with 
mucosal advancement 

(D) Radical neck dissection 

(E) Observation and biopsy of any new 
ulcers 

57. A 24-year-old computer technician notes a pro- 
gressive increase in the size of his left jaw. After 
x-rays are taken and a biopsy is done, a diag- 
nosis of ameloblastoma is established. What 
should be the next step in management? 

(A) Radiotherapy 

(B) Laser beam therapy 

(C) Curettage and bone graft 

(D) Excision of lesions with 1-2 cm of normal 
mandible 

(E) Mandibulectomy with bilateral radical 
neck dissection 

58. A 62-year-old man undergoes excision of a 
cylindroma of the submandibular gland. He is 
most likely to have an injury to which of the 
following? 

(A) Maxillary branch of the trigeminal nerve 

(B) Lingual nerve 

(C) Vagus nerve 

(D) Floor of the maxilla 

(E) Frontozygomatic branch of the facial 
nerve 

59. A 62-year-old alcoholic presents with an 
indurated ulcer, 1.5 cm in length, in the left 
lateral aspect of her tongue (not fixed to the 
alveolar ridge). There are no clinically abnor- 
mal glands palpable in the neck, and a biopsy 
of the tongue lesion reveals squamous cell car- 
cinoma (Fig. 3-3). What should she undergo? 



Questions: 53-63 



57 




62. The prognosis for squamous carcinoma of the 
floor of the mouth is adversely affected by 
which of the following (Fig. 3-4)? 



Figure 3-3. 

Oral tongue squamous cell carcinoma, (Reproduced, with permis- 
sion, from Brunicardi FC et al.: Schwartz's Principles of Surgery, 8th 
ed. 520. McGraw-Hill, 2005.) 



(A) Chemotherapy 

(B) Local excision of the ulcer 

(C) Wide excision and left radical neck dis- 
section 

(D) Antibiotic therapy and should be 
encouraged to stop smoking 

(E) Wide excision of ulcer and radiotherapy 

60. A 59-year-old woman has discomfort in the 
posterior part of her tongue. A biopsy confirms 
that the lesion is a carcinoma. What is true in 
carcinoma of the posterior third of the tongue? 

(A) Lymphoid tissue is absent. 

(B) Lymph gland spread is often 
encountered. 

(C) There is an excellent prognosis. 

(D) The tissue is well differentiated. 

(E) The recurrent laryngeal nerve is 
infiltrated. 

61. Adenocarcinoma is the predominant malignant 
lesion in which of the following? 

(A) Hard palate 

(B) Lip 

(C) Anterior two-thirds of the tongue 

(D) Larynx 

(E) Esophagus 




Figure 3-4. 

Composite resection specimen of a T4 floor of mouth squamous cell 
carcinoma. (Reproduced, with permission, from Brunicardi FC et al.: 
Schwartz's Principles of Surgery, 8th ed. 522. McGraw-Hill, 2005.) 



(A) Poor differentiation of tumor 

(B) Nonverrucous carcinoma 

(C) Presence on left side 

(D) No tongue involvement 

(E) Keratosis of the lower lip 

63. A 15-year-old immigrant from China presents 
with a mass in the left supraclavicular region. 
He is asymptomatic. Findings on endoscopy 
and biopsy show that this is a metastatic 
nasopharyngeal tumor. Clinical evidence of 
complications of this tumor would most likely 
be indicated by which of the following? 

(A) Decreased growth hormone levels 

(B) Bitemporal hemianopsia 

(C) Lateral rectus palsy 

(D) Hoarseness 

(E) Deviation of tongue to the side of lesion 



58 



3: Endocrine, Head, and Neck 



64. A 49-year-old man suffering from depression 
attempts suicide by jumping out of the window 
of his third floor apartment. He requires mul- 
tiple operations during a prolonged, compli- 
cated hospital stay. Endotracheal intubation is 
attempted in the ICU but is unsuccessful 
because of tracheal stenosis, which is attrib- 
uted to which of the following? 

(A) Prolonged nasotracheal intubation 

(B) Orotracheal intubation 

(C) Tracheostomy tubes 

(D) High oxygen delivery 

(E) Tracheal infection 

65. A 46-year-old Texan develops a lesion in the 
vestibule of his mouth that on histological 
examination is revealed to be verrucous carci- 
noma of the upper aerodigestive tract. What is 
true of this lesion? 

(A) It is most commonly found on the inside 
of the cheek. 

(B) It is associated with a high metastatic 
rate. 

(C) It is ulcerating in appearance. 

(D) It is best treated with radiation. 

(E) It is more common in the northeastern 
part of the United States. 

66. A 16-year-old boy complains of difficulty in 
breathing through his nose. Endoscopy 
reveals a tumor infiltrating the nasopharynx. 
Histology reports this as a juvenile nasopha- 
ryngeal hemangiofibroma. The boy's anxious 
mother requests information concerning the 
lesion. What should she be told? 

(A) It is a premalignant lesion. 

(B) It usually occurs with laryngeal 
obstruction. 

(C) It is treated with radiotherapy. 

(D) It may proceed to destroy surrounding 
bone. 

(E) It is found equally in teenaged girls and 
boys. 



67. A 52-year-old woman has metastatic epider- 
moid carcinoma on the left side of her neck. 
Complete head and neck workup fails to iden- 
tify the primary tumor. What is the recom- 
mended treatment? 

(A) Close follow-up monitoring until the 
primary tumor is found 

(B) Exploratory laparotomy 

(C) Radical neck dissection 

(D) Full course of radiotherapy to the head 
and neck 

(E) Combination chemotherapy using 
5-fluorouracil (5-FU), vincristine, and 
prednisone 

68. A 58-year-old woman undergoes excision 
biopsy of a tumor in the left posterior triangle 
of her neck. Histology suggests that this is a 
metastatic cancer. What is the most likely site of 
the primary tumor? 

(A) Ovary 

(B) Adrenal gland 

(C) Kidney 

(D) Piriform fossa 

(E) Stomach 

69. Arterial infusions via the external carotid artery 
with methotrexate and 5-FU for head and neck 
carcinoma have shown a 50% response rate. 
Widespread use, however, is limited. Why? 

(A) The internal carotid is inadvertently 
perfused in a large percentage of 
patients. 

(B) Ipsilateral facial slough has occurred in 
3% of patients. 

(C) Blindness occurs in 30% of patients. 

(D) The response is transient, lasting only 
2-3 months. 

(E) There is a prohibitive incidence of 
leukemia. 

70. The classic complete neck dissection for pal- 
pable adenopathy in the posterior triangle of 
the neck includes removal of which of the 
following? 



Questions: 64-76 



59 



71. 



72. 



(A) The transverse process, C2-C4 

(B) The spinal accessory nerve 

(C) Both thyroid lobes 

(D) The trapezius 

(E) The vagus 

A 69-year-old endocrinologist complains of 
progressive facial weakness and loss of taste 
sensation on the right side of her tongue. What 
is the most likely structure affected? 

(A) Lingual nerve 

(B) Middle ear 

(C) Ansa hypoglossi 

(D) Twelfth cranial nerve 

(E) Ninth cranial nerve 

A 22-year-old female student was found to 
have an anterior mediastinal mass on a chest 
x-ray for a persistent cough. What finding is 
true regarding the thymus gland? 



(A) 
(B) 
(C) 
(D) 



(E) 



It is located in the posterior mediastinum. 

It arises from the first branchial arch. 

It controls calcium metabolism. 

It is usually excised through an incision 

along the anterior branch of the 

sternomastoid. 

It results in severe pneumococcal 

infection when removed in adults. 



73. A 29-year-old woman develops difficulty in 
swallowing. Examination reveals acute pharyn- 
gitis. Which organism is most likely to be 
isolated? 

(A) Viral 

(B) Treponema 

(C) Anaerobic 

(D) Staphylococcus aureus 

(E) Escherichia coli 



74. A 43-year-old man suddenly develops odyno- 
phagia. Which organism is most likely to be 
isolated on throat culture? 

(A) Mononucleosis 

(B) S. aureus 

(C) Normal pharyngeal flora 

(D) Group A streptococci 

(E) Diphtheroid 

75. A 72-year-old man presents to the emergency 
department complaining of frequent nose- 
bleeds. What is the most likely site of acute 
epistaxis? 

(A) Turbinate 

(B) Septum 

(C) Maxillary sinus 

(D) Ethmoid sinus 

(E) Sphenoid sinus 

76. A 40-year-old woman is suspected of having 
a carotid body tumor. Which one of the fol- 
lowing is most characteristic of such a tumor 
(Fig. 3-5)? 

(A) They secrete catecholamines. 

(B) They are more common at sea level. 

(C) They arise from structures that respond 
to changes in blood volume. 

(D) They arise from the structures that 
respond to changes in P0 2 . 

(E) They are usually highly malignant. 



60 3: Endocrine, Head, and Neck 



KJ 


■ 






■ 


m 



(A) 


1 day 


(B) 


5 days 


(C) 


7 days 


(D) 


10 days 


(E) 


2 weeks 



Figure 3-5. 

Carotid body tumor. (Reproduced, with permission, from 
Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 819. McGraw-Hill, 2006.) 



77. A 32-year-old pregnant female presents with a 
1-day history of drooping of the right side of 
her face. A thorough history and physical 
examination do not reveal an obvious cause of 
the condition. What is the most likely cause of 
the patient's facial nerve weakness? 

(A) Labyrinthitis 

(B) Parotid tumor 

(C) Lyme disease 

(D) Herpes zoster 

(E) Idiopathic 

78. A 6-year-old girl complains of otalgia, fever, 
and irritability. Physical examination reveals a 
stiff, bulging, red tympanic membrane. Previous 
history of ear infections is denied. Clinical 
response to amoxicillin is maximized on which 
of the following durations? 



79. After undergoing a minor nasal operation, a 
65-year-old man is given a neuroleptic agent. 
Which is the most commonly used neuroleptic? 

(A) Droperidol (inapsine) 

(B) Ketamine 

(C) Fentanyl 

(D) Morphine 

(E) Thiopental (tentothal) be achieved for as 
long as 4-5 minutes 

80. Following surgical resection of a large thyroid 
mass, a patient complains of persistent hoarse- 
ness and a weak voice. What is the most likely 
cause of these symptoms? 

(A) Traumatic intubation 

(B) Prolonged intubation 

(C) Injury to the recurrent laryngeal nerve 

(D) Injury to the superior laryngeal nerve 

(E) Scar tissue extending to the vocal cords 

81. A 9-month-old girl is brought to the physician's 
office for noisy breathing. The child is other- 
wise healthy, and her gestation and delivery 
were uncomplicated. On physical examination, 
mild inspiratory stridor is heard. What is the 
most likely cause of stridor in an infant? 

(A) Bilateral vocal cord paralysis 

(B) Laryngomalacia 

(C) Tracheal stenosis 

(D) Epiglottitis 

(E) Arnold-Chiari malformation 

82. A 32-year-old teacher presents at her physi- 
cian's office complaining of hearing loss in her 
right ear. Physical examination reveals ceru- 
men completely obstructing the ear canal. Ear 
wax removal is recommended using which of 
the following? 

(A) Jet irrigation (Water Pik) 

(B) 3% hydrogen peroxide ear drops 



Questions: 77-89 



61 



(C) Irrigation of the eardrum if perforated 

(D) Aqueous irrigation if a bean is present 

(E) Aqueous irrigation if an insect is present 
far in the ear 

83. A 4-year-old boy requires prolonged intuba- 
tion and nasogastric tube placement in an 
intensive care setting following a closed head 
injury incurred in a car accident. He develops 
recurrent fever but is hemodynamically stable. 
What is the most likely source of sepsis? 

(A) Sinusitis 

(B) Bacterial tracheitis 

(C) Epiglottitis 

(D) Small-bowel necrosis 

(E) Deep vein thrombosis (DVT) 

84. What is the most common site for foreign 
bodies in the head and neck? 

(A) Eye 

(B) Ear 

(C) Nose 

(D) Throat 

(E) Esophagus 

85. A 25-year-old accountant is seen by her family 
practitioner for a sore throat. Her physician 
performs a Streptococcus A direct swab test 
(SADST). What is the specificity of SADST as 
compared to the standard culture method for 
the diagnosis of streptococcal pharyngitis? 

(A) 25% 

(B) 45% 

(C) 65% 

(D) 80% 

(E) 85% 

86. A 33-year-old female noted a discharge from a 
sinus in the overlying skin below the right angle 
of the mandible. She recalls previous episodes of 
fullness and mild pain in this region over the 
past several years. What is the most likely cause? 



(A) Thyroglossal duct cyst 

(B) Branchial cyst 

(C) Teratoma 

(D) Myeloma 

(E) Trauma to the neck 

87. An 85-year-old hypertensive man is evaluated 
in the emergency department for recent onset 
epistaxis. His blood pressure is 150/80 mm Hg, 
and hematocrit is 39%. What is the most likely 
source of bleeding? 

(A) Posterior nasal septum 

(B) Anterior nasal septum 

(C) Inferior turbinate 

(D) Middle turbinate 

(E) Floor of nose 

88. An elderly man complains of ear pain. During 
evaluation, the physician asks if the patient has 
tinnitus. What is tinnitus? 

(A) A subjective sensation of noise in the 
head 

(B) A complication of chronic metal ingestion 

(C) An audible cardiac murmur 

(D) Dizziness with sounds 

(E) Nystagmus 

89. A 4-year-old girl is diagnosed with bilateral 
otitis media and is treated for 10 days with an 
oral broad-spectrum antibiotic. The patient 
completes the full course of antibiotics and 
returns for regular follow-up visits. In most 
children, the appearance of the tympanic mem- 
brane returns to normal following a single 
antibiotic regimen for an episode of otitis 
media within what period? 

(A) 1 week 

(B) 2 weeks 

(C) 3 weeks 

(D) 1 month 

(E) 3 months 



62 



3: Endocrine, Head, and Neck 



90. During an examination, the dentist notices a 
lump between the earlobe and mandible in 
6-year-old boy. It feels soft, but it is difficult to 
distinguish from the rest of the parotid gland. 
What is the most likely diagnosis? 

(A) Lymphoma 

(B) Squamous cell carcinoma 

(C) Metastatic skin cancer 

(D) Benign mixed tumor 

(E) Hemangioma 

91. During a baseball game, the pitcher is hit in 
the left eye with a hard-hit line drive. He is 
rushed to the nearest emergency department 
where CT scan reveals left orbital rim and floor 
fractures and fluid in the left maxillary sinus. 
What are physical findings likely to include? 

(A) Exophthalmos 

(B) Lateral diplopia 

(C) Cheek numbness 

(D) Epistaxis 

(E) Blindness 

92. A 2-year-old child undergoes tympanostomy 
tube placement for treatment of chronic bilat- 
eral serous otitis media. Which of the following 
complications is least likely to occur subse- 
quent to surgery? 

(A) Otorrhea 

(B) Chronic perforation 

(C) Cholesteatoma 

(D) Tympanosclerosis 

(E) Scarring of the external auditory canal 

DIRECTIONS (Questions 93 through 106): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. Each lettered option 
may be selected. EACH ITEM WILL STATE THE 
NUMBER OF OPTIONS TO SELECT. 

Question 93 

(A) Recurrent laryngeal 

(B) Internal laryngeal 

(C) External laryngeal 



93. 



(D) Pharyngeal branch of vagus 

(E) Phrenic 

(F) Sympathetic 

(G) Glossopharyngeal 
(H) Ansa hypoglossi 

After undergoing a left thyroid operation, a 
42-year-old opera singer notes no change in 
speech, but she has difficulty in singing high- 
pitched notes. Which nerve is most likely to be 
injured? SELECT ONE. 



Question 


94 


(A) 


Scrofula 


(B) 


Carotid body tumor 


(C) 


Ganglioneuroma 


(D) 


Virchow node 


(E) 


Sternomastoid tumor 


(F) 


Glomus tumor 


(G) 


Cervical rib 


(H) 


Sarcoid 



94. A 67-year-old woman has lost weight and 
complains of night sweats. She had previously 
undergone treatment for tuberculosis. She has 
lymph node enlargement in the neck that has 
broken down to form sinus with overhanging 
bluish edges. What is the diagnosis? SELECT 
ONE. 



Question 


95 


(A) 


Erysipelas 


(B) 


Eczema 


(C) 


Scarlet fever 


(D) 


Mucor mycosis 


(E) 


Coccydynia 


(F) 


Ameba 


(G) 


Schistosomiasis 


(H) 


Actinomycosis 


(I) 


Tuberculosis 



95. A 63-year-old man with insulin-dependent dia- 
betes develops a black, crusting lesion in the 
nose and left maxillary sinus. Biopsy reveals 
nonseptate hyphae, which confirms the diag- 
nosis of what? SELECT ONE. 



Questions: 90-101 



63 



Question 


96 


(A) 


Cholesteatoma 


(B) 


Dermoid cyst 


(C) 


Glomus tumor 


(D) 


Neurofibroma 


(E) 


Hemangioma 


(F) 


Epidermoid cyst 


(G) 


Mikulicz's lesion 


(H) 


Sarcoma 



96. This develops along lines of embryological 
fusion in the floor of the mouth. SELECT ONE. 



Question 


97 


(A) 


Optic neuroma 


(B) 


Constricted pupil 


(C) 


Cerebellar dysfunction 


(D) 


Hamartomatous polyps in the small 




intestine 


(E) 


Diverticulitis 


(F) 


Melanosis coli 


(G) 


Cancer of the breast 


(H) 


Melanoma 



97. A 32-year-old man presents with abdominal 
pain. On examination, he is noted to have pig- 
mented spots in the buccal region. He is diag- 
nosed to have Peutz-Jeghers syndrome, which 
also results in what? SELECT ONE. 

Question 98 

(A) Lymphoma 

(B) Squamous cell carcinoma 

(C) Metastatic skin cancer 

(D) Benign mixed tumor 

(E) Hemangioma 

(F) Neurofibroma 

(G) Paget's disease 
(H) Ranula 

98. A businessman notices a lump in front of his 
ear while shaving one morning. His wife thinks 



it has been there for several months. What is 
the most likely cause of a mass in the parotid 
gland in this patient? SELECT ONE. 

Questions 99 and 100 

(A) Foramen cecum 

(B) Foramen ovale 

(C) Foramen rotundum 

(D) Foramen spinosum 

(E) Foramen magnum 

(F) Foramen jugulare 

(G) Foramen of Munro 
(H) Foramen of Magendie 

99. A 46-year-old accountant notices that he keeps 
cutting the right side of his lower face while 
shaving. On self-examination, he notes a loss of 
sensation of the skin and lower teeth on that 
side. At his physician's office, a CT scan is 
ordered. Which structure should be carefully 
evaluated for this patient's complaint? SELECT 
ONE. 

100. A 4-year-old boy is brought to the physician's 
office by his father for evaluation of small 
stature. A thyroid scan is ordered and shows no 
uptake in the neck. Which structure is embry- 
ologically related to the thyroid gland and 
should be carefully evaluated? SELECT ONE. 



Question 


101 


(A) 


Human papillomavirus (HPV) 


(B) 


Epstein-Barr virus 


(C) 


HIV 


(D) 


Varicella zoster virus 


(E) 


Herpes type 2 virus 


(F) 


Microcytic anemia 


(G) 


Autoimmune deficiency 


(H) 


Meningioma 



101. Mononucleosis in the blood is associated with 
what? SELECT ONE. 



64 



3: Endocrine, Head, and Neck 



Question 


102 


(A) 


Mental status change 


(B) 


Anosmia 


(C) 


Hypopituitarism 


(D) 


Meningitis 


(E) 


Neck mass 


(F) 


Deafness 


(G) 


Bitemporal hemianopsia 


(H) 


Neck stiffness 



104. 



(G) Dermoid cyst 

(H) Nevi 

(I) Lipoma 

(J) Tay-Sachs disease 

Midline swelling causing a double chin appear- 
ance is what? SELECT ONE. 



102. A middle-aged woman from China presents at 
her physician's office with a history of nasophar- 
ynx cancer. A medical history is obtained about 
her illness. What is the most common complaint 
of patients presenting with nasopharynx cancer? 
SELECT ONE. 

Question 103 

(A) Lymphoma 

(B) Squamous cell carcinoma 

(C) Metastatic skin cancer 

(D) Benign mixed tumor 

(E) Hemangioma 

(F) Sebaceous cyst 

(G) Sjogren's syndrome 
(H) Ectopic thyroid 

103. A 63-year-old bartender presents at his physi- 
cian's office complaining of a painful sore on 
his tongue. On examination, it is found that he 
has an ulcerated lesion on his tongue and a 
mass in the submandibular gland triangle. 
What is the most likely diagnosis? SELECT 
ONE. 

Question 104 

(A) Funnel chest (pectus excavatum) 

(B) Pectus carinatum (protrusion at the 
sternum) 

(C) Flail chest 

(D) Cystic hygroma 

(E) Rickets 

(F) Sebaceous cyst 



Question 


105 


(A) 


Metastasis from a parathyroid carcinoma 


(B) 


Osteitis fibrosa cystica (brown tumor) 




and subperiosteal resorption of the 




phalanges 


(C) 


Atypical mycobacterium 


(D) 


Eosinophilic granuloma 


(E) 


Chondroma 


(F) 


Dermoid cyst 


(G) 


Thyroglossal duct cyst 


(H) 


Laryngocele 


(I) 


Warthin's tumor 



105. A 5-year-old boy is taken to his pediatrician for 
a laceration on his right knee. A mass on his 
neck is noticed; his mother states it has been 
there for several months and is slowly getting 
larger. The mass is slightly to the left of midline. 
Ultrasound findings are shown in Fig. 3-6. What 
is the most likely diagnosis? SELECT ONE. 




Figure 3-6. 

Ultrasound of neck. Midline hypoechogenic mass anterior and supe- 
rior to the thyroid gland. 



Questions: 102-109 



65 



DIRECTIONS (Questions 106 through 109): Each 
of the numbered items in this section is followed 
by five answers. Select the ONE lettered answer 
that is BEST in each case. 



106. 



107. 



A 60-year-old woman, complaining of joint 
pains and muscle ache has a normal physical 
examination. Her routine blood work reveals a 
normal hemoglobin (Hb). Serum potassium is 
4 mEq/L. BUN and creatine are normal. Serum 
calcium is 11-12 mgm/dL. Which one of the 
following is not associated with this condition? 

(A) Myoglobin in the urine 

(B) Serum, parathyroid hormones (PTH) is 
elevated 

(C) Increased urinary excretion of calcium 

(D) Pancreatic tumors may be present 

(E) Pituitary tumors 

A 5-year-old girl presents with difficulty 
breathing. On examination, of the oral cavity a 
3-cm mass is found in the midline on the pos- 
terior aspect of the tongue. The most likely 
diagnosis is: 

(A) Lingual tonsil 

(B) Lingual thyroid 

(C) Foreign body stuck to the tongue 



(D) Dermoid 

(E) Angioneurotic edema 

108. A 40-year-old woman presents with weight 
loss, palpitations, and exopthalmos. On phys- 
ical examination, the thyroid gland is diffusely 
enlarged. Blood tests reveal primary hyper- 
thyroidism. Which one of the following is not 
the treatment of hyperthyroidism? 

(A) Methimazoli 

(B) Lugols iodine 

(C) I 131 

(D) Subtotal thyroidectomy 
(E) Steroids 

109. Which one of the following is not part of the 
management of a patient with hyperparathy- 
roidism 

(A) Hydration with intravenous normal 
saline 

(B) Steroids 

(C) Exploration of the neck for 
parathyroidectomy 

(D) Parathyroid scan 
(E) Vitamin D 



Answers and Explanations 



(A) The anterior jugular vein can cross the mid- 
line overlying the proximal trachea. Midline 
cervical dissection without adequate visuali- 
zation can injure the vein and require open sur- 
gical repair. The other veins do not cross the 
midline and are not generally at risk in tra- 
cheotomy. 

(C) The cervical branch of the facial nerve 
innervates the lower lip through the marginal 
mandibular branch of the nerve (Fig. 3-7). As 
no cross innervation exits to other branches of 



3. 



the facial nerve, marginal mandibular branch 
injuries always yield paralysis of the same side 
of the lower lip. Injuries of the main trunk of 
the facial nerve or its temporal branch would 
usually produce upper facial paralysis as well. 

(E) The phrenic nerve is the only component 
of the cervical plexus, which is not sacrificed 
during a radical neck dissection. It can be 
identified as superficial to the anterior sca- 
lene muscle (Fig. 3-8) with a nerve stimula- 
tor, although direct visualization is usually 



Anterior facial 
artery and vein 



Marginal 
mandibular nerve 




Submandibular gland 



Hypoglossal nerve 

Internal jugular vein 
Common facial vein 



External carotid artery 



Common facial vein 



Figure 3-7. 

The cervical branch of the facial nerve innervates the lower lip through the marginal mandibular branch of the 
nerves. 



66 



Answers: 1-13 



67 




Phrenic nerve 



Figure 3-8. 

The phrenic nerve is the only component of the cervical plescia, 
which is not sacrificed during a radical neck dissection. (Reproduced, 
with permission, from Brunicardi FC et al.: Schwartz's Principles of 
Surgery, 8th ed. 156. McGraw-Hill, 2005.) 



sufficient. Injury to the phrenic nerve can result 
in paralysis of the corresponding side of the 
diaphragm. 

4. (E) Temporal artery inflammation causes severe 
throbbing unilateral temporal headache, low- 
grade fever, visual changes, sweating, and 
malaise. Acute treatment with prednisone can 
be followed by temporal artery resection. 

5. (C) Hypoxia can become the primary stimula- 
tion for respiration. Sudden elevation of P0 2 
can eliminate the respiratory drive, which will 
resume by lowering the PC0 2 . 

6. (E) Prolapse of mucosa overlying the true vocal 
cords (ventricle of Morgagni) can occur in 
people who routinely elevate air pressure in 
the chest and larynx. Treatment involves direct 
laryngoscopy and excision of the protruding 
mucosa. The other choices, although less likely, 
must also be considered. 

7. (D) Spasmodic dysphonia often occurs in both 
men and women over 40-years old who strain 
their voices. Fluctuation with normal speech 
can occur, unlike the other choices presented. 
The vocal cords appear normal on routine 
laryngeal exam. Temporary improvement 
using botulinum toxin is reported. 



8. (A) Compression of the recurrent laryngeal nerve 
due to compression of the cricothyroid joint can 
occur subsequent to choking injury of the neck. 
Although fracture and internal bleeding can also 
occur, these are less likely. Acute onset dyspnea 
secondary to laryngeal tumor is unlikely. 

9. (C) Dysphagia and aspiration can result from 
disruption of the internal branch of the superior 
laryngeal nerve, resulting in sensory loss of the 
larynx. Contralateral superior laryngeal nerve 
compensation usually corrects these symptoms. 

10. (C) Unilateral nasal discharge in a young child is 
often due to foreign body in the nose. Although 
the other choices should also be considered in the 
differential diagnoses of rhinorrhea, nasal for- 
eign body in the child is most likely. 

11. (E) Papillary cystadenoma lymphomatosum is 
also called Warthin's tumor. It occurs mainly in 
men. The epithelial component is interspersed 
with lymphoid tissue that shows germinal cen- 
ters. The most common tumor of the parotid 
gland is a pleomorphic adenoma, with papil- 
lary cystadenoma (although much less fre- 
quent) as the second most common tumor. 
Mikulicz's disease involves chronic inflamma- 
tion and swelling of the salivary glands, which 
is benign and usually painless. 

12. (B) The most common cause of primary medi- 
astinal tumor is a neurogenic tumor (20-25%), 
and 10% are malignant (more likely in chil- 
dren). They usually arise from an intercostal 
nerve or sympathetic ganglion. Varieties of 
neurogenic tumors include neurilemmoma 
(schwannoma), neurofibroma, ganglioneu- 
roma, and neuroblastoma. Next in frequency 
(of primary mediastinal tumors) are thymoma, 
congenital cysts, and lymphoma. New diag- 
nostic techniques have resulted in detection of 
larger numbers of these lesions. 

13. (C) Spinal anesthesia induces venous vasodila- 
tion because of sympathetic blockade. Venous 
pooling can seriously impair venous return. It is 
the sympathetic blockade and not somatic nerve 
blockade that is responsible for the vasomotor 
and respiratory changes. It is important to 



68 



3: Endocrine, Head, and Neck 



ensure that volume depletion is corrected before 
spinal anesthesia, because venous return and 
hence cardiac output are diminished. These 
changes are aggravated by keeping the head up. 

14. (D) The role of thymectomy in treating patients 
with myasthenia gravis who have a thymoma 
is well established. The thymus gland is located 
in the anterior mediastinum and can be 
approached by a cervical or mediastinal 
approach. It arises from the third and fourth 
branchial arches. Thymectomy is frequently 
advised for patients with myasthenia gravis 
who do not have a thymoma; however, there 
are some authorities who would treat these 
patients initially with an anticholinesterase 
drug such as pyridostigmine (Mestinon). 
Corticosteroid therapy may be indicated when 
thymectomy has failed, but it must be under- 
taken cautiously, because the drug may 
precipitate severe weakness. Pneumococcal 
infections (which may occur after splenectomy 
performed in children) are not a specific com- 
plication noted after thymectomy. 

15. (C) Bronchogenic carcinoma accounts for 
70-80% of all cases of superior vena cava (SVC) 
obstruction; primary mediastinal tumors are 
the second most common cause. The main 
bronchial lymphatics are located at the tracheal 
bifurcation and immediately to the right and 
left of the trachea. Tuberculosis and mycotic 
infections are the most likely causes of chronic 
fibrosing mediastinitis. 

16. (D) CT is useful, because it delineates the cal- 
cification and shows the pattern of the calcifi- 
cation. There is no need for intervention at this 
stage, because most lesions of this nature are 
probably benign granulomas. 

17. (D) By definition, a solitary nodule is one that is 
5 cm or less in diameter. In most series, 60% of 
such lesions are benign, and 40% are malignant. 
The presence of irregular margins, the absence of 
calcification, a recent onset of symptoms, or an 
increase in size of the lesion within a relatively 
short period (several months) indicate the 
greater likelihood of malignancy. Thin-section 
CT scanning may add further information. 



18. (A) Bronchoscopy is the initial step, particularly 
if the patient is a smoker and a good risk for sur- 
gery. If cancer is confirmed, thoracotomy will 
probably be undertaken. Patient age is an impor- 
tant consideration in the management of a soli- 
tary pulmonary nodule; malignancy occurs in 
less than 1% of patients under 35 years of age. 
Benign lesions, such as bronchopulmonary 
sequestration, which usually affects the poste- 
rior aspect of the inferior lobes of the lung, must 
be considered. Bronchopulmonary sequestra- 
tion is usually asymptomatic, unless complica- 
tions occur. 

19. (E) In apical lung cancers, the malignant tumor 
may extend above the thoracic inlet, penetrate 
the suprapleural membrane, and infiltrate the 
structures found at the root of the neck. The first 
thoracic nerve and lower trunk of the brachial 
plexus are most likely to be involved initially, as 
Tl passes along the inner border of the first rib 
to reach the neck. If the sympathetic nerve is 
involved, pupil constriction and ptosis may be 
evident (Horner syndrome). The other listed 
items are all features of the paraneoplastic syn- 
drome associated with lung cancer and do not 
necessarily indicate extranodal metastasis. 
Cushing's syndrome in lung cancer occurs more 
frequently in men and in an older age group 
and has a more rapid downhill course than typ- 
ical Cushing's syndrome. SIADH should be sus- 
pected if the patient with a lung lesion develops 
unexplained mental changes and an extremely 
low serum sodium level. Fluid restriction is 
required. Urine osmolarity is low. 

20. (A) Hypercalcemia is attributed to the secre- 
tion of parahormone from a localized squa- 
mous cell carcinoma (paraneoplastic effect); as 
such, improvement may be seen after surgical 
resection. Following extension of the tumor 
into the chest wall, radiotherapy and subse- 
quent extensive resection carried out in selected 
cases may occasionally be indicated. Small-cell 
carcinoma (also known as oat-cell carcinoma) 
accounts for 20-25% of cases of bronchogenic 
carcinoma, arises centrally and tends to metas- 
tasize widely. The initial treatment is combi- 
nation chemotherapy followed by radiotherapy 
in those whose cancer responds. 



/Answers: 14-28 



69 



21. (B) Uncorrected hypercarbia is the major con- 
traindication to total pneumonectomy. Surgery 
is the treatment of choice for nonsmall-cell 
carcinoma of the lung. Although 25% of 
patients with bronchogenic carcinoma may 
undergo thoracotomy many of these patients 
will have unresectable lesions. Patients with a 
FEVj less than 2 L, a FVC under 70% of pre- 
dicted value, and maximal voluntary ventila- 
tion (MVV) under 50% are likely to tolerate 
operation poorly. The normal FEVj/FVC ratio 
is 0.7 or less; in severe obstructive dysfunction, 
it is under 0.45. Total atelectasis of the lung 
may be associated with obstruction of the main 
bronchus by the tumor. 

22. (D) Patients with small-cell carcinoma should 
not be treated initially by thoracotomy. This 
cancer responds favorably to combination 
chemotherapy, but few patients survive for 
more than 1 year. More than 160,000 cases of 
bronchogenic carcinoma are diagnosed in the 
United States per year. It accounts for 33% of all 
cancer deaths in men and 20% of all cancer 
deaths in women. The most common cancers of 
the lung are squamous carcinoma, 30% (tumor 
tends to be central); adenocarcinoma, 30%, 
(tumor tends to be peripheral) small-cell carci- 
noma, 20% (tumor tends to be central); and 
large-cell carcinoma, 15% (tumor tends to be 
peripheral). 

23. (A) The arch of the aorta is above the arbitrary 
line drawn between the manubrio sternal joint 
(angle of Louis) and the lower border of the 
fourth thoracic vertebra level. Therefore, it is 
located entirely in the superior mediastinum 
behind the manubrium. The projected line 
passing behind the manubriosternal junction 
and the lower border of T4 is a key surgical 
anatomic landmark of this region. The ascend- 
ing aorta (anteriorly), descending aorta (poste- 
riorly), and pulmonary trunk are below this 
level. The left recurrent laryngeal nerve curves 
around the ligamentum arteriosus, the arch of 
the azygous vein enters the SVC, and the upper 
third of the esophagus are separated arbitrarily 
from the middle third at this level. On a plain 
film of the chest, the tracheal bifurcation 
(carina) is a useful marker of this line. 



24. (C) Although there is a history of previous thy- 
roid cancer, the presence of a solitary nodule on 
chest x-ray is more likely to represent a pri- 
mary carcinoma of the lung than a solitary sec- 
ondary metastasis. In metastasis, the lesions 
are more often multiple, they frequently appear 
bilaterally, and they more commonly present in 
the lower area of the lungs. A CT scan would be 
helpful in delineating the pulmonary findings. 

25. (C) The most likely diagnosis, malignant 
epithelioma, commonly occurs following chronic 
exposure (>20^0 years) to asbestos. We need to 
consider this diagnosis in those employed in 
milling and construction, as well as in workers 
in pipe, textiles, gaskets, and other industries in 
which asbestos (especially crocidolite form) is 
used. In 75%, the diffuse (malignant) form 
occurs; less than 25% will survive more than 1 
year after the diagnosis is established. In 
advanced disease, lesions below the diaphragm 
are frequently encountered. 

26. (C) Cystic fibrosis is the most common cause of 
chronic obstructive lung disease (COLD) in chil- 
dren and adolescents. It is an autosomal-reces- 
sive disease that affects widespread exocrine 
glands. COLD is evident in all patients who 
survive childhood. 

27. (A) Ipratropium bromide broncho dilator ther- 
apy will frequently improve pulmonary func- 
tion in patients with COPD. Two to four 
inhalations every 4-6 hours are prescribed. 
COPD is due to emphysema (COPD type A) or 
chronic bronchitis (COPD type B). In the early 
stages, small airway dysfunction (abnormal 
closing volume) is found. As the disease pro- 
ceeds, the FEVj is reduced, then the FEVj/FVC 
ratio (<0.7). 

28. (C) The presence of multiple masses on a chest 
x-ray should alert the physician to the possible 
diagnosis of pulmonary AV fistula. Needle 
biopsy and endobronchial biopsy of the lesion 
should not be attempted, because severe hem- 
orrhage maybe precipitated. Paradoxical emboli, 
brain abscess, and hemothorax are recog- 
nized complications. If the fistula is localized, 
resection is undertaken; in multiple lesions, 



70 



3: Endocrine, Head, and Neck 



therapeutic embolization is done. In addition to 
AV malformation, multiple masses on a chest x- 
ray could be due to metastasis, granulomatous 
infection, or sarcoid or rheumatoid arthritis. 

29. (D) In mediastinal tamponade, hypotension, 
dyspnea, cyanosis, and a decrease in pulse 
pressure will be evident. During inspiration, 
the pulse pressure is further impeded to cause 
obstruction to transmitted ACV waves in the 
neck; in congestive cardiac failure, the ACV 
waves recorded in the neck are more promi- 
nent. Paresis of the arm is unlikely to occur, 
because the lower part of the brachial plexus 
(Tl) passes along the inner border of the first 
rib to reach the neck. 

30. (B) Mediastinal hemorrhage after trauma may 
result from blunt or penetrating injuries. Tam- 
ponade should be suspected if hypotension, 
cyanosis, dyspnea, and venous congestion occur. 

31. (B) Dissecting thoracic aneurysm should be 
suspected in Marfan's syndrome, pregnancy, 
bicuspid aortic valves, and coarctation. The 
onset of pain is sudden and severe and radiates 
to the back. Pulse discrepancy is frequently seen. 
The hypertension should be treated initially 
before any surgery is contemplated. The mor- 
tality rate of immediate (within 24 hours) sur- 
gical resection of the ascending aorta (type A) is 
20%; however, if surgery is delayed, the mor- 
tality is 50% at 2 weeks and 90% at 3 months. 

32. (E) The eleventh and twelfth ribs are free ante- 
riorly and like other ribs articulate with costal 
cartilage anteriorly. However, the anterior mar- 
gins of these ribs are free (float) and do not form 
part of the costal margins. The pleural reflection 
posteriorly intersects the twelfth rib. Ribs that 
articulate with the sternum are called true (ribs 
1-6 or 7); the remainder are called false ribs. 

33. (D) In ARDS, poor alveolar gas exchange and 
interstitial edema are evident in the presence of 
normal or lowered PCWP The changes are 
caused by damage to capillary and alveolar 
epithelial cells consequent to the release of 
proinflammatory cytokines, which, in turn, arise 



from stimulated lymphocytes and macrophages. 
Other clinical features suggestive of ARDS are 
diffuse ("fluffy") pulmonary infiltrates and 
refractory hypoxemia (Pa0 2 /Fi0 2 <200). 

34. (C) ARDS is caused by pulmonary or systemic 
insult. It is characterized by bilateral pul- 
monary infiltrates, hypoxemia, noncompliant 
lungs, and a normal or low PCWP, and steroids 
have no proved value in the management of 
ARDS, and their use may be deleterious in the 
presence of sepsis. PEEP, if required, should be 
used cautiously with the lowest Fi0 2 that main- 
tains the P0 2 above 60 mm Hg. Excessive fluid 
overload should be avoided. Ventilation should 
be with lower tidal volumes and decreasing 
peak airway pressures. Management strategies 
in ARDS are aimed largely at supportive care, 
maintaining tissue oxygenation and preventing 
further lung injury secondary to mechanical 
ventilation. Smaller tidal volumes are used 
(5-7 mL/kg) to prevent volutrauma as well as 
to decrease the peak inspiratory pressures. 

35. (E) Culture for mycobacterium usually requires 
6 weeks before a diagnosis can be made. The 
clinical and x-ray features are suggestive of 
tuberculosis. The sedimentation rate is increased 
in the presence of active disease. The incidence 
of tuberculosis in the United States has 
increased in recent years. In many cases of pri- 
mary infection, resolution occurs without 
symptoms. The pulmonary focus remains dor- 
mant (Ghon) and may become activated, caus- 
ing caseation of the lung, formation of a 
thick-walled fibrous cavity, tuberculous bron- 
chitis, bronchiectasis, hemoptysis, and cavita- 
tion. Sputum examined for acid-fast bacilli may 
be inadequate, because saprophytic organisms 
may be detected. The Kveim test is used in the 
differential diagnosis to exclude sarcoid. 

36. (D) In the early stages of HIV infection, skin 
testing for tuberculin is intact; however, false- 
positive results occur because of infection by 
nontuberculous mycobacteria and are common 
because of the immune disorder. Most patients 
with tuberculosis, who are compliant, can be 
treated on an outpatient basis. 



/Answers: 29-42 



71 



37. (B) Bronchiectasis is caused by a congenital or 
acquired dilation of the segmental, subseg- 
mental, or branches of the bronchi. Patients 
with B lymphocyte disorders are more likely to 
develop lower respiratory tract infection and 
bronchiectasis than those with impaired T-cell 
immunity. Treatment is aimed at obtaining 
maximal drainage. Resection may be indicated 
when the disease is localized and persistent 
symptoms and complications occur. 

38. (A) Cystic fibrosis is an autosomal-recessive 
disorder of the exocrine glands and occurs in 
neonates who survive an episode of intestinal 
obstruction due to mucoviscidosis. Cystic fibro- 
sis accounts for more than one-half of the cases 
of bronchiectasis seen today. Other causes 
include acute and chronic lung infections, 
humoral immunodeficiency, and localized 
bronchial obstruction (e.g., carcinoma). The 
basal segments of the lung, lingula, and right 
middle lobes are involved most frequently. 

39. (C) Bronchogenic cysts are located in the medi- 
astinum but are seen most frequently behind 
the carina. They have a thin wall, are lined by 
bronchial epithelium, and contain mucus. 
Bronchogenic cysts are usually asymptomatic, 
but symptoms may occur because of compres- 
sion, with cough, wheezing, and possibly dys- 
phagia. Bronchogenic cysts may become infected 
and rupture into surrounding organs. Cysts 
constitute 20% of mediastinal mass lesions. The 
most common mediastinal cyst is the pericar- 
dial cyst, which is found most often at the right 
costophrenic angle. 

40. (D) Bronchopulmonary sequestration can be 
differentiated from a bronchogenic cyst; in that 
it is composed of nonfunctioning lung tissue 
that is disconnected from the remaining lung; 
it has a separate blood supply. Glomus tumors 
are rare tumors that arise in the middle ear or 
jugular bulb. Patients complain of tinnitus and 
hearing loss. 

41. (D) There are three major openings of struc- 
tures that penetrate the diaphragm at differ- 
ing thoracic vertebra levels. The IVC enters at 



T8 (to the right of the midline), the esophagus 
at T10 (to the left of the midline), and the aorta 
at T12 in the midline. 

42. (A) Funnel chest (Fig. 3-9) is the most impor- 
tant congenital chest wall deformity. It is usu- 
ally present at birth, and there is marked 
asymmetry. The heart is displaced to the left. 
There is often a familial history, and associated 
congenital heart disease may frequently be 
encountered. Correction is recommended in 
asymptomatic patients with prominent defor- 
mity to avoid permanent cardiopulmonary 
changes. In flail chest, paradoxical respiration 
occurs as the chest wall deformity is sucked 
inward during inspiration. It occurs after exten- 
sive rib trauma where individual ribs are sep- 
arated in two different sites. 




Figure 3-9. 

Funnel chest is the most important congenital chest wall 
deformity. (Reproduced, with permission, from Doherty 
GM: Current Surgical Diagnosis and Treatment, 12th ed. 
1283. McGraw-Hill, 2006.) 



72 



3: Endocrine, Head, and Neck 



43. (A) Any object that compromises the blood 
supply to the tracheal mucosa or cartilage can 
cause stenosis. When the mean intramural 
pressure exceeds 20-30 mm Hg, damage may 
be anticipated. Riedel struma is a rare fibrosing 
thyroid condition, which must be differenti- 
ated from carcinoma and may cause severe tra- 
cheal stenosis. Achalasia is a neuromuscular 
defect at the lower end of the esophagus caus- 
ing dysphagia, because of nonmechanical 
esophageal obstruction. 

44. (A) On the left side, the pleural reflection devi- 
ates to the left, anteriorly between the fourth 
and sixth costal cartilages, to accommodate the 
cardiac notch. Although the right and left pleu- 
ral reflections approach each other in the mid- 
line, there is no direct communication between 
the two sides. 

45. (D) Frequently, a fracture cannot be seen on the 
chest x-ray; however, the patient should be 
treated for fracture, although none is seen on the 
x-ray. Pneumothorax may occur if more than 
one rib is involved, but a chest tube is indicated 
only if it is of substantial size or increasing in 
amount. Hemothorax usually occurs because 
of a tear in the intercostal or other intrathoracic 
vessels. 

46. (D) A thoracoabdominal incision is still used 
occasionally where access to both the upper 
abdomen and posterior thoracic structures is 
required. The main reasons for less frequent 
use of this incision are poor healing of the 
divided costal margin, postoperative pain, and 
an increased risk of infection in both the tho- 
racic and abdominal compartments. 

47. (B) Sternal injuries usually involve the body 
or manubrio sternal junction in a transverse 
direction and frequently cause displacement. 
Sternal injuries occur most commonly as a 
result of injury by steering wheel impact in car 
accidents. It is important to exclude cardiac 
and major vessel injury in such injuries. 



In general, up to 50% of the trachea may be 
resected. Unequivocal postintubation stenosis is 
treated by surgical repair. Congenital tracheal 
stenosis should be treated by surgery if symp- 
toms necessitate it. Dilatation can result in rup- 
ture of the trachea. 

49. (B) Patients with hyperparathyroidism deve- 
lop demineralization, and 1.5% shows osteitis 
fibrosa cystica. The presence of subperiosteal 
resorption of bone of the phalanges and lamina 
dura of the teeth are fairly diagnostic radiolog- 
ical findings of hyperparathyroidism. Chon- 
dromas account for 20% of benign tumors of 
the rib and occur at the costochondral junction. 
Osteochondromas arise from the cortex and usu- 
ally occur in men. Eosinophilic granuloma 
results in a destructive lesion apparent on x-ray. 

50. (D) Antibiotics and vigorous attempts to obtain 
bronchial drainage will treat the abscess ade- 
quately in the majority of cases. Lung abscesses 
commonly are associated with aspiration pneu- 
monia, where the abscess is found posteriorly. 
In the presence of an unexplained lung abscess, 
bronchoscopy is essential to exclude a foreign 
body or tumor that could cause bronchial 
obstruction. 

51. (B) Branchial cleft cysts (Fig. 3-9) arise from 
the second and third branchial clefts. Branchial 
cysts may become evident after an URTI and 
present as a mass anterior to the sternocleido- 
mastoid muscle. Intraoperatively, they can be 
traced to pass between the and external carotid 
artery to the piriform sinus or tonsillar fossa. 

52. (C) Cystic hygromas are relatively rare tumors. 
Most are encountered in the posterior triangle 
of the neck, but occasionally they are found in 
the mediastinum, axilla, or groin. They are 
often noted at birth and represent persistence of 
primary lymphatic buds. They extend into the 
surrounding tissues but are not associated with 
malignancy. Transillumination is a useful sign 
to diagnose this lesion. 



48. (B) Most lesions of the trachea, except infiltrat- 
ing adenoid cystic carcinoma, that cause tra- 
cheal stenosis should be resected when possible. 



53. (D) Females are affected by myasthenia gravis 
twice as commonly as males. It is an autoim- 
mune disease that produces antibodies to 



/Answers: 43-64 



73 



acetylcholine receptors. The external ocular and 
other cranial muscles are often involved at an 
early stage. There is a deficiency in acetylcholine 
receptors, and thymectomy is often helpful. 

54. (D) Squamous carcinoma of the lip comprises 
15-20% of all malignant tumors of the oral 
cavity. In approximately 30%, there is a clear 
association with heavy exposure to the sun. 
The incidence increases in those areas where 
there is more southerly latitude, the air is dry, 
and the altitude is higher. 




Swelling of Rpp~~r^^^ 

branchial cleft cyst «''■-- 



Sternocleidomastoid 
muscle 



55. (C) If the lesion is treated early, patients will 
achieve a cure in most cases. The upper lip is 
involved in 10% of patients. 



Figure 3-10. 

Branchial cyst, (Reproduced, with permission, from 
Lindner, HH: Clinical Anatomy. Appleton & Lange, 1989.) 



56. (C) Hyperkeratosis of the lip is a premalignant 
lesion and usually occurs in people exposed 
excessively to the sun. The mucosa undergoes 
metaplasia to keratosquamous epithelium. The 60. 
lip becomes pale, thin, and fragile, with cracks 

and fissures, and is covered with a white base. 

57. (D) Ameloblastoma is a benign tumor and 
usually occurs at the junction of the body and 
ramus of the mandible. Although it is a benign 61. 
tumor, it recurs if inadequately excised. It is 
relatively radioresistant. Histologically, odon- 
togenic epithelium is seen in connective 

tissue stroma with extensive areas of cystic 
degeneration. 62. 

58. (B) The lingual nerve swings forward deep to 
the mylohyoid muscle and crosses twice over 
the submandibular (Wharton's) duct. The 
mandibular branch of the facial nerve (not 
listed in the answer choices) may accidentally 

be injured below the angle of the mandible 63. 

(Fig. 3-10). Injury to this branch causes seri- 
ous facial deformity. 

59. (C) Squamous cell carcinoma of the tongue fre- 
quently (40-60%) metastasizes to the lymph 
glands. Carcinoma of the tongue usually com- 
mences at the tip or side. The 5-year survival 

rate for carcinoma of the tongue is 40%, but it 64. 

improves to 55% if lymph nodes are not 
involved. 



(B) Carcinoma of the posterior third of the 
tongue is often detected late and carries a 
worse prognosis. Posterior-third tongue tumors 
are also called lymphoepitheliomas. These 
lesions can be poorly differentiated. 

(A) Tumors of the hard palate usually arise 
from the minor salivary glands. Cancers of the 
lip, tongue, esophagus, and larynx are often 
squamous cell carcinoma. 

(A) Poorly differentiated squamous cell carci- 
noma of the floor of the mouth tends to be more 
invasive than better-differentiated tumors. 
Poorer prognosis can be expected when inva- 
sion is larger than 9 mm, perineural invasion is 
noted, and lymph node metastasis is evident. 

(C) Nasopharyngeal carcinoma is prevalent in 
China. It has been associated with high levels 
of Epstein-Barr virus titers. The most common 
sign is a neck mass, even when the primary 
lesion is microscopic. The first cranial nerve to 
be affected is the abducent (VI) and indicates 
cranial extension. 

(A) Any object that compromises the blood 
supply to the tracheal mucosa or cartilage can 
cause stenosis. When the mean intramural 



74 



3: Endocrine, Head, and Neck 



pressure exceeds 20-30 mm Hg over a pro- 
longed period, damage occurs. 

65. (A) Verrucous carcinoma is a low-grade malig- 
nancy and is seen more frequently in the south- 
ern part of the United States. It is found most 
commonly on the gingival-buccal junction in 
tobacco chewers. It is grayish white and exo- 
phytic. Radiation is associated with possible 
metastases. If not excised, the lesion tends to 
invade locally. 

66. (D) Juvenile nasopharyngeal hemangiofibro- 
mas are rare nonmalignant tumors containing 
both fibrous and vascular tissue. They occur 
exclusively among boys. 

67. (C) If the neck nodes are removed, some patients 
have surgically curable primary disease. In some 
series, as many as 20% remain free of disease for 
more than 5 years without any manifestation of 
a primary tumor. It is essential to search exten- 
sively for a primary source before labeling the 
lesion as a possible branchial cleft carcinoma, 
which is extremely rare. 

68. (D) More than 80% of neck gland tumors arise 
from structures above the clavicle. The piri- 
form fossa is lateral to the aryepiglottic folds 
and is a major site where a primary cancer 
may remain hidden from early detection. 
Twenty percent of neck gland tumors are pri- 
mary and 80% represent metastatic disease. 

69. (D) The response is transient, lasting only 
2-3 months. The results of this type of therapy, 
combined with those of artery occlusion, radio- 
therapy, or other modes of chemotherapy, 
require further evaluation. 

70. (B) The classic block dissection includes ster- 
nocleidomastoid muscle, the external and 
internal jugular veins, the spinal accessory 
nerve, the submandibular gland, and the lym- 
phatic tissue of the lateral compartment of the 
neck. Procedures that preserve muscle, nerve, 
or vessels are called modified neck dissection. 

71. (B) The chorda tympani (branch of the facial 
nerve) join the lingual nerve in the infratemporal 



fossa to supply the anterior two-thirds of the 
tongue with taste fibers (cell stations in the genic- 
ulate ganglion of the facial nerve). It also con- 
tains the secretory parasympathetic fibers to the 
submandibular and sublingual glands. 

72. (D) The thymus gland is removed in certain 
cases of myasthenia gravis. It is located in the 
anterior mediastinum and can be approached 
by a cervical or mediastinal approach. It arises 
from the third and fourth branchial arches. 
Pneumococcal infections are particularly likely 
to develop after splenectomy performed in 
children. 

73. (A) The most common organisms isolated in 
acute pharyngitis are streptococci, virus, 
Neisseria gonorrhoeae, and mycoplasma. 

74. (C) Odynophagia is a sensation of sharp ret- 
rosternal pain on swallowing. It is usually 
caused by severe erosive conditions such as 
Candida, herpes virus, and corrosive injury fol- 
lowing caustic ingestion. 

75. (B) The most common source of epistaxis is 
Kisselbach's vascular plexus on the anterior 
nasal septum. Predisposing factors include 
foreign bodies, forceful nose-blowing, nose- 
picking, rhinitis, and deviated septum. 

76. (D) Carotid body tumor is the most common 
type of paraganglioma in the head and neck 
region, followed by the glomus jugular tumor. 
Carotid body tumor grows slowly, rarely metas- 
tasizes, and may secrete catecholamines. The 
tumor usually is supplied by the external carotid 
artery, and dissection to remove it off the carotid 
bifurcation may be difficult and cause bleeding. 
Malignancy occurs in 6% of patients. 

77. (E) Bell's palsy (of the facial nerve) has been 
attributed to an inflammatory condition of the 
facial nerve at the site where it exits through the 
stylomastoid foramen. Its cause remains unclear, 
and recent studies indicate a possible associa- 
tion with reactivation of herpes simplex virus 
in some cases. Facial paresis usually comes on 
abruptly. 



/Answers: 65-92 



75 



78. (B) Prospective nonrandomized evaluations of 
treatment duration of acute otitis media reveal 
no difference in outcome if given over 5-day, 
7-day, or 10-day duration. However, 10-day 
treatment is indicated for children with history 
of acute otitis media within the preceding 
month. 

79. (A) Neuroleptic anesthesia is the use of agents 
that suppress psychomotor activity. Droperidol 
produces marked sedation and tranquilization. 
The onset of action is 3-10 minutes after injec- 
tion, but the full effect may not be noted until 
30 minutes after injection. The sedative action 
lasts 2—4 hours. It potentiates the action of cen- 
tral nervous system (CNS)-depressant drugs, 
can cause hypotension, and causes mild a- 
adrenergic blockade. 

80. (C) The most common complication of thyroid 
and parathyroid surgery is iatrogenic injury to 
the recurrent laryngeal nerve, which can result 
in temporary (up to 7.1%) or permanent (up to 
3.6%) paralysis of the vocal cord. 

81. (B) Laryngomalacia is characterized by inspi- 
ratory stridor and is caused by redundant 
epiglottis and ary epiglottic folds in young chil- 
dren. The condition usually resolves without 
surgical intervention. 

82. (B) Jet irrigation (e.g., Water Pik) should 
be avoided to remove cerumen impaction. 
Detergent ear drops (such as 3% hydrogen per- 
oxide) may be used. Aqueous irrigation should 
be avoided if organic material is present, 
because further swelling will be induced. 

83. (A) The presence of a nasogastric tube causes 
swelling and irritation of the nasal mucosa. 
This, in turn, may partly occlude drainage of 
the sinus into the meatus. 

84. (B) Foreign bodies in the ear canal are more 
frequently encountered in children than adults. 
In general, foreign bodies in the ear are 
removed under microscopic control to avoid 
further injury. 



85. (D) Rapid testing for streptococci with latex 
agglutination (LA) antigen test is much less 
sensitive than with solid-phase enzyme-linked 
immunoassay (ELISA). 

86. (B) Pharyngeal (branchial arch) remnants 
account for many cysts or fistulas in the lateral 
neck. The associated tract can be found in vari- 
ous locations. Thyroglossal duct cysts associated 
with the decent of the thyroid gland are usually 
midline, extending as high as the base of tongue. 

87. (A) Epistaxis in children and young adults usu- 
ally arises from the anterior nasal septum 
(Kiesselbach's plexus). In elderly persons, how- 
ever, spontaneous rupture of a sclerotic blood 
vessel in the posterior nasal septum is usually 
the cause of bleeding, especially in combination 
with hypertension. 

88. (A) Tinnitus is the perception of abnormal noise 
in the ear or head. It is usually attributed to a 
sensory loss; pulsatile tinnitus occurs with con- 
ductive hearing loss and is due to carotid pul- 
sations becoming more apparent. 

89. (E) Surgical drainage of otitis media (myringo- 
tomy) is performed in either chronic infections 
or severe infections. Complications of otitis 
media include mastoiditis and meningitis. 

90. (E) These may be difficult to excise because of 
the focal nerve involvement by the heman- 
gioma. 

91. (D) Blowout fractures of the orbit exhibit epis- 
taxis; subcutaneous emphysema and periorbital 
ecchymosis are also frequently encountered. 
Treatment of most severe injuries is by surgi- 
cal repair, often by a lower lid blepharoplasty 
incision. Enopthalmous, lateral diplopia and 
blindness do not generally occur. 

92. (E) Tympanostomy tube placement is per- 
formed through the external auditory canal 
with microscopic guidance. The tympanic 
membrane is directly visualized after clearing 
wax and debris from external auditory canal. 
Otorrhea is the most common sequela, requiring 



76 



3: Endocrine, Head, and Neck 



tube removal in 13.5% of long-term tubes and 
0.9% of short-term tubes. 

93. (C) The external laryngeal nerve supplies the 
cricothyroid muscle, which assists in tensing 
the cords. 

94. (A) Scrofula is tuberculosis lymphadenitis. It 
may occur in immunocompromised hosts as 
well as in patients from underdeveloped coun- 
tries. A chest x-ray must be obtained and a 
purified protein derivative (PPD) skin test must 
be carried out. The response rate to antituber- 
culous drugs is good, but excision of the resid- 
ual lesion may be required. 

95. (D) Mucor is an opportunistic mold that causes 
mucormycosis. At least 50% of reported cases 
are associated with uncontrolled diabetes, and 
many of the remaining patients are immuno- 
suppressed. It appears as black crusting in the 
nose and sinuses and spreads rapidly to 
involve the cerebrum. Biopsy reveals nonsep- 
tate hyphae, which confirms the diagnosis. 
Treatment is directed toward control for dia- 
betic ketoacidosis and use of amphotericin B. 

96. (B) Dermoid cysts arise along line of fusion of 
embryonic parts. In the floor of the mouth, the 
swelling forces the tongue upward. Alternatively, 
the swelling may occur below the mylohyoid 
muscle, where it gives the impression of a double 
chin. It is not a premalignant lesion. It has an 
epithelial lining and may contain secretions, 
sloughed-off cells, and hair. 

97. (D) In Peutz-Jegher syndrome, pigmented 
melanin spots are found in the buccal and per- 
ineal region. The lesions are flat and greenish 
black in the buccal region and remain after 
puberty. Pigmentation is found inside the mouth, 
nostrils, palms, and feet. Usually at about 
20-30 years of age, hamartomatous polyps are 
found in the small intestine, but other parts of 
the alimentary tract may also be involved. 
Adenocarcinoma develops in 23% of patients. 

98. (D) Benign mixed tumor (pleomorphic ade- 
noma) requires appropriate excision (superfi- 
cial parotidectomy). If the tumor is shelled out, 



recurrence is likely. Approximately 80% of 
tumors of the salivary glands occur in the 
parotid gland. 

99. (B) The trigeminal nerve exits from the foramen 
ovale to enter the infratemporal fossa. The 
motor mandibular division of cranial nerve V 
also exits through the same opening. 

100. (A) If the thyroid gland is absent from the neck, 
it may be in the lingual position at the foramen 
cecum. Excision of this lesion from the tongue 
will require thyroid hormone replacement. 

101. (B) Nasopharyngeal cancer is most closely 
associated with Epstein-Barr virus. This virus is 
also associated with infective mononucleosis 
and Burkitt's lymphoma. 

102. (E) If the tumor should extend upward into the 
sphenoid bone, the cavernous sinus may be 
involved. 

103. (B) The tip of the tongue drains into the sub- 
mental lymph nodes, whereas, the side of the 
tongue drains into the submandibular lymph 
nodes. 

104. (G) Dermoid cysts form along lines of fusion of 
embryological dermatomes of the skin. In the 
neck, they are commonly above the thyroid 
cartilage and may be classified as one of four 
varieties, central or lateral in the midline and 
above or below the mylohyoid muscle. 

105. (G) The thyroid develops from the foramen 
cecum in the tongue and descends to its defin- 
itive position in the neck. Failure of the tract to 
close may result in a thyroglossal duct cyst. 

106. (A) An elevated ionic calcium and elevated 
blood levels of intact PTH clinches the diagnosis 
of hyperparathyroid. Primary hyperparathy- 
roidism can result in bone demineralization and 
renal calculi if neglected. Hyperparathyroidism 
may be manifestation of the multiple endocrine 
neoplasia syndrome. Pancreatic islet cell tumors, 
vi2 gastinomas and insulinomas, and pituitary 
tumors are part of the multiple endocrine neo- 
plasia MEAN 1 syndrome. 



Answers: 93-109 



77 



Myoglobin in the urine is present in patients 
with rhabodmyolysis and is not associated 
with elevated serum calcium, and is after asso- 
ciated with hyperkalemia. 

107. (B) An ectopic thyroid gland can be located 
anywhere from the base of the tongue to the 
mediastinum. It often results in the failure of 
descent resulting in either a linginal thyroid or 
ectopic thyroid in the midline of the neck. The 
so called lateral aberrant thyroid is usually a 
metastasis from papillary carcinoma of the 
thyroid. 

Angioneurotic edema is an acute allergic 
reaction, which causes a sudden swelling of 
the whole tongue with airway obstruction. 

108. (E) Hyperthyroidism could be diffuse primary 
hyperthyroidisms, Graves' disease, or a toxic 
nodular goiter. Graves' disease is an autoim- 
mune hyperthyroidism. The treatment consists 
of medical management with use of antithyroid 



drugs such as methimazole, or ablation of the 
gland with radioactive I 131 , or surgically with 
subtotal thyroidectomy. Failure of medical 
management requires oblation procedures 
either with I or surgery. 

Lugols iodine is used in preparation to sur- 
gery. Steroids are not used in the treatment of 
hyperthyroidism. It may be used in the man- 
agement of thyroid storm, a life threatening 
condition. 

109. (B) Definitive treatment of hyperparathy- 
roidism is parathyroidectomy. When serum cal- 
cium is above 14 mgm/dL the patient is in 
hypercalcemic crisis. Immediate treatment of 
this condition requires hydration with normal 
saline and use of diuretics to bring down the 
serum calcium level. 

A positive parathyroid scan will help to 
locate an adenoma of the parathyroid preop- 
eratively 



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CHAPTER 4 



Cardiac and Thoracic 

Marshall O. Kramer and E. A Bonfils-Roberts 

Questions 



DIRECTIONS (Questions 1 through 30): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 



1. A 14-year-old boy is seen by a pediatric cardi- 
ologist because of increasing shortness of 
breath. Studies reveal increased pulmonary 
vascular resistance, left axis deviation on 
Electrocardiogram (ECG), and mitral regur- 
gitation murmur. What is the most likely 
diagnosis? 

(A) Ostium primum defect 

(B) Tetralogy of Fallot 

(C) Right aortic arch 

(D) Ostium secundum defect 

(E) Atrioventricular canal 

2. A cyanotic female neonate is born with trans- 
position of the great arteries. Metabolic acido- 
sis and hypoxemia are present and are life 
threatening. Which of the following is the best 
initial treatment? 

(A) Urgent Mustard operation 

(B) Prostaglandin El 

(C) Atrial septotomy 

(D) Pulmonary artery banding 

(E) Prostaglandin El and atrial septotomy 

3. A 65-year-old man undergoes cardiac surgery 
for triple vessel coronary artery disease. What 
can he anticipate? 



(A) 95% chance his grafts will occlude after 
12 months. 

(B) 5% chance of living for 5 years. 

(C) If the internal mammary artery is used 
as a conduit, patency is increased. 

(D) Mortality if 10-20% in most centers. 

(E) Functional improvement with the 
saphenous vein graft is better than 
internal memory artery. 

4. Three months after aortic valve replacement 
with a mechanical prosthesis, a 60-year-old 
man describes malaise, and increasing short- 
ness of breath. Examination reveals pulsus 
paradoxus. ECG shows low voltage precor- 
dially. What test is most useful for making the 
diagnosis? 

(A) Stress thallium exam 

(B) Computer Tomography (CT) 
examination of chest 

(C) Coronary angiography 

(D) Echocardiography 

(E) Serum creatinine phosphokinase (CPK) 

5. In the patient described above urine output 
decreases to 20 cc/h. Studies reveal paradoxi- 
cal septal motion. What is the next course of 
therapy? 

(A) Expectant medical therapy 

(B) Redo aortic valve surgery 

(C) Left chest tube 

(D) Ontra-aortic balloon 

(E) Pericardial window 



79 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



80 



4: Cardiac and Thoracic 



6. A 58-year-old man is in cardiogenic shock in 
the emergency department after sustaining an 
acute myocardial infarction (MI). An intra- 
aortic balloon pump (IABP) is inserted. Which 
statement is TRUE about IABP? 

(A) The balloon increases coronary 
perfusion during diastole. 

(B) The balloon increases coronary 
perfusion during systole. 

(C) The balloon increases peripheral 
resistance. 

(D) The balloon is inflated in systole and 
diastole. 

(E) The pump must be removed after 
24 hours. 

7. A 66-year-old female has had two Mis in the 
past. She is admitted to the emergency depart- 
ment in congestive heart failure. After admis- 
sion and appropriate therapy her Holter 
monitor shows frequent PVCs and her ejection 
fraction is found to be 35%. Appropriate treat- 
ment would include which of the following? 

(A) Single chamber pacemaker 

(B) Cardioversion 

(C) Dual chamber pacemaker 

(D) Internal cardiac defibrillator (ICD) 

(E) Greenfield filter 

8. During a routine examination of a 30-year-old 
female actuary seeking life insurance, she is 
found to have a ventricular septal defect (VSD). 
She undergoes subsequent studies including 
ECG, chest x-ray, echocardiography, and 
Doppler ultrasound. What is the major deter- 
minant of operability in VSD? 

(A) Age of patient 

(B) Pulmonary vascular resistance 

(C) Size of the VSD 

(D) Location of the VSD 

(E) Presence of cyanosis 

9. At the age of 3 years, a child with a VSD 
becomes progressively short of breath and 
requires urgent surgery. What is the most 
common type of VSD (Fig. 4-1)? 



Pulmonary valve 




Supracristal 
defect 

Crista 

supraven- 

tricularis 



Membranous 
defect 

Tricuspid 
valve 



Septal leaflet 
defect 



Muscular 
defect 



Figure 4-1. 

Anatomical locations of various ventricular septal defects. 
The wall of the right ventricle has been excised to expose the 
ventricular septum. (Reproduced, with permission, from 
Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 433. McGraw-Hill, 2006.) 

(A) Defect anterior to the crista 
supraventricular 

(B) Membranous septal defect 

(C) Posterior septal defect 

(D) Low muscular defect 

(E) Right-to-left shunt 



10. 



A 1-year-old girl is found to have a posterior 
membranous VSD. Peripheral resistance of the 
pulmonary system is 40% that of the systemic. 
How should you proceed? 

(A) Observe the child, because most VSDs 
close spontaneously. 

(B) Band the pulmonary artery and fix the 
defect at age 6. 

(C) Repair electively at age 14. 

(D) Repair electively between ages 4 and 
6 years. 

(E) Repair immediately as an emergency. 



11. At birth, the 6 weeks premature infant is 
noted to have progressive dyspnea. There is a 
continuous murmur in the pulmonic area 



Questions: 6-16 



81 



(second left intercostal space), and cyanosis is 
absent. ECG findings are normal. An x-ray of 
the heart shows cardiomegaly, and the pulse 
is bounding. Patent ductus arteriosus (PDA) 
is diagnosed. What does treatment include? 

(A) Immediate surgical correction 

(B) Administration of indomethacin 

(C) Administration of cortisone 

(D) Renal dialysis 

(E) Endotracheal intubation in all cases 

12. During a routine preschool physical examina- 
tion, the physician notes that a 3-year-old girl 
has a machinery-type murmur on auscultation 
of the chest. The pulse is bounding and palpa- 
ble in the femoral and radial region of both 
sides of her body. There were no symptoms, 
and she has excellent exercise performance. 
Persistent PDA is confirmed on subsequent 
examination. The parents should be advised 
that the girl requires which of the following: 

(A) Surgical correction and closure of the 
PDA 

(B) Indomethacin 

(C) Coronary angiography 

(D) No treatment unless symptoms occur 

(E) CT scan of the heart 

13. At the age of 34 years, a female long-distance 
runner notes increasing dyspnea after running 
more than 10 mi. On inspection and palpation, 
a prominent right ventricular heave is noted. 
There is a loud systolic murmur in the left third 
interspace. The ECG shows right-axis devia- 
tion with right bundle branch block. An x-ray 
of the chest shows a small aortic knob. What 
sign or test will most likely reveal the cause of 
the congenital heart abnormality thought to be 
atrial septal defect? 

(A) Beading (scalloping) of the ribs on x-ray 

(B) Decreased carotid pulse 

(C) Left ventricular hypertrophy on ECG 

(D) Elevated sedimentation rate 

(E) Increased oxygen saturation gradient 
between the superior vena cava and the 
right ventricle 



14. The only son of a physiology instructor dies 
suddenly at the age of 12 years following wors- 
ening symptoms of tetralogy of Fallot. What 
would an autopsy reveal? 

(A) Dextroposition of the appendix 

(B) Brachiocephalic vein draining into the 
right renal vein 

(C) Inferior vena cava (IVC) draining to the 
superior mesenteric vein 

(D) Atrial Septal Defect (ASD) 

(E) Decreased vascularity of the lung field. 

15. After suffering a streptococcal throat infection, 
a 12-year-old immigrant boy develops cardiac 
symptoms that are attributed to rheumatic 
fever. Years later, at the age of 34 he is admitted 
to the hospital with pulmonary edema. Further 
examination reveals a diastolic murmur at the 
apex and mitral stenosis is diagnosed. Before 
surgical evaluation, which of the following 
findings can be attributed to mitral stenosis? 

(A) Large left ventricle 

(B) Indentation of the middle third of the 
esophagus by an enlarged left atrium 

(C) Notching of the ribs 

(D) Bounding, full pulse 

(E) Angina pectoris 

16. A 23-year-old ballet dancer is concerned about 
the recent sudden death of a young famous 
Russian dancer on a New York stage. The 
patient seeks advice about his own risk for 
developing cardiac disease. His father died 
suddenly from ischemic heart disease at the 
age of 40. What is the most important risk 
factor that would further indicate the possibil- 
ity of coronary artery heart disease? 

(A) Diabetes mellitus 

(B) Personality type 

(C) Elevated high-density lipoprotein 

(D) Elevation of total cholesterol/ 
high-density lipoprotein ratio 

(E) Obesity 



82 



4: Cardiac and Thoracic 



17. In evaluating the risk factors involved in advis- 
ing elective cholecystectomy in a 52-year-old 
man with heart disease, which of the following 
conditions should alert the surgeon to avoid 
an elective procedure? 

(A) MI 9 months earlier 

(B) Persistent nonspecific changes on ECG 

(C) Increased frequency and severity of 
attacks of angina 

(D) Elevated alkaline phosphatase levels 

(E) Hypertension controlled with diuretics 

18. After his first heart attack 3 years ago, a 63- 
year-old painter complained of central chest 
pains that radiated to the left arm after exercise. 
The pain was alleviated by nitroglycerin. 
Recently, he fell on a steel object and severed 
the median nerve and flexor tendons at the 
wrist. The skin was sutured but he is now 
scheduled to have a second operation that will 
require anesthesia. What is the best method to 
diagnose angina pectoris? 

(A) Cholesterol/high-density lipid ratio 

(B) Isoenzymes 

(C) Stress electrocardiography 

(D) Echocardiography 

(E) Chest x-ray 

19. Eight days after undergoing a hysterectomy, a 
64-year-old woman complains of chest pain. 
After 12 hours, the internist orders tests to 
exclude MI. Which test will most likely support 
this diagnosis? 

(A) Serum glutamic oxaloacetic 
transaminase (SGOT) elevation 

(B) Increased sedimentation rate 

(C) ""Tc pyrophosphate scintigraphy 
showing a "hot spot" 

(D) Thallium 201 ( 201 T1) scintigraphy 
showing a ("hot spot") 

(E) Dimethyliminodiacetic acid (HIDA) scan 

20. After undergoing repair of a left indirect 
inguinal hernia, a 72-year-old obese man is 
admitted to the emergency department with 
severe retrosternal pain of 1-hours duration. 
The pain radiates to the medial aspect of the left 



hand. The ECG shows Q waves and an ele- 
vated ST-segment. A diagnosis of acute MI is 
established 1 hour after admission. Immediate 
management should include which of the 
following? 

(A) Thrombolytic therapy with tissue 
plasminogen activator (tPA) 

(B) Vitamin K 

(C) Ampicillin, 2 mg tid PO 

(D) Hydrochlorthiazide, 50 mg/d 

(E) Sodium, nitroprusside 0.5 mg/kg/min 

21. Following recovery from an acute MI, a 44- 
year-old embryology lecturer is discharged 
from the hospital with what instructions? 

(A) Angiogram every 3 months to evaluate 
the degree of atherosclerosis 

(B) Nitroglycerin three times a day 

(C) Digoxin 

(D) 325 mg of aspirin on alternate days 

(E) Pacemaker insertion 

22. A 63-year-old woman fell while crossing the 
street after her Thursday afternoon bridge 
game. Attempts at resuscitation for cardiac 
arrest by the emergency medical service (EMS) 
team were unsuccessful. The woman had pre- 
viously been diagnosed as having aortic steno- 
sis and left ventricular hypertrophy. In addition 
to these factors, which of the following predis- 
poses to sudden cardiac death? 

(A) Split first heart sound 

(B) Hypokalemia 

(C) Soft murmur at left of sternum that 
varies with inspiration 

(D) Failure of the central venous pressure 
(CVP) to rise more than 1 cm H 2 with 
30-second pressure on the liver (hepato- 
jugular reflux) 

(E) CVPof-lcmH 2 

23. Three days after a patient underwent hip 
replacement for a fracture of the neck of the 
femur, the resident is called to examine the 
patient and notes hypotension ( 85/60 mm Hg) 
and a pulse rate of 104 beats per minute (bpm). 
Fluids are administered, but there is no 



Questions: 17-28 



83 



improvement. The ECG shows peaked T waves 
and ST-elevation. Bedside monitoring reveals a 
cardiac index (CI) of 1.7 L/min/m 2 (normal 
>2.2), stroke work index of 16 g/m 2 (normal 
>30), and a pulmonary artery wedge pressure 
(PAWP) of 22 mm Hg (normal <15). Urgent 
treatment should involve which of the 
following? 

(A) Rapid hypertonic saline solution 
administration 

(B) Adrenaline 

(C) Inotropic agents and, if necessary, 
intra-aortic balloon counterpulsation 

(D) Indomethacin 

(E) Atropine 

24. A 58-year-old neurologist is admitted to the 
emergency department with persistent hypoten- 
sion and shock following an acute MI. He is 
placed on an IABP Which following statement is 
true about IABP? 

(A) The balloon is inflated during systole. 

(B) The balloon is inflated during diastole 
and systole. 

(C) The pump must be removed after 
10 minutes. 

(D) The balloon usually is inserted via the 
femoral artery. 

(E) Use of an IABP worsens diastolic 
coronary blood flow. 

25. While lying on the examining table before 
colonoscopy, a 68-year-old electrician notes pal- 
pitations. The colonoscopy was scheduled as a 
routine procedure following removal of a 
benign polyp 1 year earlier. He had rheumatic 
fever in infancy. His atrial rate on ECG is 450 
bpm, and his ventricular rate is 160 bpm. His 
pulse rate is 88 bpm. The left atrium is enlarged. 
Similar findings were noted 1 year ago, but he 
declined to take any medication. Treatment 
should entail which of the following? 

(A) Continue with colonoscopy 

(B) Continue with colonoscopy after 
administration of parenteral antibiotics 

(C) Immediate administration of antibiotics 
and follow-up colonoscopy at a later date 



(D) Immediate administration of 
anticoagulation and digoxin and 
follow-up colonoscopy at a later date 

(E) Immediate electrocardioversion with a 
current of 300^00 J 

26. During routine clinical examination of a 23- 
year-old seeking consultation to remove a mole 
on her left cheek, she develops tachycardia 
with a pulse rate of 186 bpm. Her pulse is reg- 
ular and is otherwise asymptomatic. An ECG 
reveals supraventricular tachycardia. What 
should the treatment be? 

(A) Alternate pressure on the right and left 
carotid sinus 

(B) Bilateral simultaneous pressure over 
right and left carotid sinus 

(C) Deep eyeball pressure 

(D) Morphine sulfate, 4-8 mg IV, given 
cautiously 

(E) Electrical cardioversion 

27. After experiencing progressive chest pain for 
2 months, a surgical-supply store owner under- 
goes a CT scan that reveals a space-occupying 
lesion of the wall of the left atrium, which was 
confirmed to be a myxoma. There is no evi- 
dence of disease elsewhere. What would the 
next line of treatment be? 

(A) Excision of a myxoma performed with a 
bypass procedure 

(B) Excision of a myxoma performed 
without a bypass procedure 

(C) Insertion of a pacemaker 

(D) Chemotherapy 

(E) Radiotherapy 

28. During examination of a 49-year-old male 
schoolteacher who presents with a swelling in 
the neck, palpation by a bounding pulse. Which 
test would be most likely to establish a possible 
cause of the underlying condition? 

(A) Funduscopic eye examination 

(B) Liver-spleen scan 

(C) Thyroid function studies 

(D) X-ray of the chest and cervical spine 

(E) Carotid sinus pressure 



84 



4: Cardiac and Thoracic 



29. Following a car accident, a 52-year-old lawyer 
complains of pain in the left abdomen and 
back. After arrival of the EMS team, her pulse 
rate is 84 bpm, but of small volume. She states 
that she has some cardiac condition but is 
uncertain of its nature. Which is the most likely 
cause of the small pulse volume? 

(A) Aortic stenosis 

(B) Syphilis 

(C) Hyperthyroidism 

(D) Carcinoid syndrome 

(E) Aortic incompetence 

30. Stenosis of which of the following vessels is 
associated with the highest patency rates fol- 
lowing angioplasty or stenting? 

(A) Medial circumflex artery 

(B) Iliac artery 

(C) Superficial femoral artery 

(D) Popliteal artery 

(E) Tibial arteries 

DIRECTIONS (Questions 31 through 42): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. Each lettered option 
may be selected once. 

Question 31 

(A) History of angina and prior MI 

(B) Left ventricular ejection fraction of 
over 50% 

(C) Aortic stenosis 

(D) Signs of left ventricular failure 

(E) Lowered jugular venous distension 

(F) Minimal decrease in hematocrit 

(G) Presence of groin hernia 
(H) Decreased bowel motility 

31. A 83-year-old retired navy general shows 
improvement in claudication following aor- 
toiliac bypass surgery. What is the factor that 
would cause the greatest concern over the 
possibility of developing cardiac complica- 
tions? SELECT ONE. 



Questions 32 through 37 



(A 
(B 
(C 
(D 
(E 
(F 
(G 

(H 
(I 
(J 

(K 



A double aortic arch 

Tetralogy of Fallot 

PDA 

Coarctation of the aorta 

Tricuspid atresia 

Umbilical caput medusa 

Neurofibromatosis (von 

Recklinghausen's disease) 

Noncyanotic ASD 

Spider nevi 

Femoral AV fistula 

Beading (notching) of the ribs 



32. Cerebrovascular accident occurs most often in 
which? SELECT ONE. 

33. Dyspnea and dysphagia occur with what? 
SELECT ONE. 

34. Differential pressure in right arm and right leg 
indicates what? SELECT ONE. 

35. A child was born with congenital heart disease. 
The mother had rubella during pregnancy. The 
child has what? SELECT ONE. 

36. Notching of ribs occurs in what? SELECT 
ONE. 

37. Hypoplasia of the right ventricle occurs in 
what? SELECT ONE. 

Questions 38 and 39 

A 62-year-old black physician complains of headache, 
nocturia, and dysuria of 3 weeks duration. Rectal 
examination reveals a palpable mass in the prostate, 
and a biopsy confirms the presence of prostatic car- 
cinoma. He is advised to undergo prostatectomy. His 
blood pressure is 160/105 mm Hg. 

(A) Verapamil 

(B) Propanalol (inderal) 

(C) Deep eyeball pressure 

(D) Hydrochlorthiazide diuretic 

(E) Calcium phosphate 

(F) Digoxin 



Questions: 29-43 



85 



(G) Cardiac catheterization 
(H) Repeat blood pressure assessment in the 
supine position 
(I) Antihistamine 

38. The next step in management is which? 
SELECT ONE. 

39. The patient's blood pressure remains elevated 
when assessment is repeated on several occa- 
sions. Investigations fail to reveal an underly- 
ing cause of hypertension. Before surgery, he 
should receive what? SELECT ONE. 

Questions 40 and 41 

While undergoing a physical examination for life 
insurance purposes, a 46-year-old executive is noted 
to have a harsh systolic murmur in the left third and 
fourth parasternal area. Further evaluation, includ- 
ing echocardiography, reveals pulmonary stenosis. 

(A) Right ventricular/pulmonary artery 
gradient of 20 mm Hg 

(B) Right ventricular/pulmonary artery 
gradient of 65 mm Hg 

(C) Left ventricular hypertrophy 

(D) Right ventricular hypoplasia 

(E) Absence of symptoms 

(F) Hyperbaric oxygen 

(G) Surgical correction 

(H) Outflow tract (tunnel) to divert blood 
from the aorta to the right ventricle 
(I) Percutaneous balloon valvuloplasty 

40. The indication for surgery in pulmonary steno- 
sis is what? SELECT ONE. 

41. The appropriate treatment for significant pul- 
monary stenosis involves which? SELECT TWO. 

Question 42 



(A) Undergo cataract surgery after oral 
diuretic therapy 

(B) Undergo cataract surgery without 
general anesthesia 

(C) Be given a discharge order and referred 
to the cardiology clinic 

(D) Undergo electrocardioversion 

(E) Be given sodium nitroprusside 
intravenously 

(F) Undergo a CT scan of the head 

(G) Undergo central venous pressure 
monitoring 

(H) Undergo arterial blood gas (ABG) 
measurement 

42. Blood pressure assessment is repeated on two 
occasions, and the same measurements are 
obtained. What should he do? SELECT ONE. 

DIRECTIONS (Questions 43 through 54): Each of 
the numbered items or incomplete statements in 
this section is followed by five answers. Select the 
ONE lettered answer that is BEST in each case. 

43 . A 61 -year-old man with a long history of heavy 
smoking shows on computed axial tomogra- 
phy (CAT) scanning a right upper lobe tumor 
and enlarged paratracheal nodes. The tumor 
has been diagnosed as malignant by bron- 
choscopy. Your next move should be: 

(A) Esophagoscopy to rule out invasion of 
the esophagus. 

(B) Proceed with lobectomy and 
paratracheal node dissection. 

(C) Begin radiation of the tumor and 
paratracheal area. 

(D) Perform a mediastinoscopy for staging. 

(E) Wait 3 months and repeat CAT scan to 
evaluate further disease progression. 



On the day of admission for elective cataract sur- 
gery, an 84-year-old retired bus driver is noted to 
have a blood pressure of 255/120 mm Hg. 



86 



4: Cardiac and Thoracic 



44. A young man is shot at the level of the right 
sternoclavicular joint. His blood pressure is 
80/60 mm Hg, pulse 120 bpm, and a chest x- 
ray shows a right hydropneumothorax. The 
first step should be: 

(A) Insert a chest tube and observe for 
drainage. 

(B) Perform an immediate right thoracotomy. 

(C) Perform an angiogram to rule out great 
vessels injury. 

(D) Perform median sternotomy with 
extension along with right anterior 
boarder of the sternocleidomastoid 
muscle. 

(E) Perform a CAT scan with contrast, to 
evaluate extent of injury. 

45. A patient with a long history of smoking, dia- 
betes, and hypertension develops a carcinoma 
of the right lung. Along the staging process he 
presents enlarged right mediastinal (paratra- 
cheal) nodes that, upon biopsy, are found to 
contain cancer cells. He is at stage: 

(A) IAN0M0 

(B) IAN1M1 

(C) IAN1M0 

(D) IIIA 

(E) IV 

46. During a car crash a young man suffers bilateral 
multiple fracture ribs. He is alert and presents 
shortness of breath. His blood pressure is 
100/60 mm Hg and chest is unstable. Treatment 
for this is: 

(A) Prolonged intubation and ventilatory 
support until rib fractures heal along 
with aggressive bronchial toilette. 

(B) Once the patient is stable, open rib fracture 
reduction and stabilization with plates. 

(C) Fracture stabiliztion, with towel clips on 
ribs and attached to weights (external 
fixation). 

(D) Avoid intubation, control pain, and 
perform aggressive bronchial toilette. 

(E) Temporary extracorporeal circulation to 
allow fractures to heal. 



47. Immediately following a bout of pneumonia, a 
young woman develops a large pleural effu- 
sion. A chest tube is inserted and 600 mL of 
thin pus is obtained. A CAT scan shows incom- 
plete drainage and multiple intrapleural locu- 
lations. Management of this empyema requires: 

(A) Insertion of multiple chest tubes under 
CAT guidance to drain either most or all 
loculations. 

(B) Treat the patient with antibiotics and 
continue single chest tube drainage. 

(C) Treat patient with antibiotics and continue 
single chest tube drainage waiting for a 
thick peel to develop and then proceed 
with open total lung decortication. 

(D) Proceed with thoracoscopy and 
intrapleural toilette. Break the 
loculations and place drains. 

(E) A thorough open total lung 
decortication immediately. 

48. A 40-year-old woman treated for many years 
for gastroesophageal reflux develops dyspha- 
gia and weight loss. Previous esophagoscopy 
has revealed cellular atypia. An esophagoscopy 
is about to be performed. What is it most likely 
to reveal? 

(A) Leiomyoma arising from the long 
esophageal muscular layer 

(B) Squamous cell carcinoma arising from 
esophageal mucosal lining 

(C) Adenocarcinoma originated from 
islands of Barrett's esophagus 

(D) Adenocarcinoma extending from the 
stomach 

(E) A large ulcer at the gastroesophageal 
junction 

49. A young woman has suffered severe achalasia 
of the lower most esophagus. Attempted dila- 
tions have failed. The best treatment is: 

(A) Left thoracotomy and extensive 
myotomy 

(B) Resection of the gastoesophageal 
junction and reanastomosis 



Questions: 44-54 



87 



50. 



51. 



52. 



(C) Left thorcotomy, myotomy, and stomach 
wrap (fundoplication) 

(D) Laparoscopic myotomy and partial 
fundoplication 

(E) Transthoracic esophagogastrostomy 
(side-to-side) anastomosis to avoid 
disrupting the gastroesophageal 
sphincter 

Shortly after an esophagoscopy, the patient 
develops shortness of breath, chest pain, and 
fever. A contrast study shows extravasation of 
contrast into the left chest cavity. You should: 

(A) Perform a cervical esophagostomy, 
gastrostomy, insert a chest tube and 
begin high dose antibiotic therapy 

(B) Insert a nasogastric tube and begin high 
dose antibiotic therapy 

(C) Perform immediate left thoracotomy 
and repair the esophageal tear 

(D) Depoly an endoscopic intraesophageal 
stent to "plug the hole" 

(E) Stop all ingestion of food, insert a chest 
tube and begin high dose antibioic 
therapy 

An 80-year-old woman walks into the emer- 
gency room complaining of vomiting and 
severe retrosternal pain. This has happened 
many times in the past. A nasogastric tube is 
inserted and there is immediate clinical 
improvement. On chest x-ray the tube is found 
looped in the chest. This patient has: 

(A) A large diveticulum of the 
mid-esophagus 

(B) The tube perforated the esophagus 

(C) Achalasia 

(D) A short esophasus 

(E) A gastric volvulus 

The best treatment of this 80-year-old woman 
with vomiting retrosternal pain and a looped 
nasogastric tube in her left chest is: 

(A) Remove the tube because the patient is 
now well and discharged. 

(B) Evaluate the esophageal myotomy to 
treat achalasia. 



(C) Immediate left thoracotomy to treat 
perforation. 

(D) Consider surgical reduction of volvulus 
and diaphragmatic repair. 

(E) Do not consider any surgical repair 
because the patient is too old. 

53. While landing at the end of flight a young 
woman develops shortness of breath and right- 
sided pressure chest pain. She is tall and thin. 
The pain, although less in intensity, occurs 
during her menstrual periods. She has not pre- 
viously consulted a doctor. A chest film is likely 
to show? 

(A) Left pleural effusion 

(B) Pneumothorax 

(C) Dilated stomach 

(D) Widening of the mediastinum 

(E) Cardiomegaly 

54. And the treatment is: 

(A) Insertion of a chest tube 

(B) Immediate cardiology consult 

(C) Thoracentesis 

(D) Insertion of a nasogastric tube 

(E) A CAT scan 

DIRECTIONS (Questions 55 through 58): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. Each lettered option 
may be selected once. 

(A) Transvalvular gradient of 50 mm or 
more 

(B) History of congestive heart failure 

(C) Transient ischemic attacks (TIA) 

(D) Angina 

(E) Aortic insufficiency 

(F) Aortic dissection 

(G) Ventricular fibrillation 
(H) Mitral insufficiency 

(I) Acute MI 



88 



4: Cardiac and Thoracic 



55. A 50-year-old man has a systolic heart murmur 
best heard in the second interspace on the right 
side. He is increasingly short of breath. Which 
of the above clinical settings would determine 
the decision to operate? SELECT ONE. 



57. A 55-year-old man with a diastolic murmur 
heard in the second interspace on the right that 
radiates toward the apex of the heart. The cardiac 
index is normal at rest but decreases with exer- 
cise. The most likely diagnosis is? SELECT ONE. 



56. A 68-year-old female with aortic stenosis needs 
a valve replacement. Which of the above might 
result in a poor result for this patient? SELECT 
ONE. 



58. A 45-year-old tall, thin, male has acute onset of 
chest pain radiating into the back. In the emer- 
gency room his right radial pulse is bounding 
but his femoral pluses are absent. The most 
likely diagnosis is? SELECT ONE. 



Answers and Explanations 



4. 



(A) Ostium primum. Typically ostium primum 
in an adolescent would be diagnosed by 
increasing symptoms, increased pulmonary 
resistance, left axis on ECG, and a mitral regur- 
gitation murmur due to a cleft mitral valve. 
Ostium secundum would cause increased pul- 
monary resistance later in life, not at age 14. AV 
canal is seen most commonly in Down syn- 
drome. Right aortic arch and tetralogy of Fallot 
do not have this symptom complex. 

(E) Prostaglandin El and Aterial septotomy. 
Prostaglandin El is used to keep the ductus 
arteriousus open in transposition. Desaturated 
"systemic" blood can pass through the pul- 
monary circulation to be oxygenated. The ate- 
rial septotomy creates an ASD, which aids in 
saturated blood being pumped peripherally, 
decreasing the cyanosis. The mustard opera- 
tion is not commonly done as the arterial 
switch operation is most common in this era, 
and in this acutely ill neonate definitive oper- 
ation would not be the best initial treatment. 
Pulmonary artery banding does not apply 

(C) Internal thoracic artery. The internal tho- 
racic artery is the conduit of choice especially 
for grafting the left anterior descending (LAD) 
artery. Arterial and venous grafts 95% of the 
time do not occlude after 12. Seventy-five per- 
cent of patients under coronary artery bypass 
graft (CABG) survive 5 years. Mortality is 2% 
or lower in most centers. 

(D) Echocardiography. This patient has a peri- 
cardial effusion. Echocardiography is the most 
useful in making the diagnosis. CAT scan of the 



chest can be used but is not the best exam. The 
other choices do not apply. 

5. (E) Pericardial window. The patient developed 
decreased cardiac output (decreasing urine 
output,)and cardiac tamponade. Emergent 
pericardial window is the treatment of choice. 
Medical therapy will result in the patient's 
death. The other choices do not apply. 

6. (A) IABP increases coronary perfusion during 
distole. The IABP inflates during diastole and 
propels blood into the coronary circulation. 
IABP decreases peripheral resistance and 
decreases afterload on the heart. The IABP can 
stay in the patient for longer than 24 hours. 

7. (D) ICD. In a patient with history of MI, con- 
gestive heart failure, and decreased ejection 
fraction coupled with frequent premature ven- 
tricular beats studies have shown that this 
subset of patient benefits from internal cardiac 
defibrillators, as the most frequent cause of 
death in these patients is sudden cardiac death 
from ventricular fibrillation. Single and dual 
chamber pacemakers are used for bradyarry- 
thmias. The other choices do not apply 

8. (B) Increase in pulmonary vascular resistance 
causes an increased cardiac output. Small shunts 
(with a pulmonary/systemic flow ratio >1.5) do 
not require surgery but must be treated with 
prophylactic antibiotics. Larger shunts should be 
repaired, because the mortality rate exceeds 50% 
when severe pulmonary pressure (>85 mm Hg) 
occurs. Closure of the VSD in the presence of 
cyanosis with established reversal of the direction 



89 



90 



4: Cardiac and Thoracic 



of flow (right to left) would be detrimental, car- 
rying a very high mortality. 

9. (B) VSD is the most common cardiac congeni- 
tal abnormality and results from failure of 
fusion of the uppermost part of the interven- 
tricular septum with the aortic septum. 
Membranous septal defects account for 90% of 
VSDs. There is usually a left-to-right shunt and 
cyanosis does not occur until pulmonary 
hypertension is severe enough to reverse flow 
across the VSD. Surgery is indicated in large 
shunts only when symptoms occur and pul- 
monary hypertension is evident. Forty percent 
will close spontaneously in childhood. 

10. (D) Increase in pulmonary resistance would 
require more urgent intervention. Because 
nearly half the cases of VSD in childhood will 
close spontaneously elective surgery is deferred 
to late childhood. Banding procedures are used 
less frequently today because of the high mor- 
tality rate. If symptoms increase in severity and 
pulmonary pressure is high, more urgent inter- 
vention is indicated. If the pulmonary systolic 
pressure is over 85 mm Hg and the left-to-right 
shunt is small, surgical mortality exceeds 50%. 

11. (B) Management of compromised respiratory 
status in the premature infant with PDA 
includes fluid restriction, adequate oxygena- 
tion, attempted closure by medication with 
indomethacin, and surgical ligation (under- 
taken when indomethacin is contraindicated). 
Good results can be anticipated in the absence 
of other serious complications. 

12. (A) In full-term infants born with persistent 
PDA, the anomaly must be closed or excised 
between 6 months and 3 years of age to avoid 
cardiac complications, including endocarditis. 
In PDA, persistence of the communication 
between the pulmonary trunk and aorta 
increases pulmonary blood flow, left atrial 
flow, left ventricular flow, and ascending aorta 
flow. PDA accounts for 15% of all congenital 
cardiac abnormalities. Cyanosis does not occur 
initially, because oxygenated blood is shunted 
from the aorta to the pulmonary trunk. The 



murmur is continuous (sounds like machinery) 
and has harsh features. Its intensity is maxi- 
mum over the left second intercostal space but 
radiates to the chest wall and the neck. 

13. (E) Cardiac catheterization is the definitive test 
for confirming the diagnosis of ASD. It quanti- 
fies the size of the shunt and confirms the 
increase in oxygen saturation between the right 
ventricle and the superior vena cava. Beading 
of the ribs is seen in coarctation, and a 
decreased carotid pulse is found in aortic steno- 
sis. An elevated sedimentation rate occurs in 
the presence of infection such as bacterial 
endocarditis. 

14. (E) There is decreased vascularity of the lungs 
seen on chest x-ray. Tetralogy of Fallot includes 
VSD, right ventricular outflow obstruction, 
dextroposition of the aorta, and right ventricu- 
lar hypertrophy. Tetralogy of Fallot accounts 
for over one-half the cases of congenital cyan- 
otic heart disease. 

15. (B) Dilation of the left atrium is the obvious com- 
plication following long-standing mitral stenosis. 
Echocardiography is the simplest and most pre- 
cise method of showing enlargement of the left 
atrium. Frequently, there is a latency period of 
15-20 years before symptoms become evident. 
Important complications of mitral stenosis 
include exertional dyspnea caused by an increase 
in left atrial pressure and backup of blood with 
possible pulmonary edema, decreased cardiac 
output, atrial fibrillation, emboli (15%), and pres- 
sure in the intermediate third of the esophagus as 
seen on an esophogram after barium swallow. 
The pulse in mitral or aortic stenosis is reduced. 

16. (D) Elevation of total cholesterol/high-density 
lipoprotein is a useful predictor of coronary 
artery disease (CAD). Other known main risk 
factors include genetic predisposition, high 
cholesterol level, arterial hypertension, and cig- 
arette smoking. Obesity, diabetes mellitus, and 
personality type are of probable importance as 
independent risk factors. The presence of 
elevated high-density lipoprotein is a favor- 
able factor. 



Answers: 9-22 



91 



17. (C) Changes in the nature of angina should alert 
the physician to the possible progression of the 
underlying cardiac status. The pain may become 
more severe and more frequent, may last longer, 
and may occur with a lesser degree of exertion. 
Nocturnal pain should likewise signal concern. 
In the face of unstable angina, 30% of patients are 
likely to develop MI within a 3-month period. 

18. (C) In about one-quarter of patients with angina 
pectoris, the ECG findings will be normal. 
Exercise electrocardiography will reveal ST- 
segment depression and possibly precipitate 
symptoms if angina pectoris is present. There is 
a risk of myocardial death in patients tested, and 
patients with symptoms after minimal exertion 
and/or unstable angina are at particular risk 
with this procedure. If hypotension, ventricular 
arrhythmia, and supraventricular arrhythmia 
occur or if the ECG shows a fall in segment ST of 
over 3 mm, the test should be discontinued. 
In these cases, 201 T1 scintigraphy would be 
used to detect cardiac ischemia or infarction. 
Echocardiography during supine exercise may 
be a helpful test in selected circumstances. 

19. (C) 99m Tc pyrophosphate scintigraphy showing a 
"hot spot." Following injection of 99m Tc pyrophos- 
phate, scintigraphy may show a hot spot in the 
infarcted area. The hot spot is developed as the 
radiotracer forms a complex with calcium in 
necrotic tissue. The test should be requested 
within the first 18 hours following the onset of 
acute MI. It is not sensitive enough to detect 
small infarctions. Following 201 T1 scintigraphy, a 
"cold spot" occurs because of hypoperfusion. 
The test is performed where exercise or dipyri- 
damole (Persantine) injection can be given. 
SGOT levels are elevated in liver disease. The 
HIDA scan is used to exclude gallbladder dis- 
ease. Cardiac enzyme levels and ECG findings 
are useful to establish a diagnosis of MI. 

20. (A) Thrombolytic therapy intravenously with 
streptokinase, urokinase, or tPA is indicated 
in most patients with MI presenting early for 
treatment. This therapy, however, is effective 
only if initiated within 6 hours after the onset 
of pain in patients with acute MI. These drugs 



are fibrinogenolytic, and aspirin and heparin 
are frequently included in the anticoagulant 
protocol. Reperfusion rates of 60% can be 
anticipated; reocclusion rates of 15% usually 
occur. Vitamin K is not indicated, because it 
would increase the coagulability of blood. If 
a diuretic, such as hydrochlorothiazide, 25-50 
mg/d is indicated to treat milder hyperten- 
sion, hypokalemia must be avoided. 

21. (D) Studies have shown that in men over the 
age of 50, taking 1 tablet of aspirin (325 mg) on 
alternate days reduces the incidence of subse- 
quent CAD complications. Nitroglycerin is pre- 
scribed if angina pectoris develops, and 
digoxin would be indicated if congestive heart 
faliure (CHF) is evident. Progression of ather- 
osclerosis should be minimized by appropriate 
diet and exercise. The intake of excess of cho- 
lesterol and saturated fats in the diet causes 
changes in the vascular endothelium and 
smooth muscle proliferation, with subintimal 
fat and fibrous tissue accumulation leading to 
occlusion of the coronary arteries, their 
branches, and other arteries. 

22. (B) Sudden cardiac death is defined as an unex- 
pected death occurring within 1 hour after the 
beginning of symptoms in a patient who was 
previously hemodynamically stable. In asymp- 
tomatic patients presenting initially with car- 
diac disease, 20% will die within the first hour 
of symptoms. Electrolyte imbalance, hypoxia, 
and conduction system defect are additional 
factors that increase the risk of sudden death 
syndrome. Split first heart sound accentuated 
on inspiration occurs in normal individuals. In 
CHF, the CVP changes more than 1 cm when 
pressure is applied below the right costal 
margin to the liver (hepatojugular reflex) for a 
30-second period. 

New York Classification of Functional 
Changes in Heart Disease 



Class 


Limitation of Physical Activity 


I 


None 


II 


Slight 


III 


Marked 


IV 


Complete (even at rest) 



92 



4: Cardiac and Thoracic 



23. (C) The patient described has cardiogenic 
shock due to postoperative MI. The mortality 
rate for patients who develop MI is increased to 
more than 60% if hypotensive cardiogenic 
shock also supervenes. Pathology studies of 
patients dying after such episodes reveal that 
more than 40% of the heart will have infarcted. 
Inotropic drugs such as dobutamine are used. 
If a rapid response is not obtained, intra-aortic 
balloon tamponade is provided to unload the 
left ventricle during systole and increase dias- 
tolic coronary arterial flow. Hypertonic solu- 
tions in graded amounts would be given only 
if hypovolemia is evident. Atropine and adren- 
aline would be contraindicated. 

24. (D) The balloon usually is inserted via the 
femoral artery. The balloon is inflated during 
diastole and deflated during systole. It is 
important that the balloon be adequately 
deflated during systole to avoid damage to the 
left ventricle. The pump can be used for a few 
days if required. 

25. (D) The major complications occurring in 
atrial fibrillation are cardiac failure, coronary 
ischemia, and emboli. Emboli may lead to 
stroke. Urgent cardioversion is required in 
patients with auricular fibrillation if heart fail- 
ure, hypotension, or angina are also present. 
Immediate cardioversion is indicated in ven- 
tricular tachycardia or ventricular fibrillation. If 
treatment with lidocaine is ineffective, electro- 
cardioversion with 100-200 J for ventricular 
tachycardia or 300^00 J for ventricular fibril- 
lation is urgently indicated. 

26. (A)Alternate pressure over the carotid sinus 
for 20 seconds will end an attack of paroxysmal 
tachycardia in nearly one-half of cases. The 
procedure is contraindicated in patients who 
have had a cerebral TIA or those who have a 
carotid bruit. Bilateral simultaneous pressure 
on the carotid sinus carries an additional risk of 
stroke and must be avoided. The common 
carotid artery usually divides at the level of 
the upper border of the thyroid cartilage or 
hyoid bone (C3). The carotid sinus may be 
located either on the proximal internal carotid 
artery or distal common carotid bifurcation. 



Eyeball pressure may be effective but carries 
the risk of retina detachment. If initial measures 
are unsuccessful, the arrhythmia is treated with 
intravenous administration of verapamil or a 
similar drug. Electrocardioversion is indicated 
in severe cases, particularly if there are adverse 
symptoms caused by the tachycardia. 

27. (A) Myxomas constitute more than 50% of all 
primary cardiac tumors. They are usually poly- 
poid and attached to the septum. Sarcomas 
constitute 20-25% of primary cardiac tumors. 
Cardiac metastases are seen in patients with 
metastatic disease. 

28. (C) The pulse is bounding when the pulse pres- 
sure is magnified because of a wide difference 
between the systolic and diastolic pressure. It 
may be due to aortic incompetence, PDA, or 
noncardiac causes that result in increase in car- 
diac output and decreased peripheral resist- 
ance (e.g., hyperthyroidism, peripheral AV 
fistula, or anemia). 

29. (A) A small pulse occurs when the cardiac 
output is decreased and/or the peripheral 
resistance is increased. The pulse is reduced in 
aortic stenosis, heart failure, pulmonary hyper- 
tension, pulmonary incompetence, mitral 
stenosis, and pericardial effusion. The typical 
cardiac lesion in syphilis is aortic incompe- 
tence, which results in a forceful bounding 
pulse with a wide pulse pressure. Other non- 
cardiac conditions that result in an increased 
pulse pressure include hyperthyroidism, carci- 
noid syndrome, and aortic incompetence. 

30. (B) Angioplasty and stenting of the iliac vessels 
has a patency rate of 75% at 5 years; PTA and 
stenting of all other vessels has a much lower 
patency than bypass procedures. The FDA has 
only approved illiac artery stenting. 

31. (D) The single most serious prognostic sign for 
adverse changes after vascular surgery is the 
presence of CHE Every effort must be made to 
correct pulmonary congestion and improve left 
ventricular function before undertaking elec- 
tive procedures. MI occurring within 3 months 
before operation carries a high mortality rate 



Answers: 23-39 



93 



that will be reduced by delaying surgery for 
3-6 months when possible. 

32. (B) Cerebrovascular accident is the most impor- 
tant cause of death during the first year of life 
in patients with tetralogy of Fallot. Over 65% of 
patients with the tetralogy have cyanosis before 
1 year of age. These patients have more severe 
polycythemia and are particularly liable to 
develop cyanotic spells of unconsciousness, 
cerebral thrombosis, hemiplegia, and death. 
Brain abscess may develop subsequent to 
infarction and bacteria's entering the systemic 
circulation via a right -to-left shunt. 

33. (A) A double aortic arch implies that there are 
two arches of the aorta; one passes posterior to 
the esophagus and the other anterior to the tra- 
chea. The right side is more common than the 
left side, and usually one of the arches is 
smaller than the other. Respiratory difficulty 
with a labored type of respiration (often pre- 
cipitated by feeding) usually occurs within the 
first few months of life. Dysphagia occurs less 
frequently. Treatment is required only if symp- 
toms are troublesome. 

34. (D) Coarctation of the aorta is a relatively 
common anomaly and accounts for approxi- 
mately 15% of all congenital anomalies. The 
most common site of coarctation is immedi- 
ately distal (within 3-A cm) to the origin of the 
left subclavian artery. Normally, pressure in 
the lower extremity is higher than that in the 
upper extremity, but in coarctation of the aorta, 
the femoral pulses are absent or markedly 
reduced. Magnetic resonance imaging (MRI) 
(cine) of chest shows coarctation (Fig. 4-2). 

35. (C) In the fetus, the sixth left aortic arch diverts 
blood in the pulmonary artery away from the 
undeveloped lungs. After birth, the channel 
closes and becomes the ligamentum arteriosum. 
In rubella, a PDA may be associated with 
mental retardation and cataracts. Most cases 
of PDA occur without a clear-cut cause. 

36. (D) In the presence of coarctation of the aorta, 
left ventricular enlargement, hypertrophy, and 
failure to develop occur. As the child grows, 




Figure 4-2. 

MRI (cine) shows coarctation of the aorta distal to the left subclavian 
artery origin. 

collaterals develop between the subclavian 
artery and the aorta via the intercostal and 
internal thoracic vessels. In children older than 
8 years of age, the intercostal arteries cause typ- 
ical notching on the inferior margin of the ribs. 

37. (E) Tricuspid atresia accounts for 5% of cyanotic 
heart disease. Blood to the lungs is maintained 
by a PDA. 

38. (H) Repeat blood pressure assessment in the 
supine position. Hypertension can be defined as 
a diastolic pressure above 90 mm Hg or systolic 
pressure above 160 mm Hg. Anxiety in an office 
setting may provide a false high reading of 
blood pressure. The pressure usually decreases 
when the individual remains seated and still for 
a short while. Essential hypertension implies 
that there is no clear associated cause to explain 
the hypertension. Approximately 10-15% of 
white adults and 20-30% of black adults in the 
United States suffer from hypertension. 

39. (D) Diuretics and angiotensinogen-converting 
enzyme (ACE) inhibitors are more likely to 
be effective in elderly black men presenting 
with hypertension. ACE inhibitors inhibit 



94 



4: Cardiac and Thoracic 



the renin-angiotensin-aldosterone system, 
sympathetic nervous system activity, and 
bradykinin degradation and cause an increase 
in prostaglandin (vasodilator) synthesis. P- 
Blockers (e.g., propanalol) and calcium channel 
blockers (e.g., verapamil, nifedipine) are the 
first line of drugs chosen for young white men 
presenting with hypertension. 

40. (B) The presence of mild stenosis (valve gradi- 
ent/right ventricular pulmonary artery <30 
mm Hg) in asymptomatic patients does not 
require surgical correction; such patients can 
anticipate a normal life expectancy. Moderate 
to severe stenosis (right ventricular /pulmonary 
artery gradient of 50-80 mm Hg) requires sur- 
gical correction. 

41. (G, I) Percutaneous balloon valvuloplasty is 
now used in many centers as an initial 
approach to correct pulmonary stenosis. Right 
ventricular hypertrophy accounts for the 
parasternal heave noted on examination. Left 
ventricular hypertrophy does not occur conse- 
quent to pulmonary stenosis. Pulmonary steno- 
sis was once considered rare but now accounts 
for 10% of cases of congenital heart disease. 

42. (E) Sodium nitroprusside, 0.5-10 mg/kg/min 
IV, is given to patients (such as the one here) 
presenting as an urgent hypertensive emer- 
gency (e.g., symptomatic hypertension with 
systolic blood pressure >200 mm Hg, or asymp- 
tomatic with systolic pressure >240 mm Hg). 
Sodium nitroprusside lowers blood pressure 
by causing arteriolar and venous dilation. 
Untreated hypertension may lead to cardiovas- 
cular, cerebrovascular, and renal disease. Other 
complications of hypertension include pul- 
monary edema, aortic dissection, progressive 
atherosclerosis, accelerated (malignant) hyper- 
tension, and, in pregnant patients, eclampsia. 

43. (D) Next move should be sampling of mediati- 
nal nodes to stage this carcinoma of the lung. If 
the nodes are positive, the patient is not a sur- 
gical candidate. He needs chemo-radiotherapy 
Radiation to the mediastinal nodes should not 
begin without pathologic confirmation of nodal 
metastasis. Waiting constitutes malpractice. 



44. (D) This patient has probably suffered a pene- 
trating injury to the vessels of the thoracic outlet 
and/or superior mediastinum. Immediate oper- 
ation is needed. This incision gives excellent 
exposure on the right and also gives access to 
both chest cavities. 

45. (D) Positive ipsilateral parathracheal nodes 
defines stage IIIA. 

46. (D) In the past, prolonged intubation (internal 
fixation) was performed with enthusiasm 
because the pulmonary failure was thought to 
be secondary to chest wall instability. Today is 
known that pulmonary failure and breathing 
problems are due to lung contusion and pain, 
respectively. Avoiding intubation, controlling 
pain, and performing aggressive bronchial toi- 
lette yield better results. 

47. (D) During the early period of the fibrinopu- 
rulent stage of empyema, thoracoscopy is the 
standard of care. 

48. (C) Adenocarcinoma, originated from islands of 
Barrett's esophagus, is today the most common 
cancer of the esophagus in the United States. 

49. (D) Today, the standard of care for classic acha- 
lasia is laparoscopic myotomy and partial 
fundoplication. 

50. (C) Perforation of the esophagus is associated 
with serious complications and death. Earliest 
repair is mandatory. Antibiotics would also be 
given. The other choices allow an on-going leak. 

51. (E) The esophagus is not perforated because of 
the patient's dramatic improvement. Achalasia 
is usually accompanied by chronic dysphagia. 
Short esophagus does not present with severe 
retrosternal pain. The nasogastric tube is 
looped inside the intrathoracic, volvulated 
stomach and the patient has improved because 
of decompression. 

52. (D) Recurrent volvulus of the stomach into the 
chest is a serious condition that can lead to incar- 
ceration and gangrene. Every attempt should 
be made to repair this diaphragmatic hernia. 



Answers: 40-58 



95 



53. 



54. 



(B) The presentation itself should alert the clini- 
cian to the possibility of a pneumothorax (Fig 
4-3). This condition is seen quite frequently with 
patients that are thin and tall. This lady presents 
with a catamenial pneumothorax syndrome. 




Figure 4-3. 

Spontaneous pneumothorax on right side. 
(Reproduced, with permission, from Doherty GM: 
Current Surgical Diagnosis and Treatment, 12th ed, 
349. McGraw-Hill, 2006.) 



(A) This is the first documented pneumothorax 
on this patient. The treatment of choice is inser- 
tion of a chest tube. If the air leak persists for 



more than 3 days or if she develops a recur- 
rence after discharge, a thoracoscopy resection 
of bullae and pleurodesis becomes the treat- 
ment of choice. 

55. (A) The decision to operate in patients with 
aortic stenosis is based on transvalvular 
gradient. 50-mm gradient is termed critical 
aortic stenosis and the valve should be replaced 
in a symptomatic patient. 

56. (B) Congestive heart failure. In patients with 
aortic stenosis, risk factors include a history of 
agina, stroke or TIAs, and a history of conges- 
tive heart failure, which indicates a compro- 
mised left ventricle. Of the three, congestive 
heart failure is the factor which is the greatest 
risk factor for patients undergoing surgery. 

57. (E) Aortic insufficiency. This is the murmur of 
a patient with aortic insufficiency. Typically, 
these patients will be well compensated at rest 
but will have decreased cardiac output with 
exercise. These patients should be operated on. 

58. (F) Aortic dissection. This describes a patient 
with Marfan syndrome, who are typically at 
risk for aortic dissection. With dissection you 
may preserve right radial pulse but lose 
femoral pulses. 



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CHAPTER 5 



Stomach, Duodenum, and Esophagus 

Soula Privolous and Max Goldberg 



Questions 



DIRECTIONS (Questions 1 through 97): Each of 
the numbered items in this section is followed by 
five answers or by completions of the statement. 
Select the ONE lettered answer or completion that 
is BEST in each case. 



1. A 45-year-old man complains of burning epi- 
gastric pain that wakes him up at night. The 
pain is relieved by eating or using over-the- 
counter antacids and H 2 blockers. Diagnosis is 
best confirmed by which of the following? 

(A) Urea breath test 

(B) Serum gastrin levels 

(C) Barium meal examination 

(D) Upper endoscopy 

(E) Upper endoscopy and biopsy 

2. A 64-year-old woman with arthritis is a chronic 
NSAID user. She develops severe epigastric 
pain and undergoes an upper endoscopy. She 
is told that she has an ulcer adjacent to the 
pylorus. Which of the following is TRUE about 
the pylorus? 

(A) It cannot be palpated at laparaotomy 

(B) It is not covered completely by omentum. 

(C) It is a distinct anatomic entity that can 
be distinguished during laparotomy. 

(D) It is a true physiologic sphincter. 

(E) It is a site where cancer is rarely found. 



3. A 30-year-old executive learns that he has a duo- 
denal ulcer. His gastroenterologist prescribes and 
outlines medical therapy. The patient worries 
that if medical therapy fails he may need surgery. 
Which of the following is the best indication for 
elective surgical therapy for duodenal ulcer 
disease? 

(A) An episode of melena 

(B) Repeated episodes of pain 

(C) Pyloric outlet obstruction due to scar 
formation from an ulcer 

(D) Frequent recurrences of ulcer disease 

(E) Referral of pain to the back, suggestive 
of pancreatic penetration 

4. A 44-year-old dentist was admitted to the hos- 
pital with a 1-day history of hematemesis 
caused by a recurrent duodenal ulcer. He has 
shown considerable improvement following 
operative treatment by a truncal vagotomy and 
pyloroplasty 10 years prior to this incident. 
Which is TRUE of truncal vagotomy? 

(A) It is performed exclusively via the thorax. 

(B) It can be performed in the neck. 

(C) If complete, it will result in increased 
acid secretion. 

(D) It requires a gastric drainage procedure 

(E) It has been abandoned as a method to 
treat ulcer disease. 



97 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



98 



5: Stomach, Duodenum, and Esophagus 



5. A 42-year-old executive has refractory chronic 
duodenal ulcer disease. His physican has sug- 
gested several surgical options. The patient has 
chosen a parietal (highly selective) vagotomy 
instead of a truncal vagotomy and antrectomy 
because? 

(A) It results in a lower incidence of ulcer 
recurrence. 

(B) It benefits patients with antral ulcers the 
most. 

(C) It reduces acid secretion to a greater 
extent. 

(D) The complication rate is lower. 

(E) It includes removal of the ulcer. 

6. A 63-year-old woman is admitted to the hospital 
with severe abdominal pain of 3-hour duration. 
Abdominal examination reveals board-like rigid- 
ity, guarding, and rebound tenderness. Her 
blood pressure is 90/50 mm Hg, pluse 110 bpm 
(beats per minute), and respiratory rate is 
30 breaths per minute. After a thorough history 
and physical, and initiation of fluid resuscitation, 
what diagnostic study should be performed? 

(A) Supine abdominal x-rays 

(B) Upright chest x-ray 

(C) Gastrograffin swallow 

(D) Computerized axial tomography (CAT) 
scan of the abdomen 

(E) Abdominal sonogram 

7. A frail elderly patient is found to have an ante- 
rior perforation of a duodenal ulcer. He has a 
recent history of nonsteroidal anti-inflammatory 
drug (NSAID) use and no previous history of 
peptic ulcer disease. A large amount of bilious 
fluid is found in the abdomen. What should be 
the next step? 

(A) Lavage of the peritoneal cavity alone 

(B) Lavage and omental patch closure of the 
ulcer 

(C) Total gastrectomy 

(D) Lavage, vagotomy, and 
gastroenterostomy 

(E) Laser of the ulcer 



8. Three months after recovery from an operation 
to treat peptic ulcer disease, a patient com- 
plains that she has difficulty eating a large 
meal. A 99m Tc -labeled chicken scintigraphy 
test confirms a marked delay in gastric empty- 
ing. A delay in gastric emptying may be due to 
which of the following? 

(A) Zollinger-EUison syndrome (ZES) 

(B) Steatorrhea 

(C) Massive small-bowel resection 

(D) Previous vagotomy 

(E) Hiatal hernia 

9 . A 64-year-old supermarket manager had an elec- 
tive operation for duodenal ulcer disease. He 
has not returned to work because he has diarrhea 
with more than 20 bowel movements per day. 
Medication has been ineffective. The exact details 
of his operation cannot be ascertained. What 
operation was most likely performed? 

(A) Antrectomy and Billroth I anastomosis 

(B) Gastric surgery combined with 
choleystectomy 

(C) Truncal vagotomy 

(D) Highly selective vagotomy 

(E) Selective vagotomy 

10. A 40-year-old man has had recurrent symptoms 
suggestive of peptic ulcer disease for 4 years. 
Endoscopy reveals an ulcer located on the 
greater curvature of the stomach. A mucosal 
biopsy reveals Helicobacter, pylori. What is TRUE 
about H. pylori? 

(A) Active organisms can be discerned by 
serology. 

(B) It is protective against gastric carcinoma. 

(C) It is associated with chronic gastritis. 

(D) It causes gastric ulcer but not duodenal 
ulcer. 

(E) It can be detected by the urea breath test 
in <60% of cases. 

11. A 35-year-old CEO underwent an antrectomy 
and vagotomy for a bleeding ulcer. Although 
usually careful with his diet, he ate a large 



Questions: 5-17 



99 



meal during a business lunch. Within 1 hour, 
he felt lightheaded and developed abdominal 
cramping and diarrhea. His symptoms may 
be attributed to: 

(A) Anemia 

(B) Jejunogastric intussusception 

(C) Dumping syndrome 

(D) Afferent loop syndrome 

(E) Alkaline reflux gastritis 

12. A 63-year-old man has an upper gastrointestinal 
(UGI) study as part of his workup for abdomi- 
nal pain. The only abnormal finding was in the 
antrum, where the mucosa prolapsed into the 
duodenum. There were no abnormal findings 
on endoscopy. What should he do? 

(A) Sleep with his head elevated. 

(B) Be placed on an H 2 antagonist. 

(C) Undergo surgical resection of the antrum. 

(D) Be observed and treated for pain 
accordingly. 

(E) Have laser treatment of the antral 
mucosa. 

13. A 63-year-old man underwent gastric resection 
for severe peptic ulcer disease. He had com- 
plete relief of his symptoms but developed 
"dumping syndrome." This patient is most 
likely to complain of which of the following? 

(A) Gastric intussusception 

(B) Repeated vomiting 

(C) Severe diarrhea 

(D) Severe vasomotor symptoms after eating 

(E) Intestinal obstruction 

14. A 65-year-old man was admitted to the hospi- 
tal for severe bilious vomiting following gastric 
surgery. This occurs in which circumstance? 

(A) Following ingestion of gaseous fluids 

(B) Spontaneously 

(C) Following ingestion of fatty foods 

(D) Following ingestion of bulky meals 

(E) In the evening 



15. A 64-year-old man has had intermittent 
abdominal pain as a result of duodenal ulcer 
disease for the past 6 years. Symptoms recurred 
6 weeks before admission. He is most likely to 
belong to which group? 

(A) A and secretor (blood group antigen in 
body fluid) 

(B) B and Lewis antigen 

(C) AB 

(D) O and nonsecretor 

(E) O and secretor 

16. A 64-year-old man was evaluated for moderate 
protein deficiency. He underwent a gastrec- 
tomy 20 years earlier. He is more likely to show 
which of the following? 

(A) Porphyria 

(B) Hemosiderosis 

(C) Aplastic anemia 

(D) Hemolytic anemia 

(E) Iron deficiency anemia 

17. A 68-year-old woman has been diagnosed with 
a benign ulcer on the greater curvature of her 
stomach, 5 cm proximal to the antrum. After 3 
months of standard medical therapy, she con- 
tinues to have guaiac positive stool, anemia, 
and abdominal pain with failure of the ulcer to 
heal. Biopsies of the gastric ulcer have not iden- 
tified a malignancy. The next step in manage- 
ment is which of the following? 

(A) Treatment of the anemia and repeat all 
studies in 6 weeks 

(B) Endoscopy and bipolar electrocautery or 
laser photocoagulation of the gastric 
ulcer 

(C) Admission of the patient for total 
parenteral nutrition (TPN), treatment of 
anemia, and endoscopic therapy 

(D) Surgical intervention, including partial 
gastric resection 

(E) Surgical intervention, including total 
gastrectomy 



100 



5: Stomach, Duodenum, and Esophagus 



18. Investigations of a 43-year-old woman with 
pluriglandular syndrome were scheduled to 
determine if a gastrinoma (ZES) was present. 
The serum gastrin level was slightly elevated. 
Further assessment to establish the diagnosis can 
be made by repeating the serum gastrin level 
after stimulation with which of the following? 

(A) Phosphate 

(B) Potassium 

(C) Calcium 

(D) Chloride 

(E) Magnesium 

19. Over the past 6 months, a 60-year-old woman 
with long standing duodenal ulcer disease has 
been complaining of anorexia, nausea, weight 
loss and repeated vomiting. She recognizes 
undigested food in the vomitus. Examination 
and workup reveal dehydration, hypokalemia, 
and hypochloremic alkalosis. What is the most 
likely diagnosis? 

(A) Carcinoma of the fundus 

(B) Penetrating ulcer 

(C) Pyloric obstruction due to cicatricial 
stenosis of the lumen of the duodenum 

(D) ZES (Zollinger Ellison Syndrome) 

(E) Anorexia nervosa 

20. A 50-year-old woman presents with duodenal 
ulcer disease and high basal acid secretory out- 
puts. Secretin stimulated serum gastrin levels 
are in excess of 1000 pg/mL. She has a long his- 
tory of ulcer disease that has not responded to 
intense medical therapy. What is the most likely 
diagnosis? 

(A) Hyperparathyroidism 

(B) Pernicious anemia 

(C) Renal failure 

(D) ZES 

(E) Multiple endocrine neoplasia 

21. A 44-year-old man underwent partial resection 
of the stomach. Following the operation, there 
was a reduction in serum gastrin levels. The 
site of resection of the stomach that removed 
the normal source of gastrin is which of the 
following (Fig. 5-1)? 



Cardiac incisure 





OXYNT1C 




GLAND 




AREA 




w >^ 


*r+\ 


'-■ A. 




Figure 5-1. 

Site of gastrin release. (Reproduced, with permission, 
from Doherty GM: Current Surgical Diagnosis and 
Treatment, 12th ed. 509. McGraw-Hill, 2006.) 



(A) Gastroduodenal junction 

(B) Lower esophagus 

(C) Antrum 

(D) Body of the stomach 

(E) Fundus of the stomach 

22. A 50-year-old man presents with vague gastric 
complaints. Findings on physical examination 
are unremarkable. The serum albumin level is 
markedly reduced (1.8 g/100 mL). A barium 
study of the stomach shows massive gastric 
folds within the proximal stomach. These find- 
ings are confirmed by endoscopy. What is the 
correct diagnosis? 

(A) Hypertrophic pyloric stenosis 

(B) Gallstone ileus 

(C) Mallory- Weiss tear 

(D) Hypertrophic gastritis 

(E) Crohn's disease 



Questions: 18-28 



101 



23. A 2-cm ulcer on the greater curvature of the 
stomach is diagnosed in a 70-year-old woman 
by a barium study. Gastric analysis to maxi- 
mal acid stimulation shows achlorhydria. What 
is the next step in management? 

(A) Antacids, H 2 blockers, and repeat 
barium study in 6 to 8 weeks 

(B) Proton pump inhibitor (PPI) 

(e.g., omeprazole) and repeat barium 
study in 6 to 8 weeks 

(C) Prostaglandin E (misoprostol) 
and repeat barium study in 6 to 
8 weeks 

(D) Immediate elective surgery 

(E) Upper endoscopy with multiple 
biopsies (at least 8 or 9) for the ulcer 

24. A 55-year-old school bus driver was diagnosed 
3 months ago with an antral ulcer. He was 
treated for H. pylori and continues to take a 
PPI. Repeat endoscopy demonstrates that the 
ulcer has not healed. What is the next treat- 
ment option? 

(A) Treatment with H 2 blockers 

(B) Vagotomy alone without additional 
surgery 

(C) Endoscopy and laser treatment of the 
ulcer 

(D) Distal gastrectomy with gastroduodenal 
anastomosis (Billroth I) 

(E) Elevating the head of the bed when 
asleep 

25. A 70-year-old woman complains of abdominal 
discomfort, anorexia, and a 10-lb weight loss. 
Endoscopy reveals a polypoid lesion in the 
antrum. The lesion is biopsied and the patient 
is informed that she has early gastric cancer 
(EGC).Why? 

(A) Because it involves only the mucosa and 
does not invade the muscular wall of 
the stomach 

(B) Because it is demonstrable on a barium 
study 

(C) Because it has a 5 year survival rate of 5% 



(D) Because surgery always cures it 

(E) Because it does not require tumor free 
margins when resected 

26. A 62-year-old man presents with guaiac posi- 
tive stool. He is asymptomatic. Workup reveals 
a 2-cm ulcerated carcinoma on the antral lesser 
curvature. Tumor markers are negative. A CAT 
scan is negative for metastatic disease and lym- 
phadenopathy liver function tests are normal. 
What is the correct treatment for this patient? 

(A) Chemotherapy only 

(B) Radiation therapy only 

(C) Combination chemotherapy and 
radiation therapy without resection 

(D) Total gastrectomy 

(E) Distal gastrectomy with en bloc removal 
of lymph nodes 

27. A 55-year-old man complains of anorexia, 
weight loss, and fatique. A UGI study demon- 
strates an ulcerated lesion at the incisura. 
Where is the incisura? 

(A) Cardia 

(B) Fundus 

(C) Greater curvature 

(D) Lesser curvature 

(E) Gastrocolic ligament 

28. A 36-year-old man presents with weight loss 
and a large palpable tumor in the upper 
abdomen. Endoscopy reveals an intact gastric 
mucosa without signs of carcinoma. Multiple 
biopsies show normal gastric mucosa. A UGI 
study shows a mass in the stomach. At sur- 
gery, a 3-kg mass is removed. It is necessary to 
remove the left side of the transverse colon. 
What is the most likely diagnosis? 

(A) Gastric cancer 

(B) Gastrointestinal stromal tumor (GIST) 

(C) Choledochoduodenal fistula 

(D) Eosinophilic gastroenteritis 

(E) Linitis plastica 



102 



5: Stomach, Duodenum, and Esophagus 



29. A 74-year-old man presents with anorexia and 
self-limited hematemesis. During endoscopy a 
mass is discovered and a biopsy is done. A 
hematopathologis diagnoses non-Hodgkin's 
lymphoma. What is the recommended therapy? 

(A) Chemotherapy alone 

(B) Immunotherapy 

(C) Radiation and chemotherapy 

(D) Surgery radiation, and chemotherapy 

(E) Surgery alone 

30. A 63-year-old woman is admitted to the hospi- 
tal with a UGI bleed that subsides sponta- 
neously within a short time after admission. A 
barium study shows a gastric ulceration that is 
described by the radiologist as having a "dough- 
nut sign." What is the most likely diagnosis? 

(A) Lipoma 

(B) Gastric ulcer 

(C) Ectopic pancreas 

(D) GIST 

(E) Carcinoma 

31. A 50-year-old woman is diagnosed with multi- 
ple hyperplastic polyps in the stomach during 
endoscopy and biopsy. How are these best 
treated? 

(A) Total gastrectomy 

(B) Partial gastrectomy 

(C) Staged endoscopic removal after 
brushing for cytologic examination 

(D) Ablation by laser 

(E) No treatment other than repeated 
endoscopy and multiple brush biopsies 

32. During a surveillance upper endoscopy, a 
35-year-old woman who was successfully 
treated for multiple familial polyposis of the 
colon, is found to have several polyps in the 
antrum. Biopsies show adenomatous polyps. 
What is the best therapy? 

(A) Observation and repeated endoscopy at 
frequent intervals 

(B) Antrectomy 



(C) Endoscopic polypectomies with repeat 
endoscopy to monitor subsequent polyp 
development 

(D) Endoscopic laser ablation of the polyps 

(E) Total gastrectomy to remove all existing 
polyps and to prevent the formation of 
potential future polyps 

33. A 64-year-old woman presents with severe 
upper abdominal pain and retching of 1-day 
duration. Attempts to pass a nasogastric tube 
are unsuccessful. X-rays show an air-fluid level 
in the left side of the chest in the posterior 
mediastinum. An incarcerated paraesophageal 
hernia and gastric volvulus is diagnosed. What 
is the next step in management? 

(A) Insertion of a weighted bougie to 
untwist the volvulus 

(B) Elevation of the head of the bed 

(C) Placing the patient in the Trendelenburg 
position with the head of the bed lowered 

(D) Laparotomy and vagotomy 

(E) Surgery, reduction of the gastric volvulus, 
and repair of the hernia 

34. A 78-year-old woman undergoes an uncompli- 
cated minor surgical procedure under local anes- 
thesia. At the completion of the operation, she 
suddenly develops pallor, sweating, bradycardia, 
hypotension, abdominal pain, and gastic disten- 
sion. What is the next stem in management? 

(A) Rapid infusion of 3 L of Ringer's lactate 

(B) Digoxin 

(C) Insertion of a nasogastric tube 

(D) Morphine 

(E) Neostigmine 

35. A 35-year-old teacher has a family history of 
gastric cancer. She has an upper endoscopy per- 
formed for epigastric symptoms. The endoscopy 
is negative. The patient ask her endoscopist if 
there are any conditions that predispose to gas- 
tric carcinoma. He provides her with the fol- 
lowing answer. 



Questions: 29-41 



103 



(A) Environmental metaplastic atrophic 
gastritis (EM AG) 

(B) Autoimmune metaplastic atrophic 
gastritis (AMEG) 

(C) Menetrier's disease 

(D) Duodenal ulcer 

(E) Hiatal hernia 

36. A 48-year-old man undergoes surgery for a 
chronic duodenal ucler. The procedure is a 
truncal vagotomy and which of the following? 

(A) Gastroenterostomy 

(B) Removal of the duodenum 

(C) Closure of the esophageal hiatus 

(D) Incidental appendectomy 

(E) No further procedure 

37. A healthy 75-year-old man bleeds from a duo- 
denal ucler. Medical management and endo- 
scopic measures fail to stop the bleeding. What 
is the next step in management? 

(A) Continued transfusion of 8 U of blood 

(B) Administration of norepinephrine 

(C) Oversewing of the bleeding point 

(D) Oversewing of the bleeding point, 
vagotomy, and pyloroplasty 

(E) Hepatic artery ligation 

38. A 60-year-old woman undergoes vagotomy 
and pyloroplasty for duodenal ulcer disease. 
Gallstones are noted at the time of the original 
operation. Eight days following surgery, she 
develops abdominal pain and right upper 
quadrant tenderness. To determine if the gall- 
bladder is the cause of her symptoms, she 
should undergo which study? 

(A) Supine x-ray 

(B) Hepatobiliary scan (HIDA) 

(C) Ultrasound 

(D) Erect x-ray 

(E) Cholangiogram 



39. A recent immigrant to the United States has 
had persistent epigastric discomfort. He delays 
seeking treatment because he could not afford 
to pay a doctor. He finally went to the emer- 
gency department and was referred to an endo- 
scopist. A submucosal mass was seen and it 
was thought to be a GIST. The most common 
site of a GIST is which of the following? 

(A) Esophagus 

(B) Stomach 

(C) Jejunum 

(D) Ileum 

(E) Colon 

40. A 60-year-old woman complains of early sati- 
ety and undergoes an upper endoscopy. A 
small mass is seen in the antrum with sparing 
of the mucosa. GIST is suspected. A CAT scan 
of the chest, abdomen, and pelvis is performed. 
What does she require next? 

(A) Fulguration of the tumor 

(B) Distal gastrectomy 

(C) Laser therapy followed by radiation 
therapy 

(D) Chemotherapy alone 

(E) Total gastrectomy 



41. 



A 67-year-old woman complains of paresthe- 
sias in the limbs. Examination shows loss of 
vibratory sense, positional sense, and sense of 
light touch in the lower limbs. She is found to 
have pernicious anemia. Endoscopy reveals an 
ulcer in the body of the stomach. What does she 
most likely have? 

(A) Excess of vitamin B 12 

(B) Deficiency of vitamin K 

(C) Cancer of the stomach 

(D) Gastric sarcoma 

(E) Esophageal varices 



104 



5: Stomach, Duodenum, and Esophagus 



42. A 79-year-old retired opera singer presents 
with dysphagia, which has become progres- 
sively worse during the last 5 years. He states 
that he is sometimes aware of a lump on the left 
side of his neck and that he hears gurgling 
sounds during swallowing. He sometimes 
regurgitates food during eating. What is the 
likely diagnosis? 

(A) Carcinoma of the esophagus 

(B) Foreign body in the esophagus 

(C) Plummer- Vinson (Kelly-Patteson) 
syndrome 

(D) Zenker's (pharyngoesophageal) 
diverticulum 

(E) Scleroderma 

43. A symptomatic patient has a barium swallow 
that reveals a 3-cm Zenker's diverticulum. The 
next step in management is? 

(A) H 2 blockers 

(B) Anticholinergic drugs 

(C) Elemental diet 

(D) Bougienage 

(E) Surgery (cricopharyngeal myotomy 
and diverticulectomy) 

44. A 30-year-old psychiatric patient has a barium 
swallow after removal of a foreign body to rule 
out a small perforation of the esophagus. No 
perforation is seen, but an epiphrenic divertic- 
ulum is visualized. An epiphrenic diverticu- 
lum may be associated with which of the 
following? 

(A) Duodenal ulcer 

(B) Gastric ulcer 

(C) Cancer of the tongue 

(D) Cancer of the lung 

(E) Hiatal hernia 

45. A 64-year-old man develops increasing dys- 
phagia over many months. A barium swallow 
is performed. What is the most likely cause of 
his clinical presentation? 

(A) Carcinoma of the esophagus 

(B) Achalasia 



(C) Sliding hiatal hernia 

(D) Paraesophageal hernia 

(E) Esophageal diverticulum 

46. A 63-year-old woman from Norway is visiting 
the United States. She presents with dysphagia. 
On endoscopy, an esophageal web is identified 
and the diagnosis of Plummer-Vinson syn- 
drome is established. What would be the next 
step in management? 

(A) Esophagostomy 

(B) Dilatation of the web and iron therapy 

(C) Esophagectomy 

(D) Gastric bypass of the esophagus 

(E) Cortisone 

47. A 53-year-old moderately obese woman pres- 
ents with heartburn aggravated mainly by 
eating and lying down in the horizontal posi- 
tion. Her symptoms are suggestive of gastroe- 
sophangeal reflux disease (GERD). Which of 
the following statements is TRUE? 

(A) It is best diagnosed by an 
anteroposterior (AP) and lateral 
film of the chest. 

(B) It may be alleviated by certain drugs, 
especially theophylline, diazepam, and 
calcium channel blockers. 

(C) It is not relieved by cessation of 
smoking. 

(D) If it is associated with dysphagia, it 
suggest a stricture or motility disorder. 

(E) It should be immediately treated with 
surgery. 

48. A 64-year-old man has symptoms of reflux 
esophagitis for 20 years. The barium study 
shown (Fig. 5-2) demonstrates a sliding hiatal 
hernia. Whis is TRUE in sliding hiatal hernia? 

(A) A hernia sac is absent. 

(B) The cardia is displaced into the posterior 
mediatstinum. 

(C) Reflux esophagitis always occur. 

(D) A stricture does not develop. 

(E) Surgery should always be avoided. 



Questions: 42-51 



105 




Figure 5-2. 

Large sliding hiatal hernia. Diaphragmatic hiatis is encir- 
cled. (Reproduced, with permission, from Doherty GM: 
Current Surgical Diagnosis and Treatment, 12th ed. 467. 
McGraw-Hill, 2006.) 



49. A 45-year-old man presents with a long his- 
tory of heartburn, especially at night. He uses 
three pillows to sleep and has medicated him- 
self with a variety of antacids over the past 
15 years. Recently he has been complaining of 
dysphagia that he localized to the precordial 
area. Which is the most likely diagnosis? 

(A) Adenocarcinoma of the esophagus 

(B) Angina pectoris 

(C) Benign peptic stricture of the esophagus 

(D) Achalasia of the esophagus 

(E) Lower esophageal ring (Schatzki's ring) 

50. A 54-year-old man presents with dysphagia, 
heartburn, belching, and epigastric pain. A 
barium swallow shows a sliding hiatal hernia 
and a stricture situated higher than usual in the 



mid-esophagus. Endoscopic findings suggest 
Barrett's esophagus (ectopic gastric epithelium 
lining the esophagus). Marked esophagitis with 
linear ulcerations are seen during endoscopy. A 
biopsy shows columnar epithelium at the 
affected area and normal squamous epithelium 
above, confirming the diagnosis. What state- 
ment is TRUE regarding this condition? 

(A) Adenocarcinoma is less common in 
Barrett's esophagus 

(B) Most patients do not have associated 
gastroesophageal reflux 

(C) The presence of ectopic gastric lining 
protects against aspiration during sleep 
and prevents recurrent pneumonitis. 

(D) The present treatment is aimed at 
preventing esophagitis. 

(E) When strictures form, they are always 
malignant. 

51. A 75-year-old woman presents with a parae- 
sophageal hiatal "rolling" hernia. Diagnosis is 
made by radiologic studies (Fig. 5-3). What 
can this patient be told about paraesophageal 
hernias? 

(A) They constitute about 50% of all 
esophageal hiatal hernias and are more 
common in women over the age of 60. 

(B) They cause the gastroesophageal (GE) 
junction to become displaced from its 
normal position below the diaphragm to 
above the diaphragm. 

(C) They prevent herniation of the stomach 
and intestine above the diaphragm. 

(D) They may result in volvulus and 
stangulation of the stomach or bleeding. 

(E) They are treated medially with attention 
to diet, position during sleep, antacids, 
and omeprazole [H+/K+ adenosine 
triphosphate (ATP-ase) pump 
inhibitors] 



106 5: Stomach, Duodenum, and Esophagus 




Figure 5-3. 

Paraesophageal hernia. (Reproduced, with permission, 
from Doherty GM: Current Surgical Diagnosis and 
Treatment, 12th ed. 468. McGraw-Hill, 2006.) 



52. A 52-year-old gastroenterologist suffers from 
intermittent dysphagia attributed to the pres- 
ence of a lower esophageal stricture. The 
doctor's condition is characterized by which 
of the following? 

(A) A full thickness scar in the upper 
esophagus 

(B) Symptoms of mild-to-moderate 
dysphagia 

(C) A low incidence in men 

(D) The absence of a sliding hiatal hernia in 
most case 

(E) The need for antireflux surgery at an 
early stage 

53. A 54-year-old clerk complains of having had 
dysphagia for 15 years. The clinical diagnosis of 
achalasia is confirmed by a barium study. What 
is TRUE in this condition? 

(A) The most common symptom is 
dysphagia. 

(B) In the early stages, dysphagia is more 
pronounced for solids than liquids. 



(C) The incidence of sarcoma is increased. 

(D) Recurrent pulmonary infections are rare. 

(E) Endoscopic dilatation should be avoided. 

54. A 69-year-old man is admitted to the emergency 
department with an acute UGI hemorrhage fol- 
lowing a bout of repeated vomiting. Fiberoptic 
gastoscopy reveals three linear mucosal tears 
at the GE junction. What is the diagnosis? 

(A) Reflux esophagitis with ulceration 

(B) Barrett's esophagus 

(C) Carcinoma of the esophagus 

(D) Mallory- Weiss tear 

(E) Scleroderma 

55. A 60-year-old man presents with excruciating 
chest pain. The pain follows an episode of vio- 
lent vomiting that occurred after a heavy meal. 
Subcutaneous emphysema was noted in the 
neck. X-rays shows air in the mediastinum and 
neck, and a fluid level in the left pleural cavity. 
What is the most likely diagnosis? 

(A) Perforated duodenal ulcer 

(B) Spontaneous rupture of the esophagus 

(C) Spontaneous pneumothorax 

(D) Inferior wall myocardial infarction 

(E) Dissecting aortic aneurysm 

56. A patient is diagnosed with Boerhaave's syn- 
drome. Management involves which of the 
following? 

(A) Administration of intravenous 
antibiotics and TPN 

(B) Administration of intravenous 
antibiotics and TPN, and insertion of a 
chest tube and a nasogastric tube 

(C) Administration of intravenous 
antibiotics and TPN, and insertion of a 
nasogastric tube 

(D) Resuscitation and emergency surgery 
either by laparotomy or thoracotomy 

(E) Resuscitation, administration of 
intravenous antibiotics, replacement of 
fluids and electrolytes; elective surgical 
intervention when the general status of 
the patient improves 



Questions: 52-61 



107 



57. A chest CAT scan is done to further delineate 
an abnormality seen on a chest x-ray. The supe- 
rior mediastinum at the level of T4 is evaluated. 
Which structure is remote from the esophagus? 

(A) Trachea 

(B) Recurrent laryngeal nerves 

(C) Aorta 

(D) Azygous vein 

(E) Brachiocephalic vein 

58. A 69-year-old man is informed that the cause of 
his dysphagis is a benign lesion. The barium 
swallow is shown in (Fig. 5-4). What should he 
be told regarding benign tumors and cysts of 
the eosphagus? 




Figure 5-4. 

Leiomyoma of esophagus. Note smooth rounded density 
causing extrinsic compression of esophageal lumen. 
(Reproduced, with permission, from Doherty GM: Current 
Surgical Diagnosis and Treatment, 12th ed. 469. 
McGraw-Hill, 2006.) 

(A) They occur more commonly than 
malignant tumors. 

(B) They are symptomatic at an early age. 

(C) Diagnosis is best confirmed on chest 
x-ray. 

(D) Leiomyoma is the most common benign 
tumor encountered in the esophagus. 

(E) Malignant transformation of a benign 
leiomyoma into a malignant 
leiomyosarcoma is common. 



59. A 45-year-old pilot has retrosternal burning, 
especially when he eats and lies down to go to 
sleep. He has self-medicated himself with over 
the counter heartburn medications. Upper 
endoscopy reveals an erythematous and 
inflammed distal esophagus. In severe reflux 
esophagitis, the resting pressure of the LES is 
decreased. This may be physiologically 
increased by which of the following? 

(A) Pregnancy 

(B) Glucagon 

(C) Gastrin 

(D) Secretin 

(E) Glucagon 

60. A 46-year-old man has a long history of heart- 
burn (GERD). His barium study shows an 
irregular, ulcerated area in the lower third of his 
esophagus. There is marked mucosal disrup- 
tion and overhanging edges. What is the most 
likely diagnosis? 

(A) Sliding hiatal hernia with GERD 

(B) Paraesophageal hernia 

(C) Benign esophageal stricture 

(D) Squamous carcinoma of the esophagus 

(E) Adenocarcinoma arising in a Barrett's 
esophagus 

61. A 46-year-old man present with dysphagia of 
recent onset. His esophogram shows a lesion in 
the lower third of his esophagus. Biopsy of the 
lesion shows adenocarcinoma. His general 
medical condition is excellent, and his metasta- 
tic workup is negative. What should his man- 
agement involve? 

(A) Chemotherapy 

(B) Radiation therapy 

(C) Insertion of a stent to improve 
swallowing 

(D) Surgical resection of the esophagus 

(E) Combination of chemotherapy and 
radiation therapy 



108 



5: Stomach, Duodenum, and Esophagus 



62. 



63. 



A 25-year-old man arrives in the emergency 
department in respiratory distress following a 
motor vehicle collision. A chest x-ray shows 
abdominal viscera in the left thorax. What is the 
most likely diagnosis? 

(A) Traumatic rupture of the diaphragm 

(B) Sliding esophageal hernia 

(C) Short esophagus with intrathoracic 
stomach 

(D) Rupture of the esophagus 

(E) Bochdalek hernia 

A 32-year-old man undergoes a laparotomy for 
multiple organ injury resulting from trauma. He 
is discharged after 2 weeks in the hospital, only 
to be readmitted 3 days later because of abdom- 
inal pain and sepsis. The CAT scan shows an 
accumulation of fluid in the subhepatic space 
(Fig. 5-5). This space is likely to be directly 
related to an injury involving which structure? 



Subdiaphragmatic space 



Right — 
posterior 
subhepatic \ 
space 




Anterior 

subhepatic 

space 



Figure 5-5. 

Subhepatic space; anterior view. (Reproduced, with permission, 
from Doherty GM: Current Surgical Diagnosis and Treatment, 12th 
ed. 498. McGraw-Hill, 2006.) 



(A) Inferior pole of the right kidney 

(B) Stomach 

(C) Uncinate process of the pancreas 

(D) Aortic bifurcation 

(E) Right psoas muscle 

64. A 38-year-old man attempts suicide by ingest- 
ing drain cleaner fluid. His family brings him 
to the local emergency department. Which of 
the following is TRUE? 



65. 



66. 



67. 



(A) Copious neutralizing (acid) solutions 
should be given. 

(B) Emetics should be administered. 

(C) Stricture formation is inevitable. 

(D) Fluids and solid foods can usually be 
started several days after the injury. 

(E) Esophagoscopy should be performed to 
visualize the distal extent of the injury. 

A patient is admitted to the hospital after 
ingesting lye. The following day he complains 
of chest pain. His pulse is 120 bpm. On physi- 
cal examination he is found to have subcuta- 
neous crepitus on palpation. His chest x-ray 
shows widening of the mediastinum and a 
pleural effusion. What has occurred? 

(A) Aortic rupture 

(B) Coagulation necrosis 

(C) Esophageal perforation 

(D) Oropharyngeal inflammation 

(E) Spontaneous pneumothroax 

Following an emergency operation for hepatic 
and splenic trauma, the surgeon inserts a finger 
into the foramen of Winslow in an attempt to 
stop the bleeding. Which is TRUE of the hepatic 
artery? 

(A) It is called the common hepatic artery at 
this level. 

(B) It is medial to the common bile duct and 
anterior to the portal vein. 

(C) It is posterior to the portal vein. 

(D) It is posterior to the inferior vena cava. 

(E) It forms the superior margin of the 
epiploic foramen. 

A 44-year-old patient develops a mass on the 
anterior abdominal wall. He notes that the mass 
has gradually increased in size over the last 3 
months. On examination, the lesion is a 5 x 8 
cm mass in the left iliac fossa and hypogas- 
trium. Which test will establish whether the 
tumor is arising from the abdominal wall or the 
abdominal cavity? 

(A) Needle biospy 

(B) Ability to elicit a cough impulse 



Questions: 62-73 



109 



(C) Transillumination 

(D) Examination of the mass with the 
patient in a prone position 

(E) Examination of the mass with the 
patient instructed to attempt sitting up 

68. A 26-year-old man is diagnosed with adeno- 
carcinoma of the stomach. He wants to know 
what could have caused him to develop this 
condition. He does an internet search. Which of 
the following is a risk factor for developing 
gastric cancer? 

(A) Exposure to ionizing radiation 

(B) Blood group B 

(C) A diet high in fiber 

(D) H. pylori infection 

(E) North American descent 

69. A 44-year-old woman is scheduled for gastric 
surgery. She has no comorbid disease. The 
anesthesiologist has difficulty inserting the oro- 
tracheal tube. In between intubation attempts 
he uses an ambu-bag to oxygenate the patient. 
The patient's abdomen gets distended and 
tympany is noted in the left upper quadrant. 
Suddenly the patient becomes hypotensive. 
Which of the following can cause a vosogvagal 
response during anesthesia? 

(A) The gastric remnant following a distal 
gastrectomy 

(B) Corrosive gastritis 

(C) Pernicious anemia 

(D) Gastric volvulus 

(E) Acute gastric dilatation 

70. A 42-year-old taxi driver is diagnosed with a 
gastric tumor. He delays definitive therapy 
because he is afraid of losing his job. He finally 
has surgery and the mass is invading the trans- 
verse colon. Which of the following has the 
best long term survival despite local invasion? 

(A) Adenocarcinoma 

(B) Lymphosarcoma 

(C) Linitis plastica 



(D) Chordoma 

(E) GIST 

71. A 46-year-old man remains disease free follow- 
ing a total colectomy for familial adenomatous 
polyposis 24 years ago. He now presents with 
obstructive jaundice of 1 month's duration and 
guaiac positive stool. He does not have calculus 
disease. What is his diagnosis? 

(A) Adenomatous gastric polyps 

(B) Leiomyosarcoma 

(C) Lymphosarcoma 

(D) Linitis plastica 

(E) Ampullary carcinoma 

72. A 40-year-old woman complains of heartburn 
located in the epigastic and retrosternal areas. 
She also has symptoms of regurgitation. 
Endoscopy shows erythema of the esophagus 
consistent with reflux esophagitis. The patient 
has tried conservative measures, including PPls 
with no improvement in symptoms. Which of 
the following is TRUE? 

(A) Manometry does not add any additional 
information. 

(B) The 24-hour pH test is no longer used. 

(C) If endoscopy has been done, an 
esophagogram is unnecessary. 

(D) Nissen fundoplication is the surgical 
treatment of choice. 

(E) Toupet fundoplication is 360 nic nerve. 



73. 



A 50-year-old man is involved in a major motor 
vehicle collision and suffers multiple trauma. 
He is admitted to the intensive care unit. After 
2 days of hospital admission he bleeds mas- 
sively from the stomach. What is the probable 
cause? 

(A) Gastric ulcer 

(B) Duodenal ulcer 

(C) Hiatal hernia 

(D) Mallory- Weiss tear 

(E) Erosive gastritis 



110 



5: Stomach, Duodenum, and Esophagus 



74. 



75. 



76. 



77. 



A 65-year-old lawyer has an elective colon 
resection. On postoperative day number five, 
the patient develops fever, leukocytosis, and 
increasing abdominal pain and distension. An 
anastomotic leak is suspected. During the 
preparation for a CAT scan, fresh blood and 
coffee grounds are seen in the nasogastric tube. 
Acute stress gastritis is best diagnosed by? 

(A) CAT scan 

(B) UGI series 

(C) Angiogram 

(D) Capsule endoscopy 

(E) Upper endoscopy 

A previously healthy florist presents to the 
emergency department after vomiting blood 
in his flower shop. While waiting to be seen he 
has another episode of hematemesis. What is 
the most likely cause of his bleeding? 

(A) Peptic ulcer disease (stomach or 
duodenum) 

(B) Hiatal hernia 

(C) Mallory- Weiss tear 

(D) Gastric carcinoma 

(E) Esophagitis 

A 22-year-old student is involved in a motorcyle 
accident. He sustains multiple injuries includ- 
ing an intracranial hemorrage and a pelvic frac- 
ture. Despite ulcer prophylaxis he develops a 
UGI bleed. Which of the following is effective in 
protecting the gastric mucosa but has not 
proven useful in the management of erosive 
gastritis because of side effects (diarrhea)? 

(A) H 2 blockers 

(B) Intrinsic factor 

(C) Cortisone 

(D) Adrenaline 

(E) Protaglandin E (misoprostol) 

A 33-year-old man is admitted to the hospital 
for evaluation and treatment of a gastrojejunal 
ulcer. At age 25, he was treated surgically with 
an omental (Graham) patch for a perforated 
duodenal ulcer. At age 30, he was treated with 
a truncal vagotomy and antrectomy for a 
chronic duodenal ulcer. He now has a stomal 



78. 



79. 



(gastrojejunal) ulcer that is refractory to med- 
ical therapy. Which of the following should be 
checked? 

(A) Intrinsic factor 

(B) Gastrin level 

(C) Adrenaline 

(D) Corstisol 

(E) Potassium 

A 73-year-old woman is admitted to the hospi- 
tal with a mild UGI hemorrhage that stopped 
spontaneously. She did not require transfusion. 
She had ingested large amounts of aspirin in 
the past 4 months to relieve the pain caused by 
severe rheumatoid arthritis. Endoscopy con- 
firms the presence of a duodenal ulcer. A 
biopsy is done. What is the next step in the 
management of a duodenal ulcer associated 
with a positive biopsy for H. pylori? 



(A) 
(B) 
(C) 
(D) 
(E) 



H 2 blockers 



Bipolar electrocautery of the ulcer 
Triple therapy 
Photocoagulation 
Elective surgery 



A 52-year-old artist develops epigstric pain that 
is relieved by antacids. She also complains that 
her stool has changed color and is black and 
tarry. What is the most important cause of the 
entity presenting above other than H. pylori? 

(A) Submucosal islet cells 

(B) Hyperglycemia 

(C) Diet 

(D) Acid secretion 

(E) Acute erosive gastritis 



80. An 80-year-old grandfather gets admitted to 
the hospital for a UGI bleed. He undergoes 
upper endoscopy and bleeding ulcer is visual- 
ized. Attempts at endoscopic cauterization and 
epinephrine injection are unsuccessful at stop- 
ping the bleeding. A previous attempt at 
angioembolization was also unsuccessful. 
What is the next definitive step in therapy? 

(A) Elective surgery 

(B) High-dose antibiotics 



Questions: 74-85 



111 



(C) Blood transfusion 

(D) Repeated attempts at bipolar electocanter 

(E) Emergency surgery 

81. An elderly patient delayed seeking medical 
attention for his early satiety and weight loss 
because he attributed these changes to aging. 
When he underwent upper endoscopy a large 
mass was seen in the stomach. Which state- 
ment is TRUE regarding gastric carcinoma? 

(A) During resection, it is safe to leave 
cancer at the cut edges. 

(B) The incidence is increased in patients 
with gastric ulcer disease. 

(C) Draining lymph nodes should not be 
removed. 

(D) It is caused by diverticulitis. 

(E) It is associated with hyperchlorhydria. 

82. An alert nursing home patient is unable to 
swallow because of a neurologic disease and 
has lost a significant amount of weight. What 
treatment should be offered? 

(A) Central hyperalimentation 

(B) Intralipids 

(C) Percutaneous endoscopic gastrostomy 
(PEG) 

(D) Nasogastric feeding 

(E) Cervical esophagostomy 

83. A 32-year-old waitress is interested in learning 
about gastric bypass surgery. She consults her 
primary care physician to see if she is a candi- 
date. Her doctor refers her to an obesity center 
because? 

(A) She has not lost enough weight after her 
pregnancies. 

(B) She is hypertensive and overweight. 

(C) Her weight is 50 lb greater than her 
ideal body weight. 



(D) She has a body mass index (BMI) 
greater than 35 kg/mg. 

(E) She is tired of diet and exercise. 

84. A morbidly obese patient is told that he quali- 
fies for bariatric surgery. He is given several 
options. He chooses to undergo a gastric 
bypass procedure (GBP). Which of the follow- 
ing is TRUE? 

(A) Malabsorptive jejunoitial bypass is a 
more effective operation with less 
complications. 

(B) Vertical banded gastroplasty is 
technically easier and more effective 
than gastric bypass surgery. 

(C) Patients lose up to two-thirds of their 
excess weight. 

(D) Gastrojejunal leakage rate is in excess 
of 20%. 

(E) The gastric pouch capacity should be 
lOOcc. 

85. A 50-year-old gynecologist complains of dys- 
phagia, regurgitation, and weight loss. She also 
states that she feels as if food is stuck at the 
level of the xiphoid. An upright chest x-ray 
shows a dilated esophagus with an air-fluid 
level. Which of the following is FALSE? 

(A) A barium swallow will show a "bird's 
beak" deformity 

(B) Manometry will demonstrate that the 
LES fails to relax during swallowing. 

(C) Upper endoscopy should be avoided 
because of the risk of complications. 

(D) Medical treatment includes nitrates and 
calcium channel blockers. 

(E) Intersphincteric injection of botulinum 
toxin can be therapeutic. 



112 



5: Stomach, Duodenum, and Esophagus 



86. A patient has been diagnosed with achalasia. 
He refused surgery initially, preferring to try 
nonoperative therapy. He tried life style mod- 
ification, calcium channel blockers, botulin 
toxin injection, and endoscopic pneumatic 
dilatation. None of the treatments alleviated 
his symptoms. What are his surgical options? 

(A) Esophagectomy 

(B) Surgical esophagomyotomy proximal to 
theLES 

(C) Modified Heller myotomy and partial 
fundoplication 

(D) Repeat pneumatic dilation using 
pressures of loops 

(E) Nissen fundoplication 

87. A 50-year-old man presents to the emergency 
department with chest pain. The patient is eval- 
uated for an myocardioinfarction. The workup 
is negative. On further questioning, his symp- 
toms include dysphagia (with both liquids and 
solids). Which of the following is TRUE? 

(A) A barium swallow will always show a 
corkscrew esophagus. 

(B) Manometry shows simultaneous 
high-amplitude contractions. 

(C) Initial evaluation should exclude 
coronary artery disease. 

(D) A pulsion diverticulum may be present. 

(E) Patients refractory to medical 
management may respond to long 
e sop hagomy o tomy 

88. A 60-year-old man with a long history of GERD 
has worsening symptoms. He has an upper 
endoscopy that shows esophagitis. A biopsy is 
taken that shows intestinal metaplasia. Which 
of the following is TRUE? 

(A) Barrett's esophagus is more common in 
women. 

(B) 50% of patients with GERD have 
Barrett's esophagus. 

(C) High-grade dysplasia is an indication 
for prophylactic esophagectomy. 



(D) Cells typically found in the esophagus 
are columnar develop adenocarcinoma. 

(E) 100% of patients with Barrett's 
esophagus develop adenocarcinoma. 

89. A 60-year-old man has been having vague 
symptoms of upper abdominal discomfort, 
early satiety, and fatigue. He is referred to a 
gastroenterologist, who performs an upper 
endoscopy. Although a discrete mass is not 
visualized, the stomach looks abnormal. It does 
not distend easily with insufflation. A biopsy 
shows signet ring cells. Which of the folowing 
is TRUE? 

(A) Signet ring cells are typically found in 
intestinal type gastric adenocarcinoma. 

(B) Signet ring cell cancer is the most 
common type of gastric cancer. 

(C) "Leather bottle stomach" is a term used 
to describe a nondistensible stomach 
infiltrated by cancer. 

(D) The gross appearance of the stomach 
always shows classic findings of linitus 
plastica. 

(E) Linitus plastica has an excellent 
prognosis. 

90. A patient presents to the emergency department 
with obstructive jaundice. A percutaneous tran- 
shepatic cholangiogram and biliary drainage is 
performed. Shortly afterward, the patient devel- 
ops a UGI bleed. What is the most likely cause? 

(A) The patient has developed stress gastritis. 

(B) The patient has ingested NSAIDs after 
the procedure. 

(C) The patient has developed hemobilia. 

(D) The patient is bleeding from esophageal 
varices. 

(E) The catheter has migrated from the 
biliary tree into the stomach. 

91. A 56-year-old woman with Sjorgen's syndrome 
complains of fatigue and melena. She is pale 
and anemic. Endoscopy reveals ectatic vessels 
radiating from the pylorus. Which of the fol- 
lowing is TRUE? 



Questions: 86-97 



113 



(A) These findings are very common. 

(B) This condition occcurs exclusively in 
patients with autoimmune diseases. 

(C) The only treatment for this condition is 
surgery. 

(D) It occurs more often in men. 

(E) Ectatic vessels are frequently found in 
the colon. 

92. A known HIV positive patient complains of 
severe odynophagia. He avoids eating and 
drinking because of the intense pain, and he 
has lost a significant amount of weight. Which 
of the following is TRUE? 

(A) Esophagectomy is the treatment of 
choice. 

(B) Cancer is the only condition that can 
explain these findings. 

(C) UGI series is not useful. 

(D) Candida is the most common cause of 
infectious esophagitis. 

(E) Esophageal candidiasis is almost certain 
if the patient has oral thrush. 

93. A 54-year-old man presents with a massive 
UGI bleed. After resuscitation, endoscopy is 
performed. No esophageal varices, gastritis, or 
gastric ulcers are seen. After copious irrigation, 
a pinpoint lesion is seen near the GE junction. 
What can be said about this lesion? 

(A) It is a carcinoid. 

(B) It is related to alcohol use. 

(C) It is exclusively a mucosal lesion. 

(D) Surgery if first -line therapy. 

(E) Bleeding is from a submucosal vessel. 

94. A 60-year-old diabetic woman had a partial gas- 
trectomy 15 years ago for peptic ulcer disease. He 
now complains of nausea, vomiting, early satiety, 
and weight loss. She has palpable upper abdom- 
inal mass. She reluctantly agrees to have an 
upper endoscopy because she is fearful of being 
told that she has cancer. She is happy to hear 
that she does not have a maligancy and agrees to 
ingest meat tenderizer and have a repeat 
endoscopy. Which of the following is TRUE? 



(A) 


She has a GIST. 


(B) 


She is in denial. 


(C) 


She has a cancer at the gastrojejunal 




anastomosis. 


(D) 


A barium study is nondiagnostic. 


(E) 


She has a phytobezoar. 



95. A 65-year-old man has a chest x-ray done for an 
insurance physical. A posterior mediastinal 
mass is seen. After a complete evaluation, he is 
diagnosed with an esophageal duplication cyst. 
Which of the following is TRUE regarding 
these congenital cysts? 

(A) Communication with the true lumen is 
uncommon. 

(B) Malignant degeneration is common. 

(C) Most cysts are symptomatic. 

(D) All cysts should be removed. 

(E) Thoracoscopic excision is contraindicated. 

96. A patient has compressive symptoms of the 
esophagus. He has a barium esophagram that 
shows posterior extrinsic compression of the 
esophagus. Which of the following is true? 

(A) Vascular rings are acquired 
atherosclerotic lesions. 

(B) Both the trachea and esophagus can be 
affected by vascular rings. 

(C) The two most common types of 
complete vascular rings are double 
aortic arch and left aortic arch. 

(D) There is no role for Echo and Doppler. 

(E) Surgery involves division of the 
esophagus. 

97. A 70-year-old man has surgery for an abdomi- 
nal aortic aneurysm. About 1 month later the 
patient presents with a massive UGI bleed. 
Which of the following statements is TRUE? 

(A) He should be given PPLs and observed 
in the intensive care unit. 

(B) Most aortoenteric fistulas are primary. 

(C) Most aortoenteric fistulas occur between 
the aorta and duodenum. 

(D) It is not improtant to separate the aorta 
from the eosphagus after aortic surgery. 

(E) This condition is always fatal. 



Answers and Explanations 



1. (E) Duodenal ulcer is best diagnosed by upper 
endoscopy and biopsy. Findings of gastritis 
and the presence of H.pylori are indications to 
prescribe appropriate therapy. This typically 
includes a PPI and two antibiotics (one regimen 
includes amoxicillin and clarithromycin). 
Although the urea breath test is the most sen- 
sitive and specific test used to detect H. pylori, 
it is not readily available in all settings. 

2. (C) The pylorus is palpable but it is not a true 
physiologic sphincter. It does not demonstrate 
reciprocal contraction when the stomach 
relaxes, nor does it relax when the stomach 
contracts. The pylorus is normally in tonic con- 
traction It is partially covered by omentum and 
cancer is commonly found there. 



situations — intractable pain, hemorrhage, per- 
foration, and obstruction. Noncompliance with 
medication is often the cause of recurrence. 
Patients with gastic decompression need a naso- 
gastric tube and fluid and electrolyte correction 
prior to surgery. 

(D) If vagotomy alone is performed, gastric 
stasis occurs in more than 40% of cases. 
Branches of the vagus nerve innervate the 
pylorus. A drainage procedure is necessary; a 
pyloroplasty or a gastroenterostomy should be 
performed and both of these require a laparo- 
tomy. Truncal vagotomy can also be done 
through a thoracic approach. Transection of the 
vagus nerve in the neck results in paralysis of 
the recurrent laryngeal nerve. 



(C) Surgical intervention for peptic ulcer disease 
is uncommon. It is indicated by four clinical 



(D) In highly selective vagotomy (Fig. 5-6), 
the nerve supply to the pylorus is left intact 



Types of vagotomy 

A 



Truncal 



Selective 



Parietal cell 






Figure 5-6. 

Various types of vagotomy currently popular for treating duodenal ulcer disease. (Reproduced, with permission, 
from Doherty GM: Current Surgical Diagnosis and Treatment, 12th ed. 517. McGraw-Hill, 2006.) 



114 



Answers: 1-11 



115 



(and therefore no drainage procedure is nec- 
essary). During this operation, the branches of 
the vagus nerve that supply the parietal cell 
mass are meticulously divided, leaving the 
main anterior and posterior nerves of Latarjet 
intact. The main vagal trunks are also left 
intact, thus sparing the nerve supply to the 
liver, gallbladder, pancreas, and intestines. To 
ensure completeness of the procedure, great 
care is taken to divide the proximal (criminal) 
nerve of Grassi. Although the complication 
rate is lower, the recurrence rate is higher than 
that of an antrectomy and truncal vagotomy. 

6. (B) An upright chest x-ray will demonstrate 
free air below the diaphragm in about 70-75% 
of patients presenting with a perforated duo- 
denal ulcer. An abdominal sonogram may 
demonstrate free fluid, but not free air. 
Although a CAT scan will show both free fluid 
and free air, it will take longer to perform and 
may delay the definitive treatment. The com- 
bination of an acute abdomen and an upright 
chest x-ray with free air under the diaphragm 
provides enough information to take the 
patient to the operating room for exploration. 

7. (B) Although surgery is generally recom- 
mended for perforation, conservative measures 
can be considered in select cases. A patient who 
has a benign clinical presentation or one who is 
improving, might be considered for treatment 
with antibiotics and nasogastric decompression. 

Patients who have an acute abdomen and 
are hemodynamically unstable should not be 
observed. Board-like rigidity of the abdomen 
occur as a result of chemical peritonitis. These 
patients should have fluid and electrolyte 
repletion, and anitbiotics followed by surgery. 

Choice of the operative procedure should 
be guided by the information obtained during 
the history, the presence of comorbid disease, 
and hemodynamic stability during the opera- 
tion. A omental (Graham) patch will seal the 
ulcer, but it will not prevent recurrence. 

8. (D) Following truncal land selective vagotomy, 
gastric empyting is delayed. If a vagotomy (trun- 
cal or selective) is performed, a drainage 
procedure is necessary (e.g., pyloroplasty). A 



disturbance is gastric motility with a delay in 
gastric emptying may occur with a mechanical 
gastric outlet obstruction, diabetes, myxedema, 
hypokalemia, or the administration of anti- 
cholinergic or opiate drugs. Rapid gastric empyt- 
ing may be seen with ZES, retained gastric 
antrum syndrome, steatorrhea, or massive small- 
bowel resection where there is impared ability to 
reduce gastric acid secretion. Failure of switch-off 
mechanism to inhibit acid secretion also results 
in increased motility and emptying of the 
stomach. 

9. (C) Although a milder type of diarrhea is not 
uncommon after gastrectomy, fulminant diar- 
rhea may be a problem after vagotomy (it is one 
of the many complications collectively referred 
to as post vagotomy syndromes). The exact mech- 
anism is not known. It occurs in 1-2% of 
patients following truncal vagotomy and is less 
likely to be found after selective or highly selec- 
tive vagotomy. 

10. (C) H. pylori (previously called Campylobacter 
pylori) is associated with chronic gastritis, duo- 
denal ulcers, gastric ulcers, and gastric cancer. 
Serology can accurately detect H. pylori but 
remains positive for up to 1 year post treat- 
ment. The urea breath test is highly sensitive 
(96%) and specific (94%). In 2005, Barry 
Marshall and J. Robbin Warren won the Nobel 
Prize in medicine for their work on H. pylori 
and its role in gastritis and peptic ulcer disease. 

11. (C) Postgastrectomy syndromes collectively refer 
to complications that can occur after gastric 
surgery. This constellation of syndromes 
includes delayed gastric emptying, recurrent 
ulcers, diarrhea, anemia, jejunogastric intus- 
susception, afferent loop syndrome, alkaline 
reflux gastritis, and dumping syndrome. There 
are two types of dumping syndrome, early and 
late. Early dumping occurs within 30 minutes 
and is caused by rapid gastric emptying of a 
hyperosmolar load into the small bowel. Late 
(hypoglycemic) dumping occurs 1-3 hours 
after eating. Symptoms are mostly vasomotor. 
They are related to the excessive release of 
insulin in response to the rapid rise in post- 
prandial glucose. 



116 



5: Stomach, Duodenum, and Esophagus 



12. (D) Prolapse of gastric mucosa into the duode- 
num may be difficult to distinguish from a 
polyp in the antrum. It may be detected in a 
patient who is asymptomatic. Surgical correc- 
tion should be reserved for patients with 
obstructive symptoms (e.g., vomiting). 
Sleeping with they head elevated, H 2 antago- 
nist, and laser treatment have no role. 

13. (D) Dumping syndrome is a symptom complex 
ocurring after gastric surgery. It is character- 
ized by fatigue, abdominal distension, pain, and 
vasomotor symptoms caused by the rapid entry 
of food into the small intestine. Tachycardia, 
sweating, and feeling lightheaded after eating 
are symptoms patients may feel. There are two 
types of dumping syndrome, early and late. 

14. (B) Bilious vomiting is usually spontaneous 
and should be differentiated from vomiting 
that occurs after eating. The most likely cause 
of this complication is reflex of bile into the 
stomach. Bile gastritis with intestinalization of 
the gastric mucosa is a likely cause. 

15. (D) Group O is the most common blood type in 
patients with duodenal ulcer disease. In 
patients who have bled from a duodenal ulcer, 
this observation is even more striking. Secretors 
have an excess of blood group antigen that is 
absent in nonsecretors. The secretor antigen on 
the red blood cell appears in body fluids also. 
Nonsecretors are more prone to develop dueo- 
denal ulcers than secretors. 

16. (E) There is a varying degree of impairment in 
carbohydrate, fat, protein, and mineral absorp- 
tion after gastrectomy. These changes are most 
severe after a subtotal gastrectomy and gastro- 
jejunostomy (Billroth II) (Fig. 5-7), in most 
patients these changes are mild. An acid envi- 
ronment is necessary to release ferric ion from 
food and make it available for absorption in 
the small intestine. 

17. (D) In general, vagotomy with a gastric drainage 
procedure is less satisfactory in the treatment of 
primary gastric ulcer. Treatment of a gastric ulcer 
may include partial gastrectomy with a gastro- 
duodenal anastomosis (Billroth I). Vagotomy is 



Subtotal gastrectomy 
(Billroth II) 




Figure 5-7. 

Subtotal gastrectomy; Billroth 
II, (Reproduced, with permis- 
sion, from Doherty GM: 
Current Surgical Diagnosis 
and Treatment, 12th ed. 517. 
McGraw-Hill, 2006.) 



not necessary because gastric ulcers are usually 
not associated with acid hypersecretion. A gastric 
ulcer that fails to heal despite medical therapy 
should be excised. 

18. (C) In ZES gastrin levels may be only mildly 
elevated but can be increased with provoca- 
tion with intravenous calcium or secretin. Most 
patients with gastrinoma have serum gastrin 
levels that exceed 500 pg/mL. When the range 
is lower than 200-500 pg/mL, a stimulation 
test is performed to confirm the diagnosis. A 
rise of 200 pg/mL after 15 minutes, or a dou- 
bling of the fasting level is diagnostic. ZES can 
occur sporadically or as part of multiple 
endocrine neoplasia (MEN) I. 

19. (C) Chronic duodenal ulcer, with recurrent 
episode of healing and repair, may lead to 
pyloric obstruction due to scarring and stenosis 
of the duodenum. Painless vomiting of undi- 
gested food may occur once or twice a day. 
Surgical intervention should be carried out after 
correction of fluid and electrolyte imbalances. 
Preoperative antibiotics should be used due to 
bacterial overgrowth secondary to gastric statis. 

20. (D) ZES is characterized by duodenal ulcer dis- 
ease, high basal acid secretory output, and a 
pancreatic tumor. Stimulated serum gastrin 
levels may be in excess of 1000 pg/mL or as 



Answers: 12-29 



117 



high as 10,000 pg/mL. ZES is due to a true pan- 
creatic tumor in adults, but may be secondary to 
hyperplasia in children. Growth of the tumor is 
usually slow and survival is often prolonged. If 
an isolated tumor is found on CAT scan, sur- 
gical resection is indicated. About two-thirds 
of these tumors are malignant. About one-forth 
of patients have MEN I syndrome tumors of 
parathyroid pituitary and pancreas. 

21. (C) Gastrin is produced in the antrum, duode- 
num, and small intestine. It is not present in the 
fundus of the stomach. When the distal stomach 
is removed gastrin levels decrease significantly. 
Gastrin stimulates parietal cells to secrete acid 
and it stimulates chief cells to secrete pepsinogen. 

22. (D) Hypertrophic gastritis is characterized by 
massive loss of plasma protein through the 
affected gastric mucosa. Most cases can be 
managed medically by maintenance of ade- 
quate nutrition. An increased incidence of gas- 
tric cancer has been reported in some series. 

23. (E) The distinction between a benign and 
malignant ulcer can be difficult. The presence 
of achlorhydria rules out peptic ulceration. 
Endoscopy is indicated so that biopsy can be 
performed. 

24. (D) A gastric ulcer that does not respond to 
medical therapy requires surgical intervention. 
An appropriate operation for an antral ulcer is 
an antrectomy with a gastroduodenal anasto- 
mosis (Billroth I). Vagotomy is not nearly as 
effective in preventing recurrences in gastric 
ulcers. It is important to realize that the man- 
agement of gastric and duodenal ulcers is not 
identical because the etiologies are different. 
Duodenal ulcers are associated with acid 
hypersecretion while gastric ulcers are associ- 
ated with impaired mucosal defense mecha- 
nisms. Both are associated with H. pylori 
(duodenal ulcers 90% and gastric ulcers 75%). 
A gastric ulcer is much more likely to harbor a 
malignancy as compared to a duodenal ulcer. A 
gastric ulcer should always be biopsied. If a 
gastric ulcer fails to heal after appropriate med- 
ical management, it should be excised. 



25. (A) EGC is found only in the mucosa and sub- 
mucosa. Regional lymph nodes may or may 
not be involved. EGC can be missed on a UGI 
series (low sensitivity). Treatment is gastric 
resection with care to ensure that the resection 
margins and the anastomosis are tumor free. 
Selected cases may be treated by endoscopic 
mucosal resection. In the United States, EGC is 
found in only 15% of patients diagnosed with 
gastric cancer. In Japan the incidence is up to 
40%. Up to 14% of patients will have synchro- 
nous cancers. Five-year survival is 85-90%. 

26. (E) The treatment of an antral gastric cancer is 
distal subtotal gastrectomy with lymph node 
dissection (provided there is no metastatic dis- 
ease). Surgical resection is the only potential 
curative therapy. Proximal margins should be 
5-6 cm. Total gastrectomy does not improve 
5-year survival. Postoperative chemoradiation 
may increase 5-year survival (limited studies). 

27. (D) The incisura is located at the distal portion 
of the lesser curvature. It is the point at which 
the body of the stomach ends and the antrum 
begins. 

28. (B) GISTs were previously called leiomyosar- 
comas. They are rare (4% of all gastrointestinal 
tumors). They can cause confusion because the 
overlying mucosa may remain intact. They 
grow slowly, invade locally and are not respon- 
sive to radiation or chemotherapy. Eosinophilic 
gastroenterisit is an infiltrative lesion that usu- 
ally involves the gastric antrum. It is of 
unknown origin and differs from Menetrier's 
disease, where the mucosal folds of the proxi- 
mal stomach are intially involved. 

29. (C) The stomach is the most common site of 
involvement in extranodal non-Hodgkin's lym- 
phoma (NHL). Lymphoma is the second most 
common malignancy of the stomach. Surgery 
was previously the treatment of choice for gas- 
tric lymphoma. More recent studies show that 
nonoperative treatment with chemotherapy and 
radiation therapy results in similar 5-year sur- 
vival and is currently first-line therapy. Surgery 
is used mainly to treat complications of gastric 



118 



5: Stomach, Duodenum, and Esophagus 



lymphoma (e.g., perforation, bleeding). Mucosa 
associated lymphoid tissue (MALT) lymphoma 
is a type of NHL. It is associated with H. pylori. 
Treatment with a PP1 and antibiotics will cure up 
to 75% of low-grade MALTomas. 

30. (D) A GIST (previously called leiomyoma or 
leiomyosarcoma) can occur in any part of the 
stomach. Most commonly they are found in 
the submucosa and grow towards the lumen. 
Ulceration may occur and give rise to the char- 
acteristic "doughnut sign" on barium studies. 
Hematemesis and/or melena may sometimes 
be massive. Local resection is curative. 

31. (C) Hyperplastic polyps are unlikely to harbor 
carcinoma. Multiplicity of hyperplastic polyps 
does not seem to predispose to the develop- 
ment of cancer. Adenomatous polyps occur 
more commonly in the antrum. Hyperplastic 
polyps are distributed more evenly throughout 
the stomach. For this reason, antral polyps 
should be removed first. (Adenomatous polyps 
may have a focus of cancer within them.) 

32. (C) Adenomatous polyps of the stomach 
resemble colon polyps. Coexisting carcinoma 
may be present in up to 20% of cases. The inci- 
dence of carcinoma is increased if lesions are 
larger than 2 cm. Both hyperplastic and ade- 
nomatous polyps are more common in long- 
term follow-up of patients treated successfully 
for familial polyposis. All adenomatous polyps 
should be removed. 

33. (E) Gastric volvulus is often associated with a 
large paraesophageal hiatal hernia. The twist 
causes a cut-off at the cardia above and at the 
pylorus below leading to distension and 
ischemia, which may progress to gangrene. 
Organoaxial volvulus is more common and 
rotation occurs along the axis between the 
cardia and the pylorus. In the less common 
type of gastric volvulus, rotation occurs 
through an axis that is at the right angle to the 
organoaxial axis described. 

34. (C) Acute gastric distension can lead to a vaso- 
vagal reaction. Treatment consists of nasogas- 
tric decompression for 24-48 hours to allow 



normal gastric tone to return. Appropriate par- 
enteral fluids should also be administered. 

35. (B) Autoimmune metaplastic atrophic gastritis 
is associated with hypochlorhydria parietal 
cell antibodies, and high gastrin levels. There 
is an increased risk for developing gastric car- 
cinoid tumors or adenocarcinomas. Other pre- 
malignant conditions include adnomatous 
polyps, gastric ulcer, previous gastric resec- 
tion (>15 years), chronic atrophic gastritis, and 
histologic changes showing intestinal meta- 
plasia and dysplasia. 

36. (A) In 1948, Dragstedt introduced a gastric 
drainage procedure to overcome stasis that 
occurred in over 30^0% of cases following 
vagotomy. Pyloroplasty, gastrojejunostomy and 
antrectomy are the three recognized drainage 
procedures performed in conjunction with vago- 
tomy. The decision on which one to perform is 
based on the overall condition of the patient and 
the severity of the ulcer, amongst other things. A 
drainage procedure is not necessary with a 
highly selective vagotomy because the innerva- 
tion to the pylorus is left intact. 

37. (D) In general, surgery for peptic ulcer bleeding 
is indicated at an earlier stage in an older patient 
because vessels are atherosclerotic and less 
likely to stop bleeding spontaneously. In addi- 
tion, diminished perfusion of the heart, brain, 
and kidneys is less well tolerated in elderly 
patients. At surgery, the gastroduodenal artery 
is oversewn, and a vagotomy and drainage pro- 
cedure is performed. 

38. (B) The scan will fail to visualize the gallbladder 
if acute cholecystitis is present. In a patient with 
cholelithiasis, the incidence of cholecystitis and 
associated biliary complications is increased fol- 
lowing truncal vagotomy. A sonogram will 
show gallstones but may not distinguish acute 
cholecystitis. 

39. (B) GIST is the most common sarcoma of the 
gastrointestinal tract. It is most commonly found 
in the stomach (60-70%). Other sites include 
small intestine (25%), rectum (5%), esophagus 
(2%), and other less frequent locations. It may be 



Answers: 30-49 



119 



difficult to distinguish between malignant and 
benign GISTs. Factors that are correlated with 
improved prognosis include gastric location, 
low mitotic index <2 cm diameter, and absence 
of tumor rupture and spoilage during resection. 

40. (B) If the mass is deemed resectable, the goal of 
surgery is resection with grossly negative mar- 
gins. Precautions should be taken to prevent 
rupture of the mass. Radiation and chemother- 
apy have traditionally been ineffective. Clinical 
trials with the drug imatinib mesylate (Gleevec) 
are promising. 

41. (C) Patients with pernicious anemia have 
achlorhydria and an increased risk (about 5%) 
of developing gastric carcinoma. There is a 
deficiency in vitamin B 12 that leads to mega- 
loblastic anemia and neurologic involvement 
(subacute degeneration of the dorsal and lateral 
spinal columns). 

42. (D) A Zenker's (pharyngoesophageal) diver- 
ticulum is a mucosal outpouching through the 
triangular bare area between the cricopharyn- 
geus muscle and the inferior constrictor muscle 
of the pharynx (Killian's triangle). Most present 
on the left side of the neck. 

43. (E) The current surgical treatment for a symp- 
tomatic pharyngoesophageal diverticulum is 
myotomy. If the diverticulum is >2 cm, it should 
be resected. Small asymptomatic diverticulae 
require no treatment. Failure of relaxation of 
the cricopharyngeus muscle is thought to result 
in the development of the diverticulum. 

44. (E) An epiphrenic (supradiaphragmatic) diver- 
ticulum is a pulsion diverticulum and is asso- 
ciated without any obvious lesions (35%) or 
with hiatal hernia (30%), diffuse esophageal 
spasm (DES) (20%), achalasia (10%), and mis- 
cellaneous causes (5%). It is located with 10 cm 
of the cardia. An epiphrenic diverticulum is 
commonly asymptomatic and should not be 
treated surgically unless symptoms are clearly 
related to it. Parabronchial lymphadenopathy 
can cause traction diverticulae (which are 
located at a higher level). 



45. (A) The appearance of unexplained dysphagia in 
adults requires urgent evaluation. Esophageal 
carcinoma is particularly prevalent in certain 
parts of Africa and Asia, but the incidence is 
increasing in Western countries. In achalasia 
there is initially a greater tolerance for solids over 
liquids. In carcinoma, dysphagia for solids is 
noted initally, and later there is difficulty in swal- 
lowing liquids as well. Esophagoscopy is 
required in the workup of dysphagia. It is imper- 
ative to rule out an underlying carcinoma. 

46. (B) In addition to the presence of an upper 
esophageal web leading to dysphagia, the 
Plummer- Vinson syndrome is characterized by 
atrophic oral mucosa, spoon-shaped brittle nails 
(koilonychia), and iron deficiency anemia. 
Endoscopy reveals a fibrous web just below the 
cricopharyngeus muscle. There is an increased 
risk of developing cancer of the esophagus. 

47. (D) Nonoperative therapy is the initial treat- 
ment of GERD. The treatment is weight loss, 
avoidance of fatty meals, smoking cessation, 
abstinence from alcohol, positional awareness, 
avoidance of lying supine, and avoidance of cer- 
tain foods (e.g., chocolate) and drugs (e.g., theo- 
phylline, anticholinergic agents, a-adrenergic 
antagonists). Dysphagia requires special atten- 
tion to rule out a stricture, cancer, or a motility 
disorder. Poor results are more likely when pre- 
vious surgery has failed and in patients with 
scleroderma. 

48. (B) The cardia is displaced into the posterior 
mediastinum. The term sliding hernia (Fig. 5-8) 
indicates that a part of the peritoneum slips or 
slides with the hernia into the posterior medi- 
astinum. The wall of the sac is formed medially 
by the stomach and laterally by the peritoneum. 
Reflux esophagitis is more likely to occur with 
this type of hernia. The sliding hiatal hernia may 
be entirely symptomatic or lead to reflux 
esophagitis and possibly esophageal stricture. 

49. (C) Benign peptic strictures of the esophagus 
are submucosal fibrotic rings that narrow the 
lumen and obstruct the passage of food. They 
present with dysphagia. They tend to be 



120 



5: Stomach, Duodenum, and Esophagus 



Esophagus 



Card oesophageal 

junction 



Peritoneal 
reflection 

Diaphragm 



Phrenoesophageal 
ligament 




Esophagus 



Peritoneal reflection 



Herniated portion 
of stomach 



Diaphragm 



Phrenoesophageal 
ligament 



Intra-abdominal portion 
of stomach 



Figure 5-8. 

Sliding esophageal hiatal hernia; correlate with x-ray in 
Fig. 5-2. (Reproduced, with permission, from Doherty 
GM: Current Surgical Diagnosis and Treatment, 12th ed. 
467. McGraw-Hill, 2006.) 

between 1 and 4 cm in length. GERD is the 
most common cause. Other associated motility 
disorders often occur. Heartburn may improve 
because of the obstruction to refluxed bile. 

50. (D) The present treatment is aimed at prevent- 
ing esophagitis. Barrett's esophagus is regarded 
as a premalignant condition and is character- 
ized by columnar metaplastic of the normal 
squamous epithelial lining of the esophagus. 
The cancer risk is increased 20-50-fold. About 
one-third of patients present with malignancy 
and many cases of adenocarcinoma of the 
esophagus arise from Barrett's mucosa. There is 
an increased risk for the development of squa- 
mous carcinoma. It is found in 8-10% of 
patients with long standing reflux. 

51. (D) This is a type 4 hiatal hernia (Fig. 5-9). In 
the classic case of a paraesophageal "rolling" 
hernia, the GE junction remains below the 
hiatus, allowing the stomach and sometimes 
other viscera to migrate upward into the chest 
alongside the esophagus. Paraesophageal her- 
nias are prone to obstruction, bleeding, and 
volvulus (either mesoaxial or organoxial rota- 
tion). Chronic symptoms include pain and 
postprandial fullness, with heartburn in 90% of 
cases. Gastric ulcers develop in as many as 30% 
of cases and they may cause acute or chronic 



Card i oesophageal 

junction 

Phrenoesophageal 
ligament 



Diaphragm 




Herniated portion 

of stomach 



Peritoneal 
reflection 



Diaphragm 



Intra-abdominal portion 
of stomach 

Figure 5-9. 

Paraesophageal hernia; correlate with x-ray in Fig. 5-3. 
(Reproduced, with permission, from Doherty GM: 
Current Surgical Diagnosis and Treatment, 12th ed. 468. 
McGraw-Hill, 2006.) 

(MISSING BOTTOM LINE) indicated and 
effective to relieve symptoms and to prevent 
complications, which may be catastropic. 

52. (B) Schantzki's ring is a thin, circumferential 
scar in the lower esophagus, more common in 
men (65) or greater. It is acquired and probably 
results from repeated trauma to the mucosa 
with chronic inflammation and fibrosis. 
Endoscopic dilation is the usual treatment. It is 
usually successful but antireflux surgery is 
occasionally necessary for severe GERD, espe- 
cially if it is worsened by dilatation. Associated 
hiatal hernia is very common. 

53. (A) Dysphagia in esophageal achalasia is 
described as paradoxical in that it is more pro- 
nounced for liquids than solids. There are 
numerous reports of an increased incidence of 
carcinoma in achalasia, ranging from 3% to 
10%. In 1975, Belsey reported a 10% incidence 
in 81 patients in whom symptoms tended to 
occur at a younger age. Recurrent lung infec- 
tions from aspiration of esophageal contents 
are a troublesome complication. The treatment 
is surgical myotomy or endoscopic dilatation. 

54. (D) A Mallory-Weiss tear is characterized by 
acute and sometimes massive UGI hemorrhage. 
It accounts for up to 10% of UGI bleeds. It is due 
to arterial bleeding following repeated vomiting 
(which causes mucosal tears at the GE junction). 



Answers: 50-61 



121 



The cause is the same as that for spontaneous 
rupture of the esophagus (i.e., an increase in 
intra-abdominal pressure against a closed glot- 
tis). Causes other than vomiting such as parox- 
ysmal coughing or retching, may sometimes 
lead to this condition. Upper endoscopy con- 
firms the diagnosis. Surgery may occasionally 
be necessary to stop the bleeding. 

55. (B) Spontaneous rupture of the esophagus, or 
Boerhaave's syndrome, is most common in men 
between 35 and 55 years of age. The usual pres- 
entation is severe pain in the precordium, lower 
thorax, or epigastrium. Clasically it follows an 
episode of violent vomiting. A chest film show 
hydropneumothorax usually on the left side, 
but it may be on the right side or bilateral. Free 
air below the diaphragm is not a usual finding. 
The tear is usually located above the diaphragm 
and is longitudinal on the left posterolateral 
wall. Air passes around the mediastinum, 
which results in subcutaneous emphysemia. 

56. (D) Spontaneous rupture of the esophagus is an 
acute emergency. It requires efforts to establish a 
rapid diagnosis followed by an emergency oper- 
ation. Rapid resuscitation and antibiotics should 
be instituted prior to surgery. Shock is not a con- 
traindication to surgery because it is unlikely 
that the patient's condition will improve until 
surgery has been performed. The surgical 
approach is usually thoracic, but the abdominal 
approach may also be used. 

57. (E) The esophagus is a posterior mediastinal 
structure in much of its course. The thymus 
gland is located in the anterior mediastinum. 
The recurrent laryngeal nerve runs between the 
trachea and the esophagus. The aorta loops back- 
ward over the left side of the esophagus. At this 
level the thoracic duct is on the left side of the 
esophagus. The brachiocephalic vein is the most 
anterior structure in the superior mediastinum. 

58. (D) Leiomyoma is the most common benign 
tumor encountered in the esophagus. Malignant 
transformation is thought to be rare. Less than 
10% of alimentary tract leiomyomas are found in 
the esophagus. They are composed of spindle 



cells and grow slowly and may progressively 
cause obstructive symptoms. Leiomyomas are 
not referred to as a benign GIST. Other benign 
lesions are congenital or acquired cysts, adeno- 
matous polyps, papillomas, lipomas, neurofi- 
bromas, and hemangiomas. 

59. (C) The gastroesophageal zone of elevated 
pressure is 3-A cm long and has a resting pres- 
sure of 15-cm H 2 0. Pregnancy obesity and gas- 
tric dilatation, all result in increased 
intra-abdominal pressure and can result in 
reflux. Alkalinization of the stomach, gastrin, 
epinephrine, cholinergic agents (bethanecol), 
and a-adrenergic agents (metoclopromide) 
increase the resting pressure of the LES. 
Anticholinergic agents (atropine), glucagon, 
and secretin decrease the resting pressure, and 
is released by the vagus nerve and it stimu- 
lates the production of acid in the stomach. 

60. (E) The history of GERD coupled with these find- 
ings is highly suggestive of an adenocarcinoma 
arising in a Barrett's esophagus. Squamous car- 
cinoma is more likely to occur higher up in the 
middle third of the esophagus. Endoscopy and 
biopsy prove the diagnosis. The patient should 
be treated surgically by esophagectomy if carci- 
noma is confirmed. Inoperable upper esophageal 
squamous cell carcinomas can be treated with 
chemoradiation (survival outcomes are similar to 
surgery with less morbidity). 

61. (D) Surgical resection of the esophagus remains 
the recommended treatment for patients with 
carcinoma of the lower esophagus, provided 
that there is no metastitic disease and the 
patient's overall medical condition is compat- 
ible with a major operation. This offers the best 
palliation and the only hope for cure. The 
5-year survival rates vary between 15 and 25%. 
Radiation and chemotherapy, in combination 
with surgery in selected patients, may improve 
these statistics. There are four types of 
esophagectomy — transthoracic, en bloc, tran- 
shiatal, and video-assisted. Regardless of what 
type of operation is performed, complete 
macroscopic and microscopic removal of 
tumor, is the goal. 



722 



5: Stomach, Duodenum, and Esophagus 



62. (A) Blunt trauma is the most common cause of 
diaphragmatic rupture. Associated injuries are 
common. In blunt trauma, the left diaphragm 
is ruptured more frequently than the right. The 
stomach, spleen, colon, and omentum may 
enter the left pleural cavity. Diaphragmatic 
injury without herniation of abdominal con- 
tents is difficult to diagnose. Patients may pres- 
ent with symptoms many years after the initial 
trauma. Early surgery is indicted. 

63. (B) Subhepatic (intrahepatic) space infection 
usually occurs after surgery or peritonitis in 
the supracolic compartment. It is an unlikely 
amplication of biliary pancreatitis. Infections 
in the subhepatic space may extend to the infra- 
colic compartment via the paracolic gutter 
(of Morrison). In addition to the stomach, the 
subhepatic space may be involved with infec- 
tion secondary to injury or diseases of the the 
gallbladder, the first part of the duodenum, the 
anterior portions of the pancreas, or the liver. 
The uncinate lobe of the pancreas is the part of 
the head located posteriorly to the superior 
mesentric artery vein. 

64. (D) Oral fluids and solid foods can usually be 
started several days after the injury. Feeding at 
this stage is encouraged if the patient continues 
to show favorable improvement. If the caustic 
injury is superficial, stricture formation is 
unlikely to occur. Endoscopy to the proximal 
extend of the injury is recommended unless 
perforation is suspected. No attempt should 
be made to pass the endoscope beyond the 
proximal protion of the inflammatory segment. 
Emetics should not be administered because 
the esophagus will be reexposed to the agent 
when the patient vomits. 

65. (C) Esophageal perforation has occurred. 
Caustic alkali ingestion results in liquefactive 
necrosis while acid ingestion causes caogula- 
tion necrosis. The esoophagus is more often 
involved than the stomach during alkaline 
ingestion (and conversely, the stomach is more 
often involved than the esophagus during acid 
ingestion). Features on x-ray suggesting 
esophageal perforation include pneumothorax, 
pneumomediastinum, and pleural effusion. 



Ewald tubes or nasogastric tubes should be 
avoided because of the risk of perforation. 

66. (B) The hepatic artery is medial to the common 
bile duct and anterior to the portal vein. The 
inferior vena cava passes posterior to the 
(epiploic) foramen of Winslow, where it lies 
behind the portal vein. The foramen represents 
the only natural communication between the 
lesser and greater peritoneal bursa (sac). 

67. (E) This test is a useful method of determining if 
a mass is due to an abdominal wall lesion or an 
intra-abdominal lesion. Attempts by the patient 
to sit up will make the anterior abdominal wall 
muscles taut and thus reduce the palpability 
definition of an intra-abdominal mass. An 
abdominal wall mass will still be palpable after 
this maneuver. This is called Fothergill's sign. 

68. (D) H. Pylori infection, smoking, and a high 
salt intake are all risk factors for gastric cancer. 
A diet high in fruits, vegetables, and fiber may 
lower the risk for gastric cancer. The incidence 
of gastric cancer is low in North America. 
Gastric cancer is one of the most common can- 
cers in Japanese men. 

69. (E) Acute gastric dilatation may result in a vaso- 
vagal response. This response is characterized 
by typical signs and symptoms of marked gas- 
tric and abdominal distension. These are 
clearly demonstrable in an awake patient. 
Unfortunately, this condition may occur after 
anesthesia is administered and thus go unrec- 
ognized. Vomiting, aspiration, hypoxia, or 
bleeding from erosive stress gastritis may occur. 
Gastritis, gastric volvulus, and pernicious 
anemia do not cause a vasovagal response. 

70. (E) GISTs are the most common mesenchymal 
tumors of the gastrointestinal tract. They may be 
benign, malignant, or intermediate grade. They 
demonstrate a mutation of the c-kit oncogene. 
Distant metastases occur late. Prolonged sur- 
vival follows resection, including adjucent 
organs if necessary (e.g., colon, pancreas). 
Hemorrhage can result if the tumor erodes 
through the gastric mucosa. Malnutrition results 
from compromise of the capacity of the stomach. 



Answers: 62-80 



123 



71. (E) Patients with familial adenomatous poly- 
posis are at risk for developing carcinoma in 
adenomatous polyps arising in the stomach 
and duodenum. Ampullary and bile duct can- 
cers will result in jaundice. 

71. (D) Conservative treatment of GERD includes 
lifestyle modifications (e.g., smoking cessation, 
decreased caffeine intake, avoidance of large 
meals before lying down, elevation of the head 
of the bed, and avoidance of constrictive cloth- 
ing). PPl's are very effective if nonoperative 
management fails, surgical intervention should 
be considered. Preoperative evaluation includes 
manometry, 24-hour pH test and esopha- 
gogram, in addition to endoscopy. Manometry 
evaluates the LES resting pressure and effec- 
tiveness of peristalsis. The 24-hour pH test is the 
gold standard for diagnosing and quantifying 
acid reflux. Esophagogram shows the external 
anatomy of the esophagus and proximal stom- 
ach, as well as demonstrating the presence of a 
hiatal hernia. Nissen fundoplication is a 360° 
gastric wrap. It can be performed as an open or 
laparoscopic procedure. It is the most common 
operation performed for GERD. Partial fundo- 
plications (e.g., Thai, Dor, Toupet) are done if 
esophageal motility is poor. 

73. (E) Critically ill patients who have multiple organ 
involvement, from trauma or other diseases, are 
at risk for developing bleeding from erosive gas- 
tritis. Risk factors include multiorgan dysfunc- 
tion, sepsis, trauma, and respiratory failure 
requiring mechanical ventilation. The patho- 
genesis of acute stress gastritis is multifactorial. 
One factor is thought to involve hypoperfusion 
of the gastric mucosa and ischemia. 

74. (E) Endoscopic findings range from petechiae to 
multiple ulcers in the body of the stomach and 
duodenum. Endoscopy can safely be performed 
at the bedside in the intensive care unit. Because 
bleeding may be secondary to shallow mucosal 
erosions, a CAT scan, UGI series, and angiogram 
will not be diagnostic. Capsule endoscopy is 
sometimes used in the diagnosis of occult gas- 
trointestinal bleeding when other methods have 
not been helpful. 



75. (A) Peptic ulcer disease is the most common 
cause of UGI bleeding in patients presenting to 
the emergency department. Most bleeding 
ulcers (80%) will stop with conservative meas- 
ures. A visible vessel seen during endoscopy 
can have up to a 55% chance of rebleeding. 
Other causes of bleeding include gastritis, gas- 
tric cancer, esophagitis, Mallory-Weiss tear, 
Dieulafoy's lesion, and esophageal varices, but 
these occur less commonly than peptic ulcer 
as a likely cause of bleeding. 

76. (E) Prostaglandin E (misoprostol) has not been 
useful in the management of erosive gastritis 
because diarrhea has been a troublesome side 
effect. At lower doses it can be used as prophy- 
laxis against NSAID associated gastropathy. 

77. (B) Gastrinoma (ZES) should always be excluded 
in patients presenting with severe peptic ulcer 
disease that fails to respond to therapy. It 
accounts for 0.1-1% of peptic ulcers. It is usually 
caused by a gastrinoma (a non /3-cell tumor 
found in the pancreas or duodenum). The diag- 
nosis is based partly on an elevated fasting 
serum gastrin level (normal 60 pg/mL; in ZES > 
150 pg/mL and can be over 1000 pg/mL). Basal 
acid secretion is increased above 15 mEq/h. 
Duodenal ulcers are the most common ulcers, 
but ulcers in unusual locations (e.g., jejunum) 
may also be seen. 

78. (C) Since the patient is stable, she does not 
require any therapeutic endoscopic or surgical 
procedures. Triple therapy (a PPI and two 
antibiotics) should be initiated to eradicate the 
H. pylori organism. She should also be edu- 
cated about the association of aspirin and 
NSAIDs with peptic ulcer disease. 

79. (D) Duodenal ulcers are associated with acid 
hypersecretion and impaired neutralization of 
aid in the duodenum. The other choices are not 
associated with duodenal ulcers. 

80. (E) If all nonoperative measures have failed to 
control bleeding from an ulcer, the next defini- 
tive step is surgery. Although the patient may 
require continued resuscitation with crystalloids 



124 



5: Stomach, Duodenum, and Esophagus 



and blood products, the bleeding will not stop 
without surgical intervention. Elderly patients 
have poor toleration for hypotension due to 
comorbidities, therefore emergency surgery not 
elective is appropriate. 

81. (B) There is an increased incidence of gastric 
cancer in patients with gastric ulcer disease. 
The overall 5-year survival is 12%, but it can be 
as high as 35% if the nodes are negative (and 
7% if the nodes are involved). It is important 
that the cut edges are free of tumor othewise 
the cancer will recur. Proximal lymph nodes 
should be removed from the stomach. The 
extent of lymph node dissection remains con- 
troversial. Extended D 9 lymph nodes dissec- 
tions are performed in Japan and demonstrate 
improved survival. These results have not been 
replicated in the West. 

82. (C) Endoscopic gastrostomy by percutaneous 
means is rapid and safe. It should be considered 
in patients who are unable to maintain an appro- 
priate caloric intake orally. The procedure is per- 
formed under local anesthesia and sedation. 

83. (D) A patient is a candidate for bariatric sur- 
gery if he or she meets certain criteria. A patient 
whose weight is 100 lb greater than his ideal 
body weight or whose BMI is greater than 
35 mg/kg is morbidly obese. Prior to surgery, 
a patient must have a thorough evaluation by 
a multidisciplinary team (e.g., internist, dieti- 
cian, psychologist, surgeon, and the likes). 
Patients who are not morbidly obese and 
simply want to lose weight are not candidates 
for these procedures. Patients are at risk for 
multiple complications, including fatal pul- 
monary embolus. 

84. (C) There are multiple morbid obesity opera- 
tions. Jejunoileal bypass has a higher incidence 
of both early and late complications. Gastric 
restrictive procedures (e.g., vertical banded 
gastroplasty) are generally less effective than 
GBP. GBP patients can be expected to lose up to 
two-thirds of their weight initially. The gastric 
pouch capacity should be no larger than 30cc. 
Anastomotic leak rate should be less than 5%. 



85. (C) The symptoms and radiologic findings in this 
patient suggest achalasia. Evaluation includes 
endoscopy to rule out a stricture or cancer. 
Barium swallow will show a dilated esophagus, 
failure of the LES to relax during swallowing, 
and a lack of peristalsis. Nonoperative manage- 
ment is of limited usefulness but may be consid- 
ered in high-risk patients who are not candidates 
for surgery. 

86. (C) A healthy patient with achalasia who has 
failed nonoperative management should be 
considered for surgical intervention. Pneumatic 
dilatation is first-line therapy. It causes disrup- 
tion of the muscular layers of the LES. A bal- 
loon is placed endoscopically at the level of the 
LES. Fluoroscopic ally is used to visualize the 
balloon as it is inflated to pressures no higher 
than 10 psi. If pneumatic dilatation fails, or if 
symptoms return after successful dilation, sur- 
gery should be considered. The procedure may 
be done open or endoscopically. The operation 
involves a myotomy that divides the circular 
and longitudinal muscle fibers. It extends from 
the distal 6 cm of the esophagus, through the 
LES, and the proximal gastric cardia. A partial 
fundoplication is usually included to prevent 
gastroesophageal reflux. 

87. (A) It is important to rule out coronary artery 
disease in patients who have DES because the 
symptoms may be similar. Barium swallow and 
endoscopy are used to evaluate the esophagus. 
A corkscrew esophagus is highly suggestive of 
DES, however, it is not always seen. Manometry 
is the diagnostic study of choice. Medical man- 
agement includes nitrates and calcium channel 
blockers. 

88. (C) Barrett's esophagus is a metaplastic change 
found in 10-15% of GERD patients. The normal 
squamous cells of the esophagus are trans- 
formed into columnar cells. It is more com- 
monly seen in men. Patients with Barrett's 
esophagus (without dysplasia) require lifelong 
surveillance. Patients with severe dysplasia 
have a 40-50% chance of developing adeno- 
carcinoma of the esophagus. Prophylactic 
esophagectomy is recommended. 



Answers: 81-96 



125 



89. (C) The Lauren classification divides gastric 
adenocarcinomas into two histolgic types — 
an intestinal type and a diffuse type. The intes- 
tinal type is more common and usually forms 
a discrete lesion. The diffuse infiltrating type is 
less common and a mass may not be seen. In 
the intestinal type, cells form glandular stric- 
tives in the diffuse type, cells are poorly organ- 
ized and full of mucin (signet ring cells). The 
diffuse type may extensively infiltrate the mus- 
cles of the stomach, thus leading to rigidity. 
Gross appearance may be unremarkable, but 
palpation aids in the diagnosis. "Leather bottle 
stomach" refers to a stomach that is entirely 
involved with diffuse type cancer. The 5-years 
survival is poor. 

90. (C) Hemobilia may be secondary to instrumen- 
tation of the biliary tree, or malignancy or 
trauma. It involves bleeding from the biliary tract 
that transits through the ampulla into the duo- 
denum. Bleeding may be subacute or massive. 
Endoscopic retrograde cholangiopancreatogra- 
phy (ERCP) or angiogram may be diagnostic. 
Angioembolization may be therapeutic. 

91. (D) "Watermelon stomach" is a term used to 
describe the appearance of the stomach in a 
condition called GAVE (gastic antral vascular 
ectasis) syndrome. Dilated blood vessels radi- 
ate from the pylorus to the antrum in a pattern 
that resembles the stripes of a watermelon. It is 
an uncommon cause of gastrointestinal bleed- 
ing. It has been associated with certain autoim- 
mune diseases, however, it may also be seen in 
individuals not affected by these conditions. It 
may also be seen with portal hypertension. It is 
most commonly seen in elderly women. 
Endoscopic laser treatment is usually effective. 

92. (D) Candida is the most common cause of infec- 
tious esophagitis. Predisposing factors include 
malignancy, AIDS, and antibiotic use. A double 
contrast esophageal swallow or esophagogas- 
troduodenoscopy (EGD) can be used to make 
the diagnosis. Not all patients with oral thrush 
have Candida esophagitis; cytomegalovirus 
(CMV) esophagitis can also occur in these 
patients. Other infecious causes include 



tuberculosis (TB) and herpes. Antibiotics can 
be effective. A superficial spreading carcinoma 
of the esophagus may have a similar appear- 
ance in diagnostic studies. 

93. (E) A dieulafoy lesion is an uncommon cause of 
UGI bleeding (0.3-7%). It can occur anywhere 
in the gastrointestinal tract, but is most com- 
monly found in the stomach (near the GE junc- 
tion). It is often difficult to visualize because of 
its small size. A dilated submucosal artery is the 
source of the bleeding. First-line management 
is therapeutic endoscopy. There is no associa- 
tion with NSAIDs or alcohol. These lesions are 
more common in men. 

94. (E) Patients with impaired gastric emptying, 
such as those who have had previous gastric 
surgery or those with diabetes, can develop 
bezoars. Bezoars can be classified as two types — 
phytobezoars (undigested vegetable matter) and 
trichobezoars (hair). The diagnosis can be made 
by EGD or barium study. Nonoperative man- 
agement is often successful. Patients are told to 
ingest meat tenderizer (which contains papain) 
and repeat endoscopy is performed for further 
fragmentation and removal of the bezoar. If the 
patient is obstructed and endoscopic therapy is 
unsuccessful, surgery is indicated. Patients who 
ingest their hair should be referred for psychi- 
atric evaluation. 

95. (A) Duplication cysts are congenital. Communi- 
cation with the true lumen is uncommon. They 
are usually asymptomatic. Symptoms and 
complications can include dysphagia, infec- 
tion, perforation, and bleeding. Malignant 
degeneration is rare. Symptomatic cysts can be 
removed by open thoracotomy or videoas- 
sisted thoracoscopic (VATS) techniques. 

96. (B) Vascular rings are congenital. They can encir- 
cle the trachea and esophagus and cause com- 
pressive symptoms. The two most common 
types are double aortic arch and right aortic arch 
with left ligamentum arteriosum. Diagnostic 
studies include chest x-ray, barium study, Echo, 
CAT scan, MRI, and angiogram. Surgery 
involves division of the ring. 



126 



5: Stomach, Duodenum, and Esophagus 



97. (C) An aortoenteric fistula should be suspected 
in any patient who has had previous aortic 
surgery and presents with massive UGI bleed. 
Most aortoenteric fistulas are secondary to this 
type of surgery. It is important to separate an 
aortic graft from intestine (e.g., retroperitoneal 



tissue). Most aortoenteric fistulas occur 
between the aorta and duodenum. Mortality is 
high, but timely surgical intervention can be 
successful. Surgery may involve performing 
an extraanatomic bypass and removing the 
aortic graft. 



CHAPTER 6 



Small and Large Intestines 
and Appendix 

Evelyn Irizarry and Nicholas A. Balsano 

Questions 



DIRECTIONS (Questions 1 through 90): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 

Question 1 through 3 

A 17-year-old female model presents to the emer- 
gency room with a 1-day history of lower abdominal 
pain. On examination she is most tender in the right 
lower quadrant (RLQ) and also has pelvic tender- 
ness. White blood cell (WBC) count is 13,000 and 
temperature is 100. 6°F. A provisional diagnosis of 
uncomplicated appendicitis is made and laparo- 
scopic appendectomy is offered. 

1. Regarding laparoscopic appendectomy which 
of the following is TRUE? 

(A) It can be performed safely with minimal 
morbidity compared to open technique. 

(B) Length of hospital stay is longer than 
with open technique. 

(C) Procedure cost is less than with open 
technique. 

(D) Return to full feeding is less than with 
open technique. 

(E) Wound complication rate is greater with 
open technique. 



Possible advantages of the laparoscopic tech- 
niques include all except? 

(A) Post hospital recovery is longer. 

(B) More scar formation. 

(C) Not allow thorough inspection of the 
peritoneal contents. 

(D) Longer operative time. 

(E) No treatment for nonappendical disease. 

At open operation a normal appendix is found. 
What is the most common procedure a sur- 
geon should do if he finds a normal appendix? 



(A) 



(B) 
(C) 

(D) 

(E) 



Evaluate the pelvis for tuboovarian 
abscess pelvic inflammatory disease, 
malignancy or etopic pregnancy 
Removal of appendix 
Evaluate the terminal ileum and cecum 
for signs of regional or bacterial enteritis 
Evaluate the upper abdomen for 
cholecystitis or perforated duodenal ulcer 
Evaluate for Meckel's diverticulum 



127 



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128 



6: Small and Large Intestines and Appendix 



4. A 25-year-old male develops diarrhea and 
colicky abdominal pain. Ulcertive colitus is 
diagnosed on colonoscopy. Which of the fol- 
lowing findings is consistent with the diagnosis? 



(A) 
(B) 



(C) 



(D) 



(E) 



The rectum is not involved. 

The disease is confluent, there are no 

skip areas in the colon and the rectum is 

involved. 

The full thickness of the bowel wall is 

involved. 

Microscopic examination of the mucosa 

reveals normal cells without evidence of 

dysplasia. 

The incidence of colorectal cancer is 

equal to that of the general population. 



A 35-year-old man has known ulcerative coli- 
tis. Which of the following is an indication for 
total proctocolectomy? 

(A) Occasional bouts of colic and diarrhea 

(B) Sclerosing cholangitis 

(C) Toxic megacolon 

(D) Arthritides 

(E) Iron deficiency anemia 

Ten years after diagnosis of total proctocolitis 
this patient undergoes colonscopy and biopsy 
reveals high-grade dysplasia in 2-10 speci- 
mens. What should the physician recommend? 

(A) Repeat colonoscopy in 1 year 

(B) Increase steroid dosage 

(C) Early repeat colonoscopy and biopsy 
area again 

(D) Total proctocolectomy 

(E) Resection of the involved segment 

A 55-year-old man presents with left lower quad- 
rant (LLQ) abdominal pain of 2-day duration, 
associated with constipation. On physical exam- 
ination, he has tenderness localized to the LLQ 
with fullness in that area leukocyte count is 
22,000 and temperature is 101 .5°F. Which would 
be the best diagnostic study to evaluate this man? 

(A) Diagnostic laparoscopy 

(B) Barium enema 

(C) Plain abdominal roentgenogram 



(D) Computed tomography (CT) of the 
abdomen/pelvis with orally (PO) and 
intravenous (IV) contrast 

(E) Colonoscopy 

8. Complications of diverticulitis include: 

(A) Carcinoma of the colon 

(B) Extraintestinal manifestations such as 
arthritis, iritis, and skin rashes 

(C) Fistulisation to adjacent organs such as 
the bladder, with insueing colovesical 
fistula 

(D) Artheriovenous fistulae of the intestine 

(E) Sclerosing cholangitis 

9. A patients CT scan reveals diverticulitis confined 
to the sigmoid colon. There is no associated peri- 
colic abscess. What is best course of treatment? 

(A) Bowel rest, nasogastric suction, IV 
fluids, and broad spectrum antibiotics 

(B) Urgent surgical resection 

(C) Steroids 

(D) Diverting colostomy 

(E) Ileostomy 

10. An elderly nursing home patient is brought to 
the hospital with recent onset of colicky abdom- 
inal pain, distension and obstipation on exami- 
nation, the abdomen is markedly distended and 
tympanitic. There is no marked tenderness. Plain 
abdominal x-ray shows a markedly distended 
loop located mainly in the right upper quadrant. 
The likely diagnosis is: 

(A) Small-bowel obstruction 

(B) Large-bowel obstruction 

(C) Gallstone ileus 

(D) Mesenteric vascular occlusion 

(E) Sigmoid volvulus 

11. The standard initial therapy for acute sigmoid 
volvulus is: 

(A) Laparotomy to reduce the volvulus and 
replace the sigmoid colon to its normal 
position 

(B) IV neostigmine 

(C) Colonoscopy 



Questions: 4-16 



129 



(D) Ileostomy 

(E) Rigid sigmoidoscopy 

12. Protoscopy reveals nonbleeding grade I hem- 
orrhoids and maroon stool and clots coming 
from the proximal colon. Which of the follow- 
ing is TRUE in the management of lower gas- 
trointestinal (GI) bleeding? 

(A) Barium enema is a good tool in the early 
evaluation of massive GI bleeding. 

(B) Technetium sulfur colloid has excellent 
sensitivity in localizing lower GI bleeding. 

(C) Technetium sulfur colloid scan is useful 
because it may be repeated 24 hours 
later with single injection. 

(D) Colonoscopy should be avoided in the 
evaluation of acute lower GI bleeding. 

(E) Sensitivity specificity and accuracy rates 
vary widely and the exact role of red 
blood cell (RBC) scanning is controversial. 

13. The patient responds to resuscitation with nor- 
malization of vital signs but continues to bleed. 
He is taken to the angiography suite for further 
evaluation. Which of the following is TRUE? 

(A) The inferior mesenteric artery should be 
injected first because most diverticula 
are in the sigmoid colon. 

(B) Vasopressin be selectively infused into a 
bleeding mesentric vessel with virtually 
no risk to the patient. 

(C) Embolization with gel foam or autolo- 
gous clots may be used to stop bleeding. 

(D) Since angiography is both diagnostic and 
therapeutic surgery will not be necessary. 

(E) A bleeding rate of 0.1 mL/min is 
necessary for a positive scan. 

14. A 60-year-old man undergoes sigmoid colec- 
tomy for cancer of the midsigmoid. Path spec- 
imen reveals the following involvement. What 
is this patient's stage? 



(A) Tl No Mo— stage I 

(B) T2 Nl Mo— stage II 

(C) T3 No Mo— stage III 

(D) Tl Nl Mo— stage III 

(E) T2 Nl Mo— stage III 

15. The same patient is otherwise healthy. Which of 
the following is TRUE? 

(A) She does not need chemotherapy 
because prognosis is largely related to 
depth of tumor penetration and she has 
an early tumor. 

(B) Postoperative chemotherapy should be 
offered even though there is no proven 
benefit in stage III colon cancer. 

(C) Oral chemotherapy (capecitabine) is as 
effective as IV chemotherapy. 

(D) Patient should be offered IV 5 
fluorouracil(5 FU) chemotherapy. 

(E) Patient should be offered 5 fluorouracil 
(5 FU) and radiation therapy. 

16. A male neonate develops small-bowel obstruc- 
tion due to malrotation of the midgut segment. 
An x-ray of the abdomen confirms the pres- 
ence of small-bowel obstruction (Fig. 6-1). He 
undergoes an emergency laparotomy untwist- 
ing of the malrotated intestines, and partial 
small-bowel resection for intestinal infarction. 
Which of the following statements is true of 
the small intestine (jejunum and ileum)? 

(A) It is derived entirely from the midgut. 

(B) In the fetus, it enters the physiologic 
umbilical hernia in the the fifth month. 

(C) It remains in the physiologic hernia for 
4 months. 

(D) It is attached to the urachus. 

(E) It drains into the lymph nodes around 
the iliac arteries. 



130 



6: Small and Large Intestines and Appendix 




examination, what is noted regarding the small 
intestine (jejunum and ileum)? 



(A) 
(B) 

(C) 



(D) 



(E) 



It commences at the right of the midline. 
It contains crypts but not villi on 
histologic examination. 
It has a mesentery (parietal) attachment 
extending 61 cm along the posterior 
abdominal wall. 

It measures approximately 6 m in 

length. 

It is supplied by the inferior mesenteric 

vessels. 



Figure 6-1 . 

A. Upper Gl shows dilation of the bowel secondary to volvulus. 
B. Distension of duodenum with beaking of the second portion of 
the duodenum due to volvulus. 



17. A 64-year-old man with mitral stenosis devel- 
ops mesenteric infarction due to an embolus. 
At operation and on subsequent pathologic 



Questions 18 and 19 

A 43-year-old woman undergoes investigation for 
colitis. In her history it is noted that 20 years earlier 
she underwent a surgical procedure on the large 
intestine. 

18. The diagnosis is more likely to be Crohn's dis- 
ease rather than ulcerative colitis because the 
previous operation was which of the following? 

(A) Performed in a young patient 

(B) Confined to the colon 

(C) Followed by improvement after bypass 
of the diseased segment 

(D) Followed by improvement because 
steroids were prescribed 

(E) Grohn's disease is more premaligent 
than ulcerative cohitis 

19. Is the diagnosis more likely to be ulcerative 
colitis rather than Crohn's disease because at 
the previous operation? 

(A) All layers of the bowel wall were involved 
There was evidence of fistula formation 
The serosa appeared normal on 
inspection, but the colon mucosa was 
extensively involved 
Skip lesions were noted 
The preoperative GI series showed a 
narrowing string like stricture in the 
ileum (string sign) 



(B) 
(C) 



(D) 

(E) 



Questions: 17-25 



131 



Questions 20 and 21 

A 64-year-old woman with a known history of car- 
diac disease is admitted to the hospital with severe 
abdominal pain. Her blood pressure is 150/95 mm 
Hg, and her pulse rate is 84 beats per minute (bpm). 
There are minimal signs of intravascular depletion. 

20. The possibility of small-bowel infarction is 
characterized by which of the following? 

(A) The stack-of-coins sign 

(B) Marked distention of loops of bowel 

(C) Air in the biliary tree 

(D) Air in the bowel wall (intramural) 

(E) Air below the left diaphragm 

21. At operation, 2.5 m of distal ileum is found to 
be gangrenous. There is, however, pulsation in 
the superior mesenteric artery and its main 
branches. Small-bowel gangrene in this patient 
is caused by which of the following? 

(A) Arterial thrombosis 

(B) Embolus 

(C) Nonocclusive ischemic disease 

(D) Von Willebrand's disease 

(E) Idiopathic thrombocytopenic purpura 

22. A 48-year-old man undergoes a supine abdom- 
inal x-ray for epigastric discomfort. He has 
been on IV hyperalimentation since an opera- 
tive procedure performed 5 days previously. 
Gas is consistently absent from the alimentary 
tract because he has previously undergone 
which of the following? 

(A) Appendectomy 

(B) Gastrostomy 

(C) Ligation of the esophagus and cervical 
e sop hago stomy 

(D) Lysis of adhesions 

(E) Colostomy for large-bowel obstruction 



Questions 23 and 24 

A 64-year-old woman is admitted to the hospital with 
abdominal pain, vomiting, and abdominal disten- 
tion. Bowel sounds are increased on auscultation, 
and a plain film shows marked distention of loops of 
bowel with nonspecific pattern. 



23. 



24. 



25. 



The most likely diagnosis is which of the 
following? 

(A) Sigmoid volvulus 

(B) Cecal volvulus 

(C) Jejunal obstruction 

(D) Ileal obstruction 

(E) Pyloric obstruction 

Management, following rehydration and elec- 
trolyte imbalance correction, should initially 
involve which of the following? 

(A) Nasogastric suction, rehydration, and 
observation 

(B) Anticholinergic drugs 

(C) Laxatives 

(D) Emergency surgery and bowel resection 

(E) Appendectomy 

A 42-year-old woman is admitted to the emer- 
gency department with severe colicky pain, 
vomiting, and abdominal distention. She has 
not passed stools or flatus for 48 hours. X-rays 
of the abdomen confirm the presence of small- 
bowel obstruction. What is the most likely cause 
of small-bowel obstruction in this patient? 

(A) Adenocarcinoma 

(B) Adhesions 

(C) Crohn's disease 

(D) Ulcerative colitis 

(E) Gallstone ileus 



132 



6: Small and Large Intestines and Appendix 



26. An 80-year-old woman with a known history 
of femoral hernia is admitted to the hospital 
because of strangulation of the hernia. There is 
a tender swelling in the right femoral region 
immediately below and lateral to the pubic 
tubercle. She has had multiple bowel move- 
ments without relief of symptoms. What is the 
most likely diagnosis? 

(A) Lymphadenitis 

(B) Diverticulitis 

(C) Volvulus 

(D) Richter's hernia 

(E) Gastroenteritis 

27. A 63-year-old man from Miami presents to the 
emergency department with abdominal pain 
due to intestinal obstruction. A diagnosis of 
small-bowel volvulus is established. Primary 
small-bowel volvulus is differentiated from sec- 
ondary small-bowel volvulus. In the latter 
there is a secondary cause, such as adhesions, 
that accounts for the volvulus. Which is true of 
primary small-bowel volvulus? 

(A) It does not lead to gangrene of bowel. 

(B) It is common in the United States. 

(C) It occurs nearly exclusively in women. 

(D) It usually involves the jejunum. 

(E) It may require a limited resection of 
small intestine. 

Questions 28 and 29 

A 44-year-old man is stabbed in the abdomen. The 
injury penetrates the root of the small-bowel mesen- 
tery. At laparotomy, resection of 2 cm of ileum is 
removed. 

28. The complication that is more likely to occur 
after resection of the ileum rather than of an 
equivalent length of jejunum is the failure to 
absorb which of the following? 

(A) Iron 

(B) Zinc 

(C) Bile salts 

(D) Medium-chain triglycerides 

(E) Amylase 



29. Why is distal resection, as compared to proxi- 
mal resection, poorly tolerated? 

(A) Transit time in the ileum is slower than 
that in the jejunum. 

(B) Transit time in the jejunum is slower 
than that in the ileum. 

(C) The greater bulk of food is absorbed in 
the ileum. 

(D) Water absorption is mainly in the ileum. 

(E) All minerals are absorbed preferentially 
in the ileum. 

30. A 66-year-old woman is admitted for hyperal- 
imentation due to malnutrition consequent to 
massive small-bowel resection. What is the 
most likely condition that leads to the need to 
perform a massive resection? 

(A) Autoimmune disease 

(B) Mesenteric ischemia 

(C) Mesenteric adenitis 

(D) Cancer 

(E) Pseudomyxoma peritonei 

31. A 68-year-old female is known to have had sur- 
gery several years previously for a bowel lesion. 
Her surgeon had told her that she suffers from 
the blind loop syndrome. In which condition can 
one anticipate the blind loop syndrome to occur? 

(A) Intestinal bypass 

(B) Vesicocolic fistula 

(C) Duodenal ulcer disease 

(D) Multiple polyposis of the colon 

(E) Anteriovenous fistula of the colon 

32. A 33-year-old woman is noted to have a Meckel's 
diverticulum when she undergoes an emergency 
appendectomy. The diverticulum is approxi- 
mately 60 cm from the ileocecal valve and meas- 
ures 2-3 cm in length. What is the most common 
complication of Meckel's diverticulum among 
adults? 

(A) Bleeding 

(B) Perforation 

(C) Intestinal obstruction 

(D) Ulceration 

(E) Carcinoma 



Questions: 26-38 



133 



33. A 30-year-old male is diagnosed with Peutz- 
Jeghers syndrome. What findings is consistent 
with the diagnosis? 

(A) Adenomas 

(B) Hamartomas 

(C) Adenomatous polyps 

(D) Villoglandular polyps 

(E) Villotubular polyps 

34. A 38-year-old male is admitted to hospital with 
symptoms suggestive of small-bowel obstruc- 
tion. Examination reveals multiple loops of 
distended bowel with increased bowel sounds. 
Treatment with IV fluids and nasogastric suction 
fails to correct symptoms. Laparotomy is per- 
formed. Following surgery copious volumes of 
fluid occur through the incision. A diagnosis of 
intestinal fistula is established.What is TRUE 
of intestinal fistulas? 

(A) They may occur as a complication after 
an operation to divide adhesions. 

(B) They are rare after irradiation. 

(C) As a result of Crohn's disease, they 
almost always close spontaneously. 

(D) They should not be treated with a 
central venous line for fear of sepsis. 

(E) They most commonly arise from the 
distal colon. 

35. A 69-year-old female is found to have an ente- 
rocutaneous fistula that arises from the proxi- 
mal small intestine. Which of the following 
statements is TRUE concerning this fistula? 

(A) If internal, it occurs mainly from 
iatrogenic causes. 

(B) It occurs more commonly after an 
anastomosis than spontaneously. 

(C) If internal, it always causes serious 
complications. 

(D) If external, it closes spontaneously in 
10% of cases. 

(E) If external, it requires immediate closure 
in most cases. 



Questions 36 and 37 

36. A 68-year-old retired female plastic surgeon 
underwent laparotomy through a midline 
abdominal incision. Intestinal infarction was 
found and a distal 60% small-bowel resection 
was performed with ileocecal anastomosis. She 
was placed on hyperalimentation. Seven days 
after the operation, she underwent a second 
operation through the same incision. Wound 
healing is further impaired by which of the 
following? 

(A) Incision through the same abdominal 
wall scar 

(B) Vitamin A administration 

(C) Zinc deficiency 

(D) Increased local oxygen tension 

(E) Incision through new area of abdominal 
wall 

37. At the second operation an advanced carcinoma 
of the colon is detected. What factors would 
cause wound healing to be further impaired? 

(A) Doxorubicin is given. 

(B) Denervation of bowel or skin incision 
occur. 

(C) Mechanical lavage and oral antibiotics 
are given before surgery. 

(D) Steroids are not given. 

(E) Leavage with polyethylene glycol 
solution. 

38. A 79-year-old man has had abdominal pain for 
4 days. An operation is performed, and a gan- 
grenous appendix is removed. The stump is 
inverted. Why does acute appendicitis in elderly 
patients and in children have a worse prognosis? 

(A) The appendix is retrocecal. 

(B) The appendix is in the preileal position. 

(C) The appendix is in the pelvic position. 

(D) The omentum and peritoneal cavity 
appear to be less efficient in localizing 
the disease in these age groups. 

(E) The appendix is longer in these age 
groups. 



134 



6: Small and Large Intestines and Appendix 



Questions 39 through 41 

39. A 12-year-old boy complains of pain in the 
lower abdomen (mainly on the right side). 
Symptoms commenced 12 hours before admis- 
sion. He had noted anorexia during this period. 
Examination revealed tenderness in the right 
iliac fossa, which was maximal 1 cm below Mc 
Burney's point. In appendicitis, where does the 
pain frequently commence? 

(A) In the right iliac fossa and remains there 

(B) In the back and moves to the right iliac 
fossa 

(C) In the rectal region and moves to the 
right iliac fossa 

(D) In the umbilical region and then moves 
to the right iliac fossa 

(E) In the right flank 

40. On examination, patients presenting with appen- 
dicitis typically show maximal tenderness over 
which of the following? 

(A) Inguinal region 

(B) Immediately above the umbilicus 

(C) At a point between the outer one-third 
and inner two-thirds of a line between 
the umbilicus and the anterior superior 
iliac spine 

(D) At a point between the outer two-thirds 
and inner one-third of a line between 
the umbilicus and the anterior superior 
iliac spine 

(E) At the midpoint of a line between the 
umbilicus and the anterior superior iliac 
spine 

41. What is the mortality rate from acute 
appendicitis? 

(A) In the general population, it is 4/10,000 

(B) After rupture, appendicitis is 4-5% 

(C) For nonruptured appendicitis, it is 2% 

(D) It is 80% if an abscess has formed 

(E) It has increased in the past 40 years 

42. A 29-year-old woman presents to her physi- 
cian's office with pain in the right iliac fossa. 



Examination reveals tenderness in this region. 
Her last menstrual cycle was 2 weeks previ- 
ously and findings on gynecologic examination 
and leukocyte count are normal. A provisional 
diagnosis of acute appendicitis is made. She 
should be informed that operations to treat this 
condition reveal acute appendicitis in what per- 
centage of cases? 

(A) A small percentage of cases 

(B) 50-89% of cases 

(C) 90-99% of cases 

(D) More than 99% of cases 

(E) No reliable statistics are available 

43. A 28-year-old man is admitted to the emergency 
department complaining of pain in the umbilical 
region that moves to the right iliac fossa. Which 
is a corroborative sign of acute appendicitis? 

(A) Referred pain in the right side with 
pressure on the left (Rovsing)sign 

(B) Increase of pain with testiculalr 
elevation 

(C) Relief of pain in lower abdomen with 
extension of thigh 

(D) Relief of pain in lower abdomen with 
internal rotation of right thigh 

(E) Hyperanesthesia in the right lower 
abdomen 

44. A 28-old-male from Kosovo, who lives alone, 
presents with diarrhea. On examination he man- 
ifests clear wasting and malnutrition. His hema- 
tocrit (HCT) is 28%, serum albumin reduced to 
2.8 g%, and the blood analysis shows a macro- 
cytic anemia. The emergency department physi- 
cian is unable to secure an accurate history of the 
nature of multiple previous operations he had 
undergone before his arrival in the United States 
several months previously. What is the likely 
diagnosis that explains these features? 

(A) Blind loop syndrome 

(B) Diverticulitis of the sigmoid colon 

(C) Carcinoma of the left colon 

(D) Gastric ulcer 

(E) Carcinoid syndrome 



Questions: 39-51 



135 



Questions 45 and 46 

A 74-year-old patient has a biopsy of the prostate 
that shows malignancy. He is considering radical 
prostatectomy or radiation therapy. 

45. He is concerned about enterocolitis, which is 
likely to occur when? 

(A) After local treatment with 15 Gy 

(B) After local treatment with 35 Gy 

(C) After local treatment with 55 Gy 

(D) Less frequently after previous surgery 

(E) Less frequently in the presence of 
adhesions 

What complication should be anticipated in 
this patient? 

(A) Diverticulitis 

(B) Hemorrhoids 

(C) Complete occlusion of superior 
mesenteric artery 

(D) Complete occlusion of inferior 
mesenteric artery 

(E) Rectal bleeding 



46. 



47. 



A 49-year-old computer technician receives 
irradiation to the pelvis for cervical cancer. 
Three months after irradiation, severe rectal 
proctitis may be shown by the presence of 
which of the following? 

(A) Ulcers 

(B) Strictures at anal verge 

(C) Mucosa prolapse 

(D) Multiple telangiectasis and polypoid 
tumor 

(E) Free air under the diaphragm 



Questions 48 and 49 

A 63-year-old man is admitted to the hospital for 
abdominal pain and diarrhea of 6-day duration. X- 
ray of the abdomen shows "thumbprinting" and 
gaseous distention suggestive of ischemic colitis. 



48. What is true of colonic ischemia? 

(A) It occurs in a younger age group (40-60 
years of age). 

(B) In most cases, it occurs in patients with 
cardiac failure. 

(C) It usually causes severe abdominal pain. 

(D) It may have a predisposing associated 
colonic lesion in 20% of patients. 

(E) It results in the patient's appearing seri- 
ously ill. 

49. To confirm the diagnosis of ischemic colitis, 
what test should be requested? 

(A) Selective angiogram of inferior mesen- 
teric artery 

(B) Angiogram of superior and inferior 
mesenteric arteries 

(C) CT scan of the abdomen 

(D) Barium enema after 2 weeks 

(E) Barium enema as soon as possible 

50. A 54-year-old man with diarrhea is found to 
have ulcerative colitis. Colectomy should be 
advised in patients with ulcerative colitis who 
have symptoms that persist for more than 
which of the following? 

(A) 1 month 

(B) 6 months 

(C) 1-5 years 

(D) 10-20 years 

(E) More than 25 years 

51. A 48-year-old woman develops colon cancer. 
She is known to have a long history of ulcerative 
colitis. In ulcerative colitis, which of the follow- 
ing is a characteristic of colon cancer? 

(A) Occurs more frequently than in the rest 
of the population. 

(B) Is more likely to occur when the ulcera- 
tive disease is confined to the left colon. 

(C) Occurs equally in the right and left side. 

(D) Has a synchronous carcinoma in 4-5% 
of cases. 

(E) Has an excellent prognosis because of 
physician awareness. 



136 



6: Small and Large Intestines and Appendix 



52. A 64-year-old train conductor is diagnosed as 
having carcinoma confined to the descending 
colon. Before operation, what should be told? 

(A) He will most likely require a colostomy. 

(B) He should have the cancer excised by 
cautery. 

(C) He should undergo left hemicolectomy. 

(D) Radiotherapy is the treatment of choice. 

(E) 40% of colorectal cancer involves the 
colon. 

53. A 72-year-old woman is scheduled to undergo 
right hemicolectomy for cancer of the cecum. In 
this condition, she can anticipate subsequent 
recurrence 



(A) 
(B) 

(C) 



Of 20-30% if confined to the mucosa 
Close to 100% if there is lymph node 
involvement 



Which will not result in small-bowel 
obstruction 

(D) Which will not result in hydronephrosis 

(E) Which with microscopic lymph node 
metastasis would have a lower rate than 
that with macroscopic spread 

54. A pathology specimen indicates that synchro- 
nous lesions are present. Which of the follow- 
ing statements are true regarding colon cancer 
with synchronous lesions? 

(A) Cancer occurs in 20% of patients. 

(B) Benign lesions occur in 20-30%. 

(C) Malignant lesions are usually adjacent 
to the primary cancer. 

(D) Benign lesions are usually adjacent to 
the primary cancer. 

(E) Lesions occur much less frequently than 
metachronous lesions. 

Questions 55 and 56 

A 68-year-old dentist undergoes anterior resection 
(sigmoid resection) for cancer at the rectosigmoid 
junction. The tests performed before her surgery were 
colonscopy and biopsy. There were no other lesions 
detected with sigmoidoscopy or in the pathology 
specimen. 



55. Following operation, she requires which of the 
following within 2-3 months? 

(A) Repeat rectal examination and 
sigmoidoscopy 

(B) Colonoscopy 

(C) CT scan of the abdomen 

(D) Angiography 

(E) Bone scan 



56. 



57. 



58. 



The patient requests information from her sur- 
geon as to her subsequent prognosis. She is 
informed that the prognosis for colon and rectal 
cancer is favorably affected by which of the 
following? 

(A) Minimal serosal extension 

(B) Minimal lymph node involvement 

(C) Confinement to the mucosa 

(D) Right-sided obstructing lesions 

(E) Elevated carcinoembryonic antigen 
(CEA) levels 

An 83-year-old man is diagnosed on colono- 
scopy to have cancer of the colon. He refuses 
surgical intervention and after a 3-month follow- 
up period is admitted to the emergency depart- 
ment with large-bowel obstruction. Carcinoma of 
the colon is most likely to obstruct if found in the 

(A) Cecum 

(B) Ascending colon 

(C) Descending colon 

(D) Rectum 

(E) Transverse colon 

A 43-year-old man is seen in his physician's office 
for severe pain in the perineum. Examination 
reveals exquisite tenderness in the area to the 
right side of the anal verge due to a perianal 
abscess. Rectal examination is refused. What 
should be the next step in management? 

(A) Drainage of the abscess in the office 
under local anesthesia. 

(B) Excision of the vertical fold of Morgagni. 

(C) Drainage under general anesthesia and 
immediate colonoscopy. 

(D) CT scan of the abdomen. 

(E) Insertion of a rectal tube. 



Questions: 52-64 



137 



59. A 64-year-old man undergoes CEA surveillance 
for cancer, because his brother and father both 
had colon cancer. What information should he 
be provided? 

(A) CEA is highly sensitive for diagnosis. 

(B) If CEA is elevated preoperatively it 
implies unresectable disease. 

(C) Increases in CEA after resection may 
indicate tumor recurrence. 

(D) CEA is highly specific for the presence 
of colon cancer. 

(E) CEA is present in normal adult colonic 
mucosa. 

60. A 70-year-old man presents with pallor and 
breathlessness on exertion. He does not com- 
plain of abdominal pain. He has microcytic, 
hypochromic anemia. What is the most proba- 
ble cause? 

(A) Diverticulosis of the colon 

(B) Peptic ulcer disease 

(C) Crohn's disease 

(D) Ulcerative colitis 

(E) Carcinoma of the right colon 

61 . A 25-year-old man has recurrent, indolent fistula 
in ano. He also complains of weight loss, recur- 
rent attacks of diarrhea with blood mixed in the 
stool, and tenesmus. Proctoscopy revealed a 
healthy, normal-appearing rectum. What is the 
most likely diagnosis? 

(A) Crohn's colitis 

(B) Ulcerative colitis 

(C) Amoebic colitis 

(D) Ischemic colitis 

(E) Colitis associated with acquired immun- 
odeficiency syndrome (AIDS) 

62. A 65-year-old man presents with chronic consti- 
pation and abdominal distention of 5-day dura- 
tion. He complains of lack of appetite and general 
malaise. Findings on physical examination are 



63. 



64. 



positive for a large distended abdomen with 
hyperactive bowel sounds. Rectal examination 
shows minimal stool that is guaiac-positive. 
Sigmoidoscopy does not reveal any further find- 
ings. Abdominal x-rays show a large 10-cm 
cecum and dilated, fluid-filled transverse and 
descending colon with very little gas in the 
rectum. What is the most probable cause of this 
condition? 

(A) Volvulus of the sigmoid colon 

(B) Pseudo-obstruction of the colon 

(C) Ischemic colitis 

(D) Carcinoma of the colon 

(E) Diverticulitis of the colon 

A 27-year-old homosexual male presents with 
a foreign body in the rectum. During the extrac- 
tion of the foreign body, a large tear in the sig- 
moid colon with extensive devitalization and 
contamination is observed. What is the pre- 
ferred method of treatment? 



(A) 
(B) 
(C) 

(D) 



(E) 



Observation 

Proctoscopic repair 

Laparotomy and closure of sigmoid 

colon tear 

Laparotomy, closure of sigmoid, and 

proximal colostomy or exteriorization of 

perforation as a colostomy 

Laparotomy, resection of sigmoid colon, 

and colostomy 



A 65-year-old woman with a history of chronic 
constipation is transferred from a nursing 
home because of abdominal pain and marked 
abdominal distention. On examination, her 
abdomen is found to be distended and tender 
in the LLQ. What is the most likely diagnosis? 

(A) Appendicitis 

(B) Carcinoma of the colon 

(C) Volvulus of the sigmoid colon 

(D) Volvulus of the cecum 

(E) Small-bowel obstruction 



138 



6: Small and Large Intestines and Appendix 



65. 



66. 



A 40-year-old man with a long history of bloody 
diarrhea presents with increased abdominal 
pain, vomiting, and fever. On examination, he 
is found to be dehydrated and shows tachycar- 
dia and hypotension. The abdomen is markedly 
tender with guarding and rigidity. What is the 
most likely cause? 

(A) Toxic megacolon in ulcerative colitis 

(B) Small-bowel perforation from regional 
enteritis 

(C) Perforated carcinoma of the sigmoid 
colon 

(D) Volvulus of the sigmoid colon 

(E) Acute perforated diverticulitis 

Three days after undergoing an operation for an 
abdominal aortic aneurysm, a patient has mod- 
erate fever, abdominal pain, and rectal bleeding. 
What is the most helpful investigation? 

(A) Angiography 

(B) Upper GI endoscopy 

(C) Abdominal ultrasound 

(D) Sigmoidoscopy 

(E) Abdominal CT scan 

A 55-year-old woman presents with pain in the 
LLQ of the abdomen and fever of 102°F. On 
examination, she is found to be dehydrated 
and has tenderness in the LLQ. A CT scan 
shows a mass in the LLQ involving the sig- 
moid colon. There is a minimal amount of free 
fluid and no free air. What should the initial 
treatment of this patient include? 

(A) IV fluids, penicillin, and steroids 

(B) IV fluids, cefoxitin, and nasogastric 
drainage 

(C) IV fluids, blood transfusion, and 
laparotomy 

(D) immediate laparotomy 

(E) bowel preparation followed by 
laparotomy 



Questions 68 and 69 

A 72-year-old woman presents with bright red rectal 
bleeding, not associated with abdominal pain, of 
2-day duration. She had previous similar episodes 



67. 



but was never hospitalized. Examination reveals a 
pale but alert individual with no significant abdom- 
inal findings. Findings on rectal examination are pos- 
itive for bright red rectal bleeding. Her vital signs 
are stable and her hemoglobin is 9.5 g. 

68. What is the most probable cause of her bleeding? 

(A) Diverticulitis of the colon 

(B) Carcinoma of the sigmoid colon 

(C) Meckel's diverticulitis 

(D) Adenomatous polyp of the colon 

(E) Diverticulosis of the colon 



69. 



70. 



71. 



The patient continues to bleed per rectum and 
becomes hypotensive to a systolic pressure of 
60 mm Hg despite blood transfusion. What is 
the optimal management plan? 

(A) Emergency colonoscopy and 
cauterization of bleeding vessels 

(B) Mesenteric angiography and 
embolization of the bleeder 

(C) Bleeding scan to localize the bleeder 

(D) Laparotomy and right colon resection 

(E) Blood transfusion laparotomy and 
subtotal colectomy with or without 
ileoproctostomy 

A 60-year-old man complains of recurrent 
attacks of painless rectal bleeding. Colonoscopy 
reveals normal mucosa between the cecum and 
the anal verge. What is the most helpful test to 
determine the cause of bleeding? 

(A) Angiography to look for angiodysplasia 

(B) Technetium scan for Meckel's 
diverticulum 

(C) Upper GI endoscopy for peptic ulcer 

(D) Small-bowel series for tumor 

(E) Ultrasound for abdominal aortic 
aneurysm 

The small intestine is characterized by basal 
crypts and superficial villi (Fig. 6-2). Where 
does cell division take place? 

(A) Submucosa 

(B) Crypts 

(C) Villi 



Questions: 65-76 



139 




Figure 6-2. 

Schematic representation of 
villi and crypts of Lieberkuhn. 
(Reproduced, with permis- 
sion, from Doherty GM: 
Current Surgical Diagnosis 
and Treatment, 12th ed. 657. 
McGraw-Hill, 2006.) 

(D) Small-bowel lumen 

(E) Lamina propria 

72. A 64-year-old man has a benign lesion of the 
colon. He is informed that the lesion does not 
predispose to colon cancer. What is the lesion 
he has? 

(A) Ulcerative colitis 

(B) Villous adenoma 

(C) Hyperplastic polyp 

(D) Adenoma in familial polyposis 

(E) Colon mucosa in a patient with colon 
carcinoma 

73. A 25-year-old man complains of rectal bleed- 
ing, weight loss, and abdominal pain. He gives 
a history of similar complaints in his siblings as 
well as his mother. Findings on physical exam- 
ination are unremarkable except for guaiac- 
positive stool. What is the most likely diagnosis? 

(A) Peutz-Jegher syndrome 

(B) Familial polyposis of the colon 



(C) Ulcerative colitis 

(D) Carcinoma of the stomach 

(E) Crohn's colitis 

74. A 55-year-old man has had previous hemicolec- 
tomy for a carcinoma of the right colon. At this 
time, 3 years after the primary resection, a CT 
scan shows a solitary lesion in the right lobe of 
the liver. What is the next step in management? 

(A) Laser cauterization 

(B) Radiotherapy 

(C) Hepatic artery catheterization and local 
chemotherapy 

(D) Symptomatic treatment with analgesics, 
because the colon disease is now stage IV 

(E) Exploratory laparotomy and resection of 
the tumor 

75. Following an appendectomy, a 28-year-old man 
is placed on ceftizoxime sodium (Cefizox). This 
antibiotic is unlikely to be effective against 
which of the following? 

(A) Pseudomonas 

(B) Staphylococcus aureus 

(C) Neisseria gonorrhoeae 

(D) Bacteroides fragilis 

(E) Haemophilus influenza 

76. A 68-year-old man presents with crampy 
abdominal pain and distention with vomiting. 
Findings on physical examination are positive 
for healed abdominal scars. X-rays reveal mul- 
tiple gas fluid levels. The WBC count is 12,000. 
What is the most likely diagnosis? 

(A) Small-bowel intestinal obstruction due 
to adhesions 

(B) Hernia 

(C) Appendicitis 

(D) Inflammatory bowel disease 

(E) Gallstones and ascites 



140 



6: Small and Large Intestines and Appendix 



77. A 55-year-old woman presents with vague 
RLQ abdominal pain. A palpable mass is noted 
on abdominal examination. The mass is pain- 
less, well defined, mobile, and nonpulsatile. 
What is the most likely diagnosis? 

(A) A mesenteric cyst 

(B) Appendix mass 

(C) Perforated tubo-ovarian abscess 

(D) Cholecystitis 

(E) Meckel's diverticulum 

78. A 74-year-old woman complains of vomiting 
and intermittent colicky abdominal pain. X- 
rays reveal fluid levels and air in the biliary 
tree. What is the likely cause? 

(A) Abdominal adhesions 

(B) Gallstone ileus 

(C) Carcinoma of the right colon 

(D) Abdominal lymphosarcoma 

(E) Previous choledochoduodenostomy 

Questions 79 and 80 

A 40-year-old woman experiences flushing, diarrhea, 
and wheezing. On physical examination, she is found 
to have tricuspid valve insufficiency. 

79. What is the most likely diagnosis? 

(A) Appendiceal carcinoid 

(B) Ileal carcinoid with liver metastasis 

(C) Gastric lymphoma 

(D) Small-bowel adenocarcinoma 

(E) Bronchial carcinoid 

80. The most useful diagnostic finding is which of 
the following? 

(A) Elevated 5-hydroxyindoleacetic acid 
(5-HIAA) levels 

(B) Elevated blood sugar levels 

(C) Elevated serum gastrin levels 

(D) Elevated amylase levels 

(E) Elevated norepinephrine levels 

81. A 56-year-old man has suffered from intermittent 
claudication for 5 years. He has recently devel- 
oped cramping abdominal pain that is made 



82. 



83. 



84. 



worse by eating. He has a history of a 15-lb 
weight loss. What is the most likely diagnosis? 

(A) Chronic intestinal ischemia (intestinal 
angina) 

(B) Chronic cholecystitis 

(C) Esophageal diverticulum 

(D) Peptic ulcer 

(E) Abdominal aortic aneurysm 

A 68-year-old male musician presents to the 
emergency department with a sudden onset of 
colicky abdominal pain and massive vomiting 
of 4-hour duration. Examination shows an ele- 
vated WBC of 13,200 with a HCT of 45%. 
Electrolytes and blood urea nitrogen (BUN) are 
normal. An erect film of the abdomen reveals 
dilatation of the stomach with distended loops 
of bowel. What is his clinical diagnosis? 

(A) Complete proximal intestinal 
obstruction 

(B) Incomplete proximal intestinal 
obstruction 

(C) Complete ileal obstruction 

(D) Incomplete ileal obstruction 

(E) Small-bowel perforation 

What is true with reference to small-bowel phys- 
iology migrating motor complexes (MMC)? 

(A) They are increased after feeding. 

(B) They occur once every 10 minutes. 

(C) They continue throughout laparotomy. 

(D) They inhibit nutrient absorption. 

(E) They may explain diarrhea that occurs 
following vagotomy. 

A 38-year-old man with a history of fever asso- 
ciated with abdominal pain of 3-week dura- 
tion presents now with a sudden onset of 
abdominal pain and copious vomiting. Plain 
abdominal x-rays reveal air under a diaphragm. 
A CT scan shows mesenteric lymphadenopa- 
thy and splenomegaly is found. Laparotomy is 
performed and 3 feet of ileum resected. The 
luminal aspect of the resected bowel shows 
marked ulceration of Peyer's patches. What is 
the most likely diagnosis? 



Questions: 77-87 



141 



(A) Typhoid enteritis 

(B) Tuberculosis enteritis 

(C) Crohn's disease 

(D) Primary peritonitis 

(E) Ulcerative colitis 

Questions 85 and 86 

85. A 48-year-old man is admitted to hospital 
because of a 3-day history of mild abdominal 
pain, repeated vomiting, and marked abdominal 
distension. Immediately after the pain com- 
menced, he had one small-bowel movement but 
no further passage of stool or flatus. An abdom- 
inal flat plate revealed marked distension of 
loops of bowel confined to the small bowel. A 
plain abdominal film shows loops of bowel that 
all extensively show valvulae conniventes. What 
is the most likely site of obstruction (Fig. 6-3)? 

(A) High-small bowel 

(B) Mid-small bowel 

(C) Rectum 

(D) Colon 

(E) Duodenum 



86. 



87. 



Following insertion of a nasogastric tube and 
appropriate rehydration and electrolyte cor- 
rection, there is no change in clinical presenta- 
tion. What should the next step involve? 

(A) Barium reduction with controlled 
hydrostatic pressure 

(B) Laparoscopy 

(C) Colostomy 

(D) Needle tap to deflate bowel 

(E) Exploratory laparotomy 

Following resection of the left colon, a 67- 
year-old obese woman develops left-sided leg 
edema due to deep-vein thrombosis. She is 
placed on anticoagulants, but after 2 weeks of 
warfarin (Coumadin), she develops a pul- 
monary embolus with slight hypoxemia. 
What should the next step in management 
involve? 

(A) Increasing the dose of anticoagulants 

(B) Discontinuing anticoagulants 

(C) Use of an inferior vena cava (IVC) 
filter 

(D) CT scan of the leg and abdomen 

(E) Femoral vein ligation 





(A) High small bowel 



(B) Mid-small bowel 





(C) Distal small bowel 



(D) Colon 



Figure 6-3. 

Intestinal obstruction. (Reproduced, with permission, from Way LW: Current Surgical Diagnosis & Treatment, 10th ed. 
Appleton & Lange, 1994.) 



742 



6: Small and Large Intestines and Appendix 



Questions 88 and 89 

A 44-year-old female immigrant from India, and now 
resident in the US, has been treated for partial intes- 
tinal obstruction due to tuberculosis. There is no evi- 
dence of intestinal perforation. 

88. What should the next step in treatment involve? 

(A) Laparoscopy 

(B) Laparotomy and bowel resection 

(C) A full course of antituberculous drugs 

(D) Steroids 

(E) Radiation therapy to the abdomen 

89. What is the most likely outcome for the 
patient? 

(A) Full recovery 

(B) Rapid deterioration and possible death 

(C) Pneumonia 

(D) Empyema 

(E) Scrofula 

90. A 64-year-old woman presents with a strangu- 
lated femoral hernia. At operation, what is the 
criterion used to determine the viability of a 
loop of bowel? 

(A) Increased peristalsis 

(B) Absent arterial pulsation 

(C) Venous engorgement 

(D) Intraoperative CT scan 

(E) Serum amylase 

DIRECTIONS (Questions 91 through 98): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. Each lettered option 
may be selected once, more than once, or not at all. 

Questions 91 and 92 

(A) Vitamin A 

(B) Vitamin C 

(C) Vitamin D 

(D) Vitamin E 

(E) Vitamin K 



(F 

(G 

(H 

(I 

a: 

(K 
(L 

(M 

(n; 

(O 



Vitamin B : 

Chyle 

Sympathetic denervation 

Failure of rectal muscles to contract 

Gluten 

Peptides 

Bile salts 

Meissner and Auerbach plexus deficiency 

Vagus nerve excess 

Inferior mesenteric ischemia 



91. Steatorrhea and megaloblastic anemia, occur- 
ring in a patient after bowel resection, is caused 
by a failure to absorb what? SELECT ONE. 

92. What does Hirschsprung's disease involve? 
SELECT ONE. 



Questions 93 


(A) 


Spigelian hernia 


(B) 


Direct inguinal hernia 


(C) 


Femoral hernia 


(D) 


Richter's hernia 


(E) 


Appendix 


(F) 


Hydrocele 


(G) 


Sliding hernia 


(H) 


Bladder 


(I) 


Liver 


(J) 


Seminal vesicle 


(K) 


An adrenal metastasis 


(L) 


Ureter 


(M) 


Prostate 


(N) 


Pubic bone 


(O) 


Cowper's (bulbourethral) glands 



93. An 84-year-old man has had a reducible hernia 
in the right groin for 17 years. One day before 
admission to the hospital, he complains of 
abdominal pain; because of the swelling, the 
hernia has become irreducible. At operation, part 
of the wall of the cecum is noted to form a por- 
tion of the hernia sac. What is the hernia? 

Questions 94 through 95 

(A) Supralevator space 

(B) Perianal space 



Questions: 88-98 



143 



(C) Levator ani muscle 

(D) Intermuscular space 

(E) External sphincter 

(F) Ischioanal space 

(G) Submucous space above the levator ani 
muscle 

(H) Marginal mucocutaneous space 

94. A 25-year-old patient with a 2-cm painful 
abscess in perianal region for 1 day. The patient 
does not have fever or leukocytosis. Which 
space is this lesion in? SELECT ONE. 

95. A 30-year-old patient presents with a 5-day his- 
tory of pain to right buttock. A 7-cm firm area is 
noted on the right buttock. Patient also describes 
purulence from rectum and has a temprature 
101°F. In which space is this lesion? SELECT 
ONE. 



96. A 28-year-old woman recently treated as an out- 
patient for pelvic inflammatory disease presents 
with fever, leukocytosis, and deep rectal pain. In 
which space is this lesion? SELECT ONE. 

Questions 97 and 98 

(A) Pilonidal sinus 

(B) Posterior perianal sinus 

(C) Single anterior perianal sinus 

(D) Multiple anterior perianal sinus 

(E) Periurethral abscess 

(F) Bartholin gland abscess 

(G) Prostatic abscess 
(H) Rectovaginal fistula 

97. Which opens into the anal mucosa in the mid- 
line? SELECT ONE. 

98. What has hair inside? SELECT ONE. 



Answers and Explanations 



3. 



(C) In uncomplicated appendicitis laparoscopic 
appendectomy can be performed with similar 
outcomes to an open technique. Studies reveal 
hospital stay and return to full feeding is simi- 
lar. Wound complication and overall complica- 
tion rates are the same. Procedure cost are higher 
owing to the use of additional equipment. 

(D) Laparoscopic appendectomy does present 
the surgeon with several advantages. 
Although in hospital recovery is similar to the 
open technique, posthospital recovery can be 
shorter in uncomplicated appendicitis. In cases 
where the diagnosis of appendicitis is less cer- 
tain the laparoscopic approach confers several 
advantages. In addition to accurately diag- 
nosing appendicitis, the laparoscopic approach 
allows the surgeon the ability to inspect the 
entire abdominal cavity when a normal appen- 
dix is found. The laparoscopic approach can 
also be used to treat other intra-abdominal 
surgical pathologies and, therefore, reduces 
the need for extending or converting to a con- 
ventional laparotomy incision. Laparoscopic 
technique does result in a longer operative 
time for appendectomy with higher operative 
cost. Cosmesis is generally better with the 
laparoscopic technique owing to smaller 
wound size. 

(B) The normal appendix should be removed to 
avoid future diagnostic confusion and appen- 
dicitis. The entire abdomen should be explored 
for other potential causes of the clinical presen- 
tation. If found, other pathologies, which are the 
cause of the presentation, may be treated surgi- 
cally, either laparoscopically or open if indicated. 



4. (B) Ulcerative colitis is a disease of unknown 
etiology, which involves the colon and rectum 
and spares the remainder of the GI tract. It's 
clinical course is variable with inflammatory 
changes and clinical symptoms ranging from 
mild to severe. The process is confined to the 
mucosa and the submucosa and does not 
extend through the full thickness of the bowel 
wall. Inflammatory changes are confluent with 
no skip areas. The risk of dysplasia and col- 
orectal cancer is higher in ulcerative colitis than 
in the general population. 

5. (C) Toxic megacolon is a fulminant exacerbation 
of ulcerative colitis, causing massive dilatation of 
the colon with perforation, fecal peritonitis, and 
death. Emergency total colectomy is indicated. 

6. (D) Risk of dysplasia and colorectal cancer is 
higher in ulcerative colitis than in the general 
poulation. The severity, duration, and anatomic 
extent of the inflammation are risk factors for 
the development of dysplasia and cancer. These 
cancers do not seem to follow the adenoma 
carcinoma sequence and can arise in flat 
mucosa making them difficult to detect even 
with regular colonoscopies. After 8-10 years of 
colitis survellance colonoscopy should be per- 
formed with multiple random biopsies. The 
finding of dysplasia is an indiction for imme- 
diate total protocolectomy Centers have 
reported up to 42% of colons removed for dys- 
plasia also had colon cancer. 

7. (D) The man likely has diverticulitis. The dif- 
ferential includes irritable bowel, appendicitis, 
inflammatory bowel disease, pyelonephritis, 



144 



Answers: 1-14 



145 



ischemic colitis, and perforated carcinoma. 
Diverticulitis is an infectious complication of 
diverticulosis resulting from perforation of the 
colonic diverticulum. The resulting inflamma- 
tion may be confined to the pericolonic tissue 
(incomplicated diverticulitis) or result in 
abscess, free perforation, fistulization, or obstruc- 
tion (complicated diverticulitis). The clinical 
spectrum is correspondingly broad ranging 
from mild symptoms to peritonitis and sepsis. 
Patients with signs and symptoms of sepsis 
should be hospitalized and undergo diagnostic 
study. A CT scan is the best study to evaluate 
the extent of the inflammatory process as well 
as to exclude other pathology. Plain x-ray 
would not reveal specific pathology. Both 
barium enema and colonoscopy in the acute 
setting are risky and may cause free perforation 
and contamination of the peritoneal cavity there 
by converting a localized process to general- 
ized peritonitis. Barium has the additional risk 
of a chemical peritonitis caused by the barium 
itself. Diagnostic laparoscopy is invasive and 
may risk spreading a localized process. 

8. (C) Diverticulitis results from acute inflamma- 
tion of a colonic diverticula. The process may 
extend into adjacent organs (e.g., the urinary 
bladder and a fistula between the colon and 
bladder colovesical fistula may ensue). This 
leads to passage of colonic gas and fecal mate- 
rial into the bladder and urine resulting in 
pneumaturitis and fecaluria. Sigmoid resection 
and repair of the bladder fistula is indicated. 

9. (A) Uncomplicated diverticulitis is treated with 
broad spectrum antibiotics and bowel rest. 
Surgery is not indicated — either resection or 
diversion of the fecal stream by colotomy or 
ilestomy Anti-inflamatory agents are not indi- 
cated in the therapy of diverticulitis. The risk of 
a second episode is less than 30%. After a 
second episode, the risk is greater than 50% 
and resection may be advised at this stage. 

10. (E) This patient has sigmoid volvulus. Plain 
abdominal x-ray shows a massively distended 
loop in the right upper quadrant, because the 
sigmoid colon, as it progressively distends, as a 
result of the twist of its mesentery, has no space, 



in the LLQ to occupy and flips over to the largest 
available area — namely the right upper quad- 
rant. Given the clinical presentation and find- 
ings, the plain abdominal x-ray is diagnostic. 

11. (E) Rigid sigmoidoscopy is effective in reduc- 
tion and decompression of the volvulus, often 
resulting in a copious rush of gas and stool as 
decompression results. It also allows for eval- 
uation of bowel viability. If the point of rotation 
is beyond the 25-cm rigid sigmoidoscopy, flex- 
ible endoscopy may be attempted by an expe- 
rienced endoscopist using minimal inflation of 
air. A rectal tube should be placed to allow for 
bowel decompression. Laparotomy may occa- 
sionally be necessary in cases of perforation or 
compromised viability. 

12. (B) Technetium sulfur colloid scans have the 
advantage of immediate availability but the 
patient must be bleeding when the isotope is 
injected as the isotope is quickly cleared by the 
reticuloendothelial system of the liver and spleen. 

13. (B) Vasopressin can be selectively infused into 
a bleeding mesentric vessel. A bleeding rate of 
.5 per minute is necessary for a positive angio- 
gram. Temporary success in stopping the bleed- 
ing will not obviate the need for surgery. The 
angiodysplasia of the colon is one of the most 
common causes of lower GI bleeding in elderly 
patients. With diverticular disease, 75% of the 
patients will have only a single episode of hem- 
orrhage, whereas angiodysplasia patients are 
very likely to have recurrent episodes of variable 
severity. 

14. (C) This patient has a T2Ni stage III colon 
cancer for colon cancer — staging is categorized 
by TNM system. Where, T is depth of penetra- 
tion through bowel wall, N = nodal involve- 
ment, and M = metastatic disease. 

T l's carcinoma in situ 

T 1 invades submucosa 

T 2 invades muscularis propria 

T 3 through the muscularis propria 

T 4 through visceral peritonuem 

NO no lymph node involvement 

N 1 1-3 positive nodes 

N 2 4 or more pericolic nodes 



146 



6: Small and Large Intestines and Appendix 



N 3 any node along the main vascular 

MO no metastasis 

Ml distant metastasis 

Staging is a follows: 

Tl or T2 No Mo = stage I 
T3 or T4 No Mo = stage II 
Avg T Nl Mo = stage III 
Avg T Avg N Ml = stage IV 

15. (D) Patients with stage III colon cancer have 
5-year survival ranging from 20% to 50%. 
Prognosis is largely related to lymph node 
involvement. Recurrence is usually in liver, peri- 
toneal cavity or lungs. Adjuvant chemotherapy 
with 5 FU based regimens have proven benefit 
in decreasing recurrence and improving sur- 
vival. Capecitabine is an oral fluoropyrimidine, 
which is converted to 5 FU in tumor cells. It's 
role is still being defined in national clinical 
trials. Radiation therapy is not offered in stage III 
colon cancer as local failure is rare because ade- 
quate margins can be obtained. 

16. (A) The small intestine arises from the midgut 
segment. The midgut segment extends between 
the ampulla of Vater and the distal transverse 
colon. It enters the physiological umbilical hernia 
at sixth week and returns to the peritoneal cavity 
by the tenth week. The vitellointestinal tract (site 
from which Meckel's diverticulum arises) is 
attached to the antimesenteric margin of the 
distal ileum. The urachus is attached to the blad- 
der. The intestinal lymphatic drainage is directed 
to the preaortic glands. 

17. (D) The small intestine commences to the left of 
the midline at Treitz's ligament and ends at the 
ileocecal junction. The mesenteric attachment is 
only 15 cm in length. It is supplied by the midgut 
vessel (superior mesenteric). The sympathetic 
and parasympathetic (vagus) nerves enter the 
mesentery to supply the vessels and gut wall. 

18. (C) Crohn's disease differs from ulcerative coli- 
tis in that clinical improvement usually occurs 
when a diseased segment is excluded from the 
fecal stream. Crohn's disease involves the distal 
ileum in most patients, but almost any part of the 



alimentary tract could be affected. Steroids fre- 
quently result in improvement in patients with 
Crohn's disease and ulcerative colitis. In Crohn's 
disease, steroids are a double-edged sword, 
because they clearly allow initial improvement, 
but eventually their benefit is counteracted by 
adverse complications of steroids. 

19. (C) The serosa appeared normal on inspection, 
but the colon mucosa was extensively involved. 
In ulcerative colitis, the distal rectum and colon 
are primarily involved in continuity to the prox- 
imal extent of the lesion. In Crohn's disease, a 
similar pattern may be found on rare occasions, 
but other features, such as small intestinal dis- 
ease, transmural involvement, skip lesions, and 
fistula formation, favor Crohn's disease. The 
small bowel is not primarily involved in ulcer- 
ative colitis, but a "backwash" ileitis may be 
encountered. 

20. (D) Gangrene of the bowel occurs before the 
ominous sign of intramural air can be detected. 
The stack-of-coins sign is seen in intestinal 
obstruction where the proximal small intestine 
folds are stacked to provide this characteristic 
feature on a plain x-ray of the abdomen. 

21. (C) In a patient with small intestine infarction, 
the possibility of nonocclusive ischemic dis- 
ease should be excluded by angiography. If 
there is no evidence of gangrene, then fluid 
resuscitation and intra-arterial superior mesen- 
teric papaverine administration may be ade- 
quate, and surgical intervention may be 
avoided. Von Willebrand's disease is charac- 
terized by a mild to moderate fall in factor VIII 
levels (pseudohemophilia) but with a much 
milder bleeding tendency than in true hemo- 
philia. It affects males and females equally. 

22. (C) Most air that reaches the stomach and intes- 
tines comes from swallowed air. Air is nearly 
always seen in the small intestine on a plain film 
of the abdomen. Gas in the stomach is derived 
mainly from swallowed air, which has an 
oxygen content of 20% and nitrogen content of 
80%. C0 2 is formed by organic fermentation and 
comprises 40% of the gases in the distal bowel. 
Nitrogen is absorbed so that it is reduced below 



Answers: 15-34 



147 



50% distally. Methane and hydrogen sulfide 
gases are added in the distal bowel. 

23. (D) A plain film of the abdomen shows valvu- 
lae conniventes in jejunal (proximal) obstruc- 
tion, a featureless bowel pattern in distal ileal 
obstruction, and haustra in colon obstruction. 

24. (A) The initial management of intestinal obstruc- 
tion is to correct fluid and electrolyte imbalance. 
Surgery is indicated if strangulation is anticipated 
or if the obstruction fails to respond to conserva- 
tive management. Nasogastric suction is often 
effective in obstruction because of adhesions but 
is contraindicated when the obstruction is caused 
by a hernia and/or strangulation is suspected. 

25. (B) In patients presenting with small-bowel 
obstruction, clinical examination can usually 
identify a groin swelling attributable to stran- 
gulated hernia. If external groin hernia is 
excluded, the presence of an abdominal scar 
would highly suggest that intestinal obstruc- 
tion is caused by adhesions. Peritoneal metas- 
tasis and primary tumors, bands, Crohn's 
disease, and gallstone ileus must be excluded. 
The distention is mainly a result of swallowed 
air. If the obstruction is proximal, the onset is 
usually more severe and rapid. 

26. (D) In a Richter hernia, only part of the cir- 
cumference of the bowel wall has become 
trapped in the hernia sac, and normal bowel 
movements may still occur. In the presence of 
a reducible groin hernia, it is important on 
clinic examination to be certain that other 
pathologic conditions are not overlooked. 

27. (E) Primary small-bowel volvulus is common in 
countries where the diet is high in bulk. Except 
for the neonatal variety (associated with malro- 
tation), it is rare in the United States. Small-bowel 
volvulus secondary to adhesions is more 
common here. The ileum is more frequently 
involved than the jejunum. If a small-bowel resec- 
tion is required, it is usually of a limited nature. 

28. (C) The ileum is the exclusive site of bile salt 
absorption, and failure of its absorption con- 
tributes to the steatorrhea. Ileal resection, which 



at times includes the ileocecal valve, is more 
commonly performed than is proximal resec- 
tion. Over a longer period of time (2-3 years), 
megaloblastic anemia occurs. 

29. (A) Transit time in the ileum is slower than that 
in the jejunum. Resection of equal lengths of 
intestine results in greater deterioration after 
ileal resection as the site of slower (and there- 
fore more complete) absorption is removed. 
Jejunal resection is followed by hypertrophy 
of the residual villi in the ileum and functional 
compensation to a degree greater than in the 
jejunum after ileal resection. 

30. (B) Massive resection occurs if more than 
75-80% is resected (leaving less than 1 m of 
small bowel). The most common indications 
for major bowel resection are ischemia, Crohn's 
disease, volvulus, and trauma. 

31. (A) In the blind loop syndrome, bacteria prolif- 
erate in an affected segment that fails to show 
appropriate peristaltic activity. It may be seen in 
surgery requiring jejunal or ileal bypass, small 
intestinal diverticular disease, scleroderma, 
diabetes mellitus, and intestinal carcinoma. 
Macrocytic anemia, caused by malabsorption 
of Vitamin B 12 and folic acid, is a key diagnos- 
tic feature in its diagnosis. 

32. (C) Intestinal obstruction due to a Meckel's 
diverticulum may result from a volvulus, band 
obstruction, or intussusception. Among chil- 
dren, bleeding and inflammation are seen more 
frequently. Meckel's diverticulum is a remnant 
of the vitellointestinal duct. 

33. (B) Peutz-Jeghers syndrome is rare but should 
be considered if pigmented spots are found on 
the lips, mouth, or hands. Hamartomas are not 
neoplasms; the name is derived from the Greek 
hamartos, which refers to the misfiring of a 
javelin. The tissues appropriate to the site mis- 
fire and are arranged in an irregular order. 

34. (A) Unfortunately, in most series, division of 
adhesions accounts for as much as 25% of post- 
operative intestinal fistulas. These cases usually 
involve sites that are not recognized at the time 



148 



6: Small and Large Intestines and Appendix 



of operation. The fistulas occurring after resec- 
tion of the bowel in Crohn's disease are less 
likely to heal without surgical intervention. The 
small intestine is the most common site of intes- 
tinal fistula formation. 

35. (B) Internal small-bowel fistulas are caused 
almost exclusively by small-bowel disease or sur- 
rounding visceral disease involving the small 
bowel. Crohn's disease is the most common cause 
of internal small-bowel fistulas, but neoplasia, 
lymphoma, and tuberculosis must be excluded. 
Internal fistula may be asymptomatic or cause 
serious malabsorption (proximal to distal fistulas) 
or infection (enterovesical fistulas). 

36. (C) Both zinc and vitamin C (ascarbate) defi- 
ciency, impair wound healing. Vitamin A 
deficiency is also implicated in would heal- 
ing and supplemental Vitamin A has been 
shown in experimental studies to prevent radi- 
ation included defects in wound healing. 
Incision through the same abdominal wall scar 
incision actually promotes wound healing, 
because the initial lag interval after creation of 
the wound is avoided (unless the whole scar of 
the incision is removed). Increase in local oxygen 
tension actually promotes wound healing. 

37. (A) Doxorubicin cleaves diribonucleic acid 
(DNA) and has been shown to decrease wound 
healing. Treatment should be delayed at least 
4 weeks. Wound healing will improve by reduc- 
ing wound infection rates. This is the rational for 
the use of antibiotic prophylaxis. The use of 
mechanical cleansing alone will not reduce 
wound infection and may actually increase 
complications. Mechanical preparation with oral 
nonabsorbable antibiotics does reduce micro- 
bial flora and has been shown to reduce surgical 
infectious complications. Denervation of tissue 
surrounding the incision does not influence 
wound healing. Steroids delay the rate of 
wound healing and decrease protein synthesis. 

38. (D) The omentum and peritoneal cavity seem 
to be less efficient in localizing the disease in 
these age groups. Appendicitis has a particu- 
larly high-complication rate in infants and 
the elderly. Delay in establishing the accurate 



diagnosis in these two age groups also con- 
tributes to a worse prognosis. 

39. (D) In appendicitis, patients frequently note 
that the pain commences in the umbilical 
region and moves later to the right iliac fossa. 
Pain in the iliac fossa occurs when the overly- 
ing parietal peritoneum is involved. Patients 
with appendicitis typically indicate that they 
have anorexia. 70-80% of patients with appen- 
dicitis have vomiting. 

40. (C) This is McBurney's point and often indicates 
the region where maximal tenderness can be 
elicited. In addition to tenderness, guarding and 
percussion tenderness should be sought to verify 
whether localized and/or general peritonitis exists. 

41. (B) The mortality rate from appendicitis is 
4/1,000,000 in the general population, which is a 
20-fold decline from that reported 50 years ago. 
The mortality rate for ruptured appendicitis is 
4-5% but increases to 9% in infants and 15% in 
patients above 65 years of age and those with 
serious underlying medical illness. The high rate 
of perforation is partly due to physician delay in 
establishing the diagnosis of acute appendicitis. 
The mortality rate of 0.1% in patients with non- 
ruptured appendicitis highlights the fact that the 
condition remains a potentially lethal disease. 
The diagnosis of acute appendicitis is nearly 
always determined on clinical grounds without 
need to request a CT scan (Fig. 6-A). 

42. (C) If the surgeon's records indicate that all oper- 
ations on the appendix are abnormal, there is a 
real danger that a true appendicitis will be 
missed and that the criteria chosen are too rigid. 
On the other hand, if the rate of normal appen- 
dices removed is increased, the criteria selected 
for operation require further defining. Good clin- 
ical observation and appropriate laparoscopy in 
female patients will help achieve the goal of opti- 
mal incidence of accuracy with emergency 
appendectomy. After unwarranted appendec- 
tomy, complications include persistent pain from 
adhesions, inadvertent visceral trauma at oper- 
ation, and small-bowel obstruction. In older 
patients in particular, the usual diverse compli- 
cations of operations occur. 



Answers: 35-50 



149 




Figure 6-4. 

A. CT scan shows a fecolith in the appendix, B. CT scan shows a 
dilated appendix with fluid. 



43. (A) Rousing's sign is corroborative of acute 
appendicitis. The other signs are corroborative 
of appendicitis. Hyperesthesia is a useful sign 
provided that it is performed objectively. The 
area of hyperesthesia is a triangular area (base 
placed upward) in the right lower abdomen. 

44. (A) The presence of a blind loop leads to mal- 
absorption with steatorrhea, macrocytic 
anemia, and malabsorption. A blind loop is 
likely to occur if an antiperistaltic loop is cre- 
ated, and it is more than 3-6 inches in length. 
The antiperistaltic loop causes failure of ade- 
quate emptying of intestinal contents; this leads 
to stasis and overgrowth of bacteria. 

45. (C) Irradiation of the abdominal cavity of more 
than 50 Gy is associated with a higher rate of com- 
plications. The incidence of symptomatic sig- 
moiditis may be as high as 75%, and histologically 



abnormal rectal biopsy findings occur in 11% of 
patients undergoing treatment for pelvic malig- 
nancy. Previous surgery with possible adhesion 
formation increases the risk of irradiation damage. 

46. (E) In most patients, ischemic colitis is a self- 
limiting illness that usually resolves within 
7-10 days. Patients may manifest pyrexia and 
peritonitis, have persistent symptoms, and 
develop complications, such as stricture for- 
mation, perforation, and bleeding. Unlike 
small-bowel ischemia, the main vessels are 
characteristically patent. 

47. (A) The mucosa is friable and bleeds readily. 
Ulcers vary in size and often tend to be trans- 
verse in position and surrounded by telang- 
iectasis. They are often more prominent on the 
anterior wall around the anal verge. Rectal 
strictures usually are located about 8-12 cm 
above the anal verge. Rectovaginal fistula may 
develop in female patients. On barium enema, 
a narrow stricture is difficult to differentiate 
from a carcinoma. 

48. (D) In 90% of cases with colonic ischemia, the 
patient is over 65 years of age. Precipitating 
causes, such as cardiac disease, are much less 
frequently encountered than in small-bowel 
ischemia. In 20% of patients, an underlying 
obstructive lesion of the colon is noted. Unlike 
small-bowel ischemia, the pain is often insidi- 
ous in onset. 

49. (E) The classic finding of thumbprinting may 
be missed if the barium enema study is 
deferred for more than 10 days after onset of 
symptoms. Unlike small-bowel ischemia, the 
main vessels are patent in most cases. 

50. (D) After 10 years with ulcerative colitis, the 
chances of developing carcinoma increase four- 
fold. After 20 years, the cumulative risk is 12%, 
and at 25 years, it is 25%. Malignancy is often 
detected at a late stage and has a larger per- 
centage of synchronous lesions as compared to 
that seen in patients with cancer who do not 
have ulcerative colitis. Patients with extensive 
disease and those in whom the disease occurs at 
an earlier age must undergo careful surveillance. 



150 



6: Small and Large Intestines and Appendix 



51 . (A) Occurs more frequently than in the rest of the 
population. The cumulative risk of developing 
cancer in patients with extensive ulcerative coli- 
tis is greater than in those with more localized 
disease (42% at 25 years). Children are more 
likely to have extensive disease. Colon cancer 
occurs more frequently in the sigmoid and 
rectum in ulcerative colitis, but cancer is more 
likely to occur in patients who have universal 
disease. Synchronous carcinomas in patients 
without ulcerative colitis occur in 4%, compared 
to 25% in those with colitis. Lesions usually are 
flat, are frequently missed at examination, and 
have a worse prognosis than sporadic colon can- 
cers found in normal risk patients. Adults devel- 
oping cancer under the age of 45 have a poorer 
prognosis than those who develop it later. 



56. 



included in the definite resection for the pri- 
mary carcinoma. Thus, it is important to try, 
whenever possible, to perform colonoscopy 
before colon resection to facilitate planning of 
the operation should a synchronous lesion be 
detected. If this study is omitted, it is advisable 
to have a complete colonoscopy performed 
within the first 2-3 months after resection. 

(C) Dukes A lesions have an excellent prognosis 
of 90% 5-year survival compared to that with 
serosal extension (B2), particularly if lymph nodes 
are heavily involved. Around 70 % of obstructing 
lesions occur on the left side and 30% proximal to 
the hepatic flexure. The CEA level correlates with 
the extent of encirclement of the tumor, Dukes 
classification, and the likelihood of recurrence. 



52. (C) There has been an increase in incidence of 
colon cancer relative to that of the rectum in 
recent years. This observation may be related to 
the improved diagnostic techniques now avail- 
able with colonoscopy. The higher mortality of 
some rectal cancer patients may be attributed to 
an incomplete resection of the tumor when it is 
close to the cut edge. Each year, 14,000 new 
cases are diagnosed and over 6000 deaths occur. 

53 . (E ) Just under half of patients with local disease 
will also have associated metastatic disease. 
Patients with microscopic lymph node 
metastasis — adjacent as opposed to remote — 
and with one to three lymph nodes involved 
have a better prognosis than patients with more 
extensive disease. 

54. (B) Synchronous malignant lesions (present in 
4-5%) refer to those present at the time of sur- 
gery or found in investigations carried out 
within 6 months after operation. Metachronous 
lesions are those not detected during this period 
but subsequently identified. Metachronous car- 
cinomas occur in about 5% of cases. 

55. (B) Synchronous carcinoma and polyps, of all 
types, occur at sites in the colon not included in 
an anterior or sigmoid resection. Both syn- 
chronous carcinomas and benign polyps occur 
mainly at sites in the colon that would not be 



57. (C) The most common sites of obstruction are 
descending colon (21%), sigmoid (17%), and 
splenic flexure (15%). The percentages for cases 
with obstruction at a particular site are splenic 
flexure, 37%; sigmoid, 16%; and right colon, 14%. 

58. (A) The ducts of the anal glands drain into the 
anus and are covered by the vertical columns of 
Morgagni. Infection of these glands may account 
for some cases of perianal abscess. The folds 
end distally at about the level of the dentate line. 
The lower third of the anus receives its nerve 
supply from the pudendal nerve (somatic). In 
order to minimize spread of infection, the local 
anesthetic should be confined to the skin imme- 
diately overlying the abscess. This should be 
performed in a hospital setting, in an operating 
room, with good lighting, in the lithotomy posi- 
tion, using a combination of IV sedation andlo- 
cal anesthesia. Protoscopy/sigmoidoscopy can 
be undertaken at he same time. 

59. (C) CEA is useful in the follow-up care of 
patients with colon carcinoma after resection. 
The levels of this antigen usually come to 
normal after complete resection of the tumor. A 
subsequent elevation may suggest a recurrence 
of the tumor either at the resection margin or at 
distant sites. The sensitivity and specificity of 
CEA for diagnosis of colon carcinoma is poor. It 
has no implications for resectability of the lesion. 



Answers: 51-65 



151 



60. (E) Insidious development of a microcytic, 
hypochromic anemia is an important clue for 
the diagnosis of carcinoma of the right colon. 
Guaiac-positive stool with or without a pal- 
pable mass in the RLQ should raise the possi- 
bility. All the other possibilities listed may also 
cause lower GI bleeding but are characteristi- 
cally associated with abdominal pain (peptic 
ulcer disease, Crohn's disease, ulcerative coli- 
tis). Bleeding in sigmoid diverticulosis usu- 
ally is bright red and painless. 

61. (A) Recurrent fistulas in ano are a feature of 
Crohn's colitis. The absence in the rectum 
eliminates the possibility of ulcerative colitis. 
Amebic colitis presents with recurrent episodes 
of diarrhea with bleeding. Ischemic colitis also 
presents with diarrhea. 

62. (D) The picture described suggests large-bowel 
obstruction in a patient with a competent ileoce- 
cal valve. The most likely cause is an obstructing 
carcinoma. The site of obstruction is in the sigmoid 
colon above the level of sigmoidoscopy. Sigmoid 
volvulus, ischemic colitis, and diverticulitis will 
present some findings on sigmoidoscopy. Pseudo- 
obstruction of the colon will manifest as colonic 
distention down to the rectum (Fig. 6-5). 

63. (D) Rectosigmoid injuries should promptly raise 
a high index of suspicion, warranting immedi- 
ate sigmoidoscopy to confirm the diagnosis. 
Sigmoidoscopy, rigid or flexible, involves much 
manipulation and insufflation of air. This is 
hardly desirable or safe in the presence of a 
significant tear in the presence of a rectal foreign 
body, free air under the diaphragm, in a patient 
with an acute abdomen, is all that is necessary to 
warrant laparotomy. Following this, CT scan 
with gastrofin administered orally, will give the 
diagnosis. The best treatment is exteriorisation 
that is colostomy, at the perforated site. This will 
depend upon the location and extent of the per- 
foration. If small and localized, colostomy at the 
site or proximally may be chosen. If the tear is 
massive, then resection with proximal colostomy 
and mucous fistula (Hartman) may be indicated. 

64. (C) Volvulus of the sigmoid (secondary type) is 
common in elderly patients who are chronically 




Figure 6-5. 

Barium enema roentgenogram of an encircling carcinoma of 
the descending colon presenting an "apple core" appear- 
ance. Note the loss of mucosal pattern, the "hooks" at the 
margins of the lesion owing to undermining by the growth, 
the relatively short (6 cm) length of the lesion, and its abrupt 
ends. (Reproduced, with permission, from Doherty GM: 
Current Surgical Diagnosis and Treatment, 12th ed. 721. 
McGraw-Hill, 2006.) 



constipated. Redundancy of the sigmoid and a 
narrow mesenteric attachment predispose for 
the twisting. In the large bowel, the sigmoid is 
the most common site. Abdominal distention 
and tenderness are the common presenting 
symptoms. Volvulus of the sigmoid colon can 
usually be detected on a supine and erect 
abdominal x-ray. Sigmoidoscopy and contrast 
barium studies may be helpful to differentiate 
carcinoma from volvulus (Fig. 6-6). 

65. (A) The long history of bloody diarrhea should 
suggest a diagnosis of inflammatory bowel dis- 
ease. The acute onset of abdominal pain together 
with the findings of an acute abdomen and sys- 
temic manifestations should raise the suspicion 
of a devastating complication. The picture is 
characteristic of acute toxic megacolon in ulcer- 
ative colitis. All the other possibilities listed may 
present with an acute abdomen, but the long 
history should point to ulcerative colitis. 



152 



6: Small and Large Intestines and Appendix 




Figure 6-6. 

Volvulus of the sigmoid colon. Barium enema taken with the 
patient in the supine position. Note the massively dilated sig- 
moid colon. The distinct vertical cease, which represents jux- 
taposition of adjacent walls of the dilated loop, points toward 
the site of torsion. The barium column resembles a "bird's 
beak" or "ace of spades" because of the way in which the 
lumen tapers toward the volvulus. (Reproduced, with permis- 
sion, from Doherty GM: Current Surgical Diagnosis and 
Treatment, 12th ed. 701. McGraw-Hill, 2006.) 



66. (D) In a patient with abdominal aortic aneurysm 
resection, the most worrisome complication is 
inadequate blood supply to the sigmoid colon 
through the marginal artery. Sigmoid ischemia 
should be ruled out by sigmoidoscopy. In the 
clinical picture described, sigmoidoscopy should 
be the most important test. 

67. (B) The findings described on physical exami- 
nation and CT scan are suggestive of acute 
diverticulitis of the sigmoid colon. The initial 
treatment of this condition is expectant with 
antibiotics with or without nasogastric 
drainage. An antibiotic with specificity against 
the Bacteroides species (third-generation 
cephalosporin, metronidazole, or clindamycin) 
should be part of the regimen. Steroids have no 
place in the treatment. Laparotomy is indicated 
only after failure of conservative treatment. 



68. (E) The clinical picture of recurrent bright rectal 
bleeding that is not associated with abdominal 
pain is characteristic of diverticulosis of the colon. 
The bleeding in sigmoid carcinoma is often 
microscopic. Diverticulitis of the colon would 
present with associated pain. Adenomatous 
polyp may present with painless rectal bleeding, 
but the most common condition in this elderly 
age group is diverticulosis of the colon. 

69. (E) Laparotomy and subtotal colectomy should 
be the preferred approach in a hypotensive 
patient. There is no time for trying to localize 
the site of bleeding by scans, mesenteric angiog- 
raphy, or colonoscopy. Although the common 
site of massive diverticular hemorrhage is the 
right colon, a blind right colon resection in an 
elderly woman with hypotension is fraught with 
the danger of recurrent bleeding from the left 
colon. The safest and most expeditious manage- 
ment is subtotal colectomy. The decision for anas- 
tomosis or proximal ileostomy will depend on 
the stability of the patient. 

70. (A) A common cause of lower GI bleeding that 
is recurrent and painless is angiodysplasia of 
the colon. In the absence of diverticula or hem- 
orrhoids, the suspicion is even higher for these 
lesions. Peptic ulcer and Meckel's diverticu- 
lum can cause predominantly lower GI bleed- 
ing. However, the bleeding is usually in the 
form of melena rather than bright red. 

71. (B) Small-bowel turnover can be measured in 
rats by autoradiographic studies in which 
turnover of cells located in the crypts migrate 
along the villus toward the tip over a 2- to 3- 
day period. Intestinal villous mucosa under- 
goes hypertrophy and hyperplasia whenever 
an increased food load continuously enters the 
small intestine. 

72. (C) All the choices listed except hyperplastic 
polyp are precancerous lesions. The carcino- 
mas in ulcerative colitis and familial polyposis 
are multicentric. Large villous adenomas may 
have carcinomatous changes. Any patient with 
a colon carcinoma is predisposed to develop a 
metachronous lesion in the remaining colon, 



Answers: 66-77 



153 



hence the importance of regular follow-up 
examinations in these patients. 

73. (B) All the clinical features mentioned and the 
strong family history should raise the possibility 
of familial polyposis. Although other possibilities 
listed may also cause rectal bleeding and abdom- 
inal pain, the strong familial history should give 
a clue to the diagnosis. The early onset of inva- 
sive carcinoma in these patients makes recog- 
nizing familial polyposis very important. 

74. (E) Many patients who have metastasis to the 
liver or lung have resectable tumors. A reason- 
able disease-free interval has been reported 
after such resections, especially with carcinoma 
of the colon as the primary lesion. 

75. (A) Cefizox is not effective against many 
strains of Pseudomonas. If the drug is used in 



pseudomonas infection a higher dosage may 
be indicated, and the antibiotic should be 
changed if a quick response does not occur. 
Complications include cross reactions in 
patients who are allergic to penicillin. It does 
not seem to have nephrotoxic side effects. 

76. (A) The presence of distended loops of bowel 
indicate bowel obstruction. The clinical fea- 
tures favor mechanical obstruction rather than 
paralytic ileus due to infection. Obstruction 
due to adhesions is more common than 
obstruction due to hernia. 

77. (A) This is a relatively uncommon lesion. One 
sign that may be elicited with a mesenteric cyst 
is that the swelling moves freely in the direction 
between the left iliac fossa and the right 
hypochondria (i.e., perpendicular to the small- 
bowel mesentery axis) (Fig. 6-7). 




Figure 6-7. 

CT scan a mesenteric unilocular appearance without associated solid component strongly suggest the 
diagnosis of benign cyst. (Reproduced, with permission, from Brunicardi FC et al.: Schwartz's 
Principles of Surgery, 8th ed. 1325. McGraw-Hill, 2005.) 



154 



6: Small and Large Intestines and Appendix 



78. (B) Gallstone ileus results in "tumbling" intes- 
tinal obstruction due to the intermittent nature 
of the condition. Previous choledochoduo- 
denostomy could give air in the biliary tree but 
not obstruction. 

79. (B) The carcinoid syndrome in patients with 
intestinal carcinoid tumors will occur only in the 
presence of hepatic metastasis. Approximately 
40% of patients with hepatic metastasis from an 
ileal carcinoid will develop the syndrome. 

80. (A) Patients with carcinoid tumor due to ovar- 
ian dermoid or pulmonary lesion may 
develop the syndrome with an elevated 5- 
HIAA, although hepatic metastasis are absent. 
The liver does not counteract the hormone in 
this instance, because the portal system is 
bypassed. 

81. (A) Patients with underlying ischemic disease 
may develop acute intestinal infarction or intes- 
tinal angina, which is aggravated by eating. 

82 . (A) Mechanical obstruction implies a barrier that 
impedes progress of intestinal contents. Complete 
mid- or distal small-bowel obstruction presents 
with colicky abdominal pain, more marked 
abdominal distention but with vomiting that is 
less frequent and occurs at a later stage than that 
of proximal jejunal obstruction. 

83. (E) MMC are isoperistaltic waves and occur 
approximately once every 90 minutes. Oral 
feeding inhibits the MMC for as much as 3-4 
hours. The inhibition of the MMC in the stomach 
and intestine may account in part for nausea 
and vomiting occurring after surgery. The 
major force that drives chyme aborally is that of 
segmentation and not the MMC. 

84. (A) Typhoid fever typically presents with initial 
symptoms. Small intestine complications are 
related to involvement of Peyer's patches of 
the small intestine, which result in bleeding 
and/or perforation in the second and third 
week after symptoms are noted. 

85. (B) The absence of loops of colon makes a 
colonic site most unlikely as a cause of the 



current clinical presentation. Distention does 
not occur in high small-bowel obstruction. 

86. (E) In view of the presence of bowel obstruc- 
tion, surgery is indicated. In general, patients 
who have obstruction due to adhesions may 
undergo an initial short trial period of conser- 
vative management. Laparotomy is usually 
indicated in bowel obstruction due to other 
causes, where gangrene may be evident, and in 
all cases in which an initial period of conser- 
vative treatment fails. 

87. (C) In general, failure (or inability) to continue 
anticoagulants is an indication to insert an IVC 
filter to minimize the possibility of serious and 
possibly fatal pulmonary embolus. 

88. (C) Tuberculosis is the great mimicker of disease 
and, therefore, should always be considered in 
the differential diagnosis of different abdominal 
conditions. Surgical intervention will be 
required if the obstruction becomes complete. 

89. (A) Although intestinal tuberculosis still 
remains relatively uncommon in the United 
States, it should be particularly excluded in the 
AIDS population. In these patients, the rarity of 
the condition may make its clinical detection 
particularly difficult. Always suspect tubercu- 
losis in the differential diagnosis of fever with- 
out a clearly defined cause. 

90. (B) The blood supply to a loop of ischemic bowel 
is determined by the presence or absence of arte- 
rial pulsation, peristalsis, and color of the bowel 
after resuscitation and relief of obstruction. 

91. (L) The jejunum is the first part of the alimentary 
tract and, therefore, is the primary site of absorp- 
tion of nearly all nutrients. It is unable to absorb 
vitamin B 12 and bile salts, which are absorbed 
exclusively in the ileum. If the ileum is trans- 
posed between the duodenum and the jejunum, 
it undergoes compensatory hypertrophy and 
takes over the function of the jejunum and 
becomes the primary site of nutrient absorption. 

92. (M) In Hirschsprung's disease, there is an 
absence of myenteric plexus in the upper anal 



Answers: 78-98 



155 



segment (i.e., the most distal portion of the 
cloaca). In 15%, the myenteric plexus involves 
only the upper anus; in 70%, the rectum is also 
involved; and in 15%, part of the colon is also 
involved. The abnormal segment is contracted; 
whereas, the dilated bowel is proximal to the 
diseased segment. 

93. (G) In this variety, the hernia does not have a 
complete covering of peritoneum. It is called a 
sliding hernia. It is important that the surgeon 
does not attempt to remove peritoneum from 
the circumference bowel wall where it does 
not exist, because the bowel will become 
devascularized. 

94. (B) Perianal abscess is most common type of 
anorectal abscess. It is superficial and lies in 
perianal space. Duration of symptoms is short 
and patient is unlikely to have fever or 
leukocytosis. 

95. (F) Ischiorectal abscesses are often large, ery- 
thematous indurated, and tender. They are 
often associated with fistula. 

96. (F) Supralovator abscesses are relatively rare. 
Most patients have a pelvic inflammatory con- 
dition such as salpingitis, diverticulitis or 
Crohn's, or have had recent pelvic surgery. 



"Long 

anterior" 

fistula 



Anterior 




Secondary 
opening 

Primary opening 
in crypt 



Transverse 
anal line 



Figure 6-8. 

Salmon-Goodsall rule. The usual relation of the primary and 
secondary openings of fistulas. When the external opening 
of a fistula is anteriorly situated, the internal opening is found 
internal to it in the same radial position; when the external 
opening of a fistula is posteriorly situated, the internal open- 
ing is found in the midline posteriorly. Note the exception to 
this rule of the far lateral (anterior) fistula. (Reproduced, with 
permission, from Doherty GM: Current Surgical Diagnosis 
and Treatment, 12th ed. 754. McGraw-Hill, 2006.) 

97. (B) A single or multiple sinuses that has an 
external opening in the posterior half of the 
skin that surrounds the anus will have an inter- 
nal opening in the midline on the distal anus if 
a fistula has formed (Fig. 6-8). 

98. (A) The most common site for a pilonidal 
abscess to develop is in the midline posteriorly 
in the natal cleft posterior to the sacrum. 



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CHAPTER 7 



Pancreas, Biliary Tract, Liver, 

and Spleen 

Valerie L Katz and Akella Chendrasekhar 

Questions 



DIRECTIONS (Questions 1 through 99): Each of 
the numbered items in this section are followed 
by five answers. Select the ONE lettered answer 
that is BEST in each case. 

1. A 1-week-old infant is brought to the hospital 
because of vomiting. An upper gastrointestinal 
(GI) series reveals duodenal obstruction. On 
laparotomy, annular pancreas is found. Which 
of the following statements about annular pan- 
creas is TRUE? 

(A) Resection is the treatment of choice. 

(B) It is associated with Down's syndrome. 

(C) Symptoms usually begin with back pain. 

(D) It is most likely due to abnormal 
rotation encircling the third part of the 
duodenum. 

(E) Symptoms begin in childhood. 

2. A 60-year-old alcoholic is admitted to the hos- 
pital with a diagnosis of acute pancreatitis. 
Upon admission, his white blood cell (WBC) 
count is 21,000. His lipase is 500, blood glucose 
is 180 mg/dL, lactate dehydrogenase (LDH) is 
400 IU/L, and aspartate aminotransferase (AST) 
is 240 IU/dL. Which of the following is TRUE? 

(A) This patient is expected to have a 
mortality rate of less than 5%. 

(B) The patient's lipase level is an important 
indication of prognosis. 



(C) This patient requires immediate surgery. 

(D) A venous blood gas would be helpful in 
assessing the severity of illness in this 
patient. 

(E) A serum calcium level of 6.5 mg/dL 
on the second hospital day is a bad 
prognostic sign. 

3. A 19-year-old man is brought to the emergency 
department by emergency medical service 
(EMS) with a stab-wound to the right upper 
quadrant (RUQ) of the abdomen. A FAST scan 
shows free fluid, and the patient is taken to the 
operating room for an exploratory laparotomy. 
The findings are a nonbleeding laceration of 
the right lobe of the liver and a gallbladder lac- 
eration. Which of the following is TRUE? 

(A) The gallbladder injury can be treated 
with cholecystectomy. 

(B) Isolated gallbladder injuries are 
uncommon. 

(C) Bile is usually sterile. 

(D) The liver laceration does not require 
closed suction drainage. 

(E) A thorough exploration is not necessary 
if the bleeding is confined to the RUQ. 



157 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



158 



7: Pancreas, Biliary Tract, Liver, and Spleen 



4. A 15-year-old female presents with RUQ 
abdominal pain. Workup reveals a choledochal 
cyst. Which of the following statements is 
TRUE? 

(A) Choledochal cysts are more common in 
men. 

(B) Laparoscopic cholecystectomy is the 
recommended treatment. 

(C) Patients with a choledochal cyst have an 
increased risk of cholangiocarcinoma. 

(D) All patients with a choledochal cyst 
have abdominal pain, a RUQ mass, and 
jaundice. 

(E) The etiology is infectious. 

5. A 13-year-old female presenting with RUQ 
abdominal pain is suspected of having a chole- 
dochal cyst. Which of the following studies 
would be least helpful in confirming the diag- 
nosis in this case? 

(A) Computed tomography (CT) scan 

(B) Percutaneous transhepatic 
cholangiography 

(C) Endoscopic retrograde 
cholangiopancreatography 

(D) Magnetic resonance 
cholangiopancreatography (MRCP) 

(E) Upper GI series 

6. An intraoperative cholangiogram is performed 
during an elective laparoscopic cholecystec- 
tomy on a 30-year-old woman. She has no pre- 
vious surgical history. There is a 0.8-cm filling 
defect in the distal common bile duct (CBD). 
The surgeon should: 

(A) Complete the laparoscopic 
cholecystectomy and check liver 
function tests (LFTs) postoperatively. If 
they are normal, no further treatment is 
needed. 

(B) Complete the laparoscopic 
cholecystectomy and repeat an 
ultrasound postoperatively. Observe the 
patient if no CBD stone is visualized. 

(C) Perform a CBD exploration either 
laparoscopically or open along with a 
cholecystectomy. 



(D) Complete the laparoscopic 
cholecystectomy, no further treatment 
is necessary. 

(E) Complete the laparoscopic 
cholecystectomy and plan for a 
postoperative hydroxy iminodiacetic 
acid (HIDA) scan. 

7. An 85-year-old man is brought to the hospital 
with a 2-day history of nausea and vomiting. 
He has not passed gas or moved his bowels 
for the last 5 days. Abdominal films show 
dilated small bowel, no air in the rectum and 
air in the biliary tree. Which of the following 
statements is TRUE? 

(A) Air in the biliary tree associated with 
small-bowel obstruction suggests a 
diagnosis of gallstone ileus. 

(B) An enterotomy should be distal to the 
site of obstruction and the stone should 
be removed. 

(C) Gallstone ileus is more common in the 
young adults. 

(D) Cholecystectomy is contraindicated. 

(E) Small-bowel obstruction usually occurs 
in the distal jejunum. 

8. A 45-year-old man with hepatitis C undergoes 
an uneventful percutaneous liver biopsy. About 
6-weeks later, he complains of RUQ pain, is clin- 
ically jaundiced, with a hemoglobin of 9.2 
mg/dL and is fecal occult blood positive. Which 
diagnosis best explains this patient's symptoms? 

(A) Hepatocellular carcinoma 

(B) Chronic hepatitis C 

(C) Colon carcinoma with liver metastasis 

(D) Hemobilia 

(E) Symptomatic cholelithiasis 

9. A 40-year-old patient with a history of trauma 
to the RUQ presents with RUQ pain, clinical 
jaundice, and guaiac positive stools. Which one 
of the following studies would be most useful 
to confirm the patient's diagnosis? 

(A) Abdominal ultrasound 

(B) CT of the abdomen 

(C) Angiography 



Questions: 4-15 



159 



(D) HIDAscan 

(E) Diagnostic laparoscopy 

10. A 40-year-old female alcoholic is suspected of 
having a hepatic mass. Percutaneous ultrasound- 
guided liver biopsy is contraindicated in which 
of the following? 

(A) Hepatocellular carcinoma 

(B) Metastatic carcinoma 
(B) Cirrhosis 

(D) Hepatitis C 

(E) Hepatic adenoma 

11. A 20-year-old man is brought to the emergency 
department with a gunshot wound to the 
abdomen. His blood pressure is 70 systolic and 
his heart rate is 140 beats per minute (bpm). He 
is taken directly to the operating room for an 
exploratory laparotomy. A large, actively bleed- 
ing liver laceration is found. A pringle maneu- 
ver is performed as part of the procedure to 
control his bleeding. The pringle maneuver 
compresses which structures? 

(A) Portal vein, hepatic vein, and hepatic 
artery 

(B) Portal vein, hepatic artery, and cystic 
artery 

(C) Portal vein and hepatic artery 

(D) Portal vein, hepatic artery, and CBD 

(E) Cystic artery, cystic duct, and CBD 

12. A 22-year-old medical student is seen by the 
student health service prior to beginning 
school. Routine labs are drawn. The medical 
student immunized against hepatitis B in child- 
hood will have which hepatitis profile? 

(A) HbsAb+, HbsAg+, HbcAb+ 

(B) HbsAb+, HbsAg+, HbcAb- 

(C) HbsAb- HbsAg- HbcAb- 

(D) HbsAb+, HbsAg-, HbcAb- 

(E) HbsAb-, HbsAg+, HcbAb- 

13. A 36-year-old man presents to the emergency 
department after a motor vehicle crash. He is 
complaining of left-sided chest pain and abdom- 
inal pain. His blood pressure is 130/80 mm Hg. 
An electrocardiogram shows sinus rhythm with 



a heart rate of 95 bpm. A chest x-ray shows left 
8, 9, and 10 rib fractures. An abdominal com- 
puted axial tomography (CAT) scan is obtained. 
It shows a 3-cm laceration in the upper pole of 
the spleen with a small amount of blood around 
the spleen. No other injury is identified. Which 
of the following statements is TRUE? 

(A) This is a class I injury and it may be 
treated nonoperatively. 

(B) This is a class II injury and it may be 
treated nonoperatively. 

(C) This is a class II injury and it requires 
immediate laparotomy. 

(D) The patient should be prophylactically 
transfused in anticipation of continued 
blood loss. 

(E) Delayed splenic rupture is not possible 
with this injury. 

14. A 38-year-old man undergoes excisional biopsy 
of a cervical lymph node. Pathology reveals 
Hodgkin's lymphoma. Which of the following 
statements about Hodgkin's disease is TRUE? 

(A) Splenectomy is always required for 
accurate staging. 

(B) Staging laparotomy involves liver 
biopsy, biopsy of the spleen, and 
periaortic lymph node dissection. 

(C) Stage II disease involves disease on both 
sides of the diaphragm. 

(D) If the spleen is involved, the patient has 
stage IV disease. 

(E) Splenectomy is sometimes indicated for 
thrombocytopenia. 

15. A 50-year-old woman complains of weakness, 
profuse watery diarrhea, and crampy abdom- 
inal pain. She reports a 10-lb weight loss. Her 
serum potassium is 2.8 mEq/L. Select the most 
likely diagnosis. 

(A) Watery, diarrhea, hypokalemia, and 
achlorhydria (WDHA) syndrome 

(B) Somatostatinoma 

(C) Glucagonoma 

(D) Insulinoma 

(E) Multiple endocrine neoplasia type 
l(MEN-l) 



160 



7: Pancreas, Biliary Tract, Liver, and Spleen 



16. A 45-year-old man presents with an upper GI 
bleed. An upper endoscopy reveals multiple 
duodenal ulcers and an enlarged stomach. 
Select the most likely diagnosis. 

(A) WDHA syndrome 

(B) Glucagonoma 

(C) Zollinger-EUison syndrome 

(D) Insulinoma 

(E) Somatostatinoma 

17. A 35-year-old woman with epigastric pain, 
which did not improve on ranitidine, is found 
to have a nonhealing pyloric channel ulcer on 
upper endoscopy. Her serum calcium level is 
12 mg/dL. Select the most likely diagnosis. 

(A) WDHA syndrome 

(B) MEN-1 

(C) MEN-2A 

(D) MEN-2B 

(E) Zollinger-EUison syndrome 

18. A 30-year-old man is noted to be anemic, with 
clinical jaundice and a palpable spleen on 
abdominal exam. Splenectomy is the only 
treatment for this patient's autosomal domi- 
nant disorder. Select the most likely diagnosis. 

(A) Thalassemia 

(B) Hereditary spherocytosis 

(C) Sickle cell disease 

(D) Idiopathic autoimmune hemolytic 
anemia 

(E) Thrombotic thrombocytopenic purpura 
(TPP) 

19. The peripheral smear of a child with anemia 
shows hypochromic microcytic anemia with 
target cells. What is the child's diagnosis? 

(A) Thalassemia 

(B) Hereditary spherocytosis 

(C) Sickle cell disease 

(D) Idiopathic autoimmune hemolytic 
anemia 

(E) TTP 

20. A woman with longstanding rheumatoid 
arthritis has neutropenia on routine labs and 



splenomegaly is noted on physical examina- 
tion. Which is the most likely diagnosis? 

(A) Thalassemia 

(B) Hereditary spherocytosis 

(C) Sickle cell disease 

(D) Idiopathic autoimmune hemolytic 
anemia 

(E) Felty's syndrome 

21. A 50-year-old woman underwent wide exci- 
sion of a 2.5-cm infiltrating ductal carcinoma 
of the breast with axillary lymph node dis- 
section followed by radiation and chemother- 
apy 2 years ago. The patient now complains of 
RUQ abdominal pain. A CAT scan reveals two 
masses in the right lobe of the liver. Select the 
most likely diagnosis. 

(A) Adenoma 

(B) Focal nodular hyperplasia 

(C) Hemangioma 

(D) Hepatocellular carcinoma 

(E) Metastatic carcinoma 

22. A 35-year-old woman complains of RUQ pain 
after meals with nausea and vomiting. An 
ultrasound reveals cholelithiasis and an ane- 
choic 3-cm mass on the inferior surface of the 
right lobe of the liver. Select the most likely 
diagnosis. 

(A) Nonparasitic cyst 

(B) Hydatid cyst 

(C) Hamartoma 

(D) Adenoma 

(E) Focal nodular hyperplasia 

23. A 42-year-old man who consumed more than 
3 bottles of vodka weekly over the past 20 years 
is admitted with upper abdominal pain radi- 
ating to the back, nausea, and vomiting. Serum 
amylase and lipase are elevated, and a diagno- 
sis of pancreatitis is made. In determining his 
prognosis, which of the following factors would 
cause the greatest concern? 

(A) Hypercalcemia (Ca >12 mg/dL) 

(B) Age over 40 years 

(C) Hypoxemia 



Questions: 16-29 



161 



24. 



25. 



26. 



(D) Hyperamylasemia (>600 U) 

(E) Elevated lipase 

A 24-year-old college student recovers from a 
bout of severe pancreatitis. He has mild epi- 
gastric discomfort, sensation of bloating, and 
loss of appetite. Examination reveals an epi- 
gastric fullness that on ultrasound is confirmed 
to be a pseudocyst. The swelling increases in 
size over a 3-week period of observation. What 
should be the next step in management? 

(A) Percutaneous drainage of the cyst 

(B) Laparotomy and internal drainage of 
the cyst 

(C) Excision of pseudocyst 

(D) Total pancreatectomy 

(E) Administration of pancreatic enzymes 

A 40-year-old alcoholic male is admitted with 
severe epigastric pain radiating to the back. 
Serum amylase level is reported as normal, but 
serum lipase is elevated. The serum is noted to be 
milky in appearance. A diagnosis of pancreatitis 
is made. The serum amylase is normal because 

(A) The patient has chronic renal failure. 

(B) The patient has hyperlipidemia. 

(C) The patient has alcoholic cirrhosis. 

(D) The patient has alcoholic hepatitis. 

(E) The diagnosis of pancreatitis is incorrect. 

A 52-year-old woman is admitted to the hospi- 
tal with abdominal pain. She reports that she 
drinks alcohol only at social occasions. The 
amylase is elevated to 340 U. Which following 
x-ray finding would support a diagnosis of 
idiopathic pancreatitis? 

(A) Hepatic lesion on CT scan 

(B) Choledocholithiasis on ultrasound 

(C) Anterior displacement of the stomach 
on barium upper GI series 

(D) Large loop of colon in the RUQ 

(E) Irregular cutoff of the CBD on 
cholangiogram 



27. 



28. 



29. 



A 67-year-old woman is noted to have a grad- 
ual increase in the size of the abdomen. A CT 
scan reveals a large pancreatic mass. The lesion 
was excised; on pathology examination, it is 
shown to be a TRUE cyst. Which statement is 
correct regarding true cysts? 

(A) They are commonly seen in alcoholic 
pancreatitis. 

(B) They commonly occur after trauma. 

(C) They are frequently malignant. 

(D) They are associated commonly with 
choledochocele. 

(E) They have an epithelial lining. 

A 40-year-old man with a history of alcohol con- 
sumption of 25-year duration is admitted with 
a history of a 6-lb weight loss and upper abdom- 
inal pain of 3-weeks duration. Examination 
reveals fullness in the epigastrium. His temper- 
ature is 99°F, and his WBC count is 10,000. 
Which is the most likely diagnosis? 

(A) Pancreatic pseudocyst 

(B) Subhepatic abscess 

(C) Biliary pancreatitis 

(D) Cirrhosis 

(E) Splenic vein thrombosis 

A 58-year-old man with a 30-year history of alco- 
holism and pancreatitis is admitted to the hos- 
pital with an elevated bilirubin level of 5 mg/dL, 
acholic stools, and an amylase level of 600 U. 
Obstructive jaundice in chronic pancreatitis usu- 
ally results from which of the following? 

(A) Sclerosing cholangitis 

(B) CBD compression caused by 
inflammation 

(C) Alcoholic hepatitis 

(D) Biliary dyskinesia 

(E) Splenic vein thrombosis 



162 



7: Pancreas, Biliary Tract, Liver, and Spleen 



30. A 48-year-old woman is admitted with acute 
cholecystitis. The bilirubin level is elevated, as 
are the serum and urinary amylase levels. 
Which radiologic sign indicates biliary obstruc- 
tion in pancreatitis? 

(A) Pancreatic intraductal calcification 

(B) Smooth narrowing of the distal CBD 

(C) Stomach displaced anteriorly 

(D) Calcified gallstone 

(E) Air in the biliary tree 

31. A 62-year-old man is admitted with abdominal 
pain and weight loss of 5 lb over the past 
month. He has continued to consume large 
amounts of rum. Examination reveals icteric 
sclera. The indirect bilirubin level is 5.6 mg/dL 
with a total bilirubin of 6 mg/dL. An ultra- 
sound shows a 4-cm pseudocyst. What is the 
most likely cause of jaundice in a patient with 
alcoholic pancreatitis? 

(A) Alcoholic hepatitis 

(B) Carcinoma of pancreas 

(C) Intrahepatic cyst 

(D) Pancreatic pseudocyst 

(E) Hemolytic anemia 

32. A 42-year-old woman with a history of chronic 
alcoholism is admitted to the hospital because 
of acute pancreatitis. The bilirubin and amylase 
levels are in the normal range. An ultrasound 
reveals cholelithiasis. The symptoms abate on 
the fifth day after admission. What should she 
be advised? 

(A) To start on a low-fat diet. 

(B) To increase the fat content of her diet. 

(C) To undergo immediate cholecystectomy. 

(D) To undergo cholecystectomy during the 
same hospital stay as well as an 
assessment of her bile ducts. 

(E) That she will be discharged and now 
should undergo elective cholecystectomy 
after 3 months. 

33. Following a motor vehicle accident a truck 
driver complains of severe abdominal pain. 
Serum amylase level is markedly increased to 
800 U. Grey Turner's sign is seen in the flanks. 



Pancreatic trauma is suspected. Which state- 
ment is true of pancreatic trauma? 

(A) It is mainly caused by blunt injuries. 

(B) It is usually an isolated single-organ injury. 

(C) It often requires a total pancreatectomy. 

(D) It may easily be overlooked at operation. 

(E) It is proved by the elevated amylase level. 

34. A 40-year-old woman with severe chronic pan- 
creatitis is scheduled to undergo an operation, 
because other forms of treatment have failed. 
The ultrasound shows no evidence of pseudo- 
cyst formation or cholelithiasis and endoscopic 
retrograde cholangiopancreatogram (ERCP) 
demonstrates dilated pancreatic ducts with 
multiple stricture formation. Which operation 
is suitable to treat this condition? 

(A) Pancreaticojejunostomy (Puestow 
procedure) 

(B) Gastrojejunostomy 

(C) Cholecystectomy 

(D) Splenectomy 

(E) Subtotal pancreatectomy 

35. A 26-year-old woman with a known history of 
chronic alcoholism is admitted to the hospital 
with severe abdominal pain due to acute pan- 
creatitis. The serum and urinary amylase levels 
are normal. On the day following admission to 
the hospital, there is no improvement, and she 
has a mild cough and and slight dyspnea. What 
is the most likely complication? 

(A) Pulmonary atelectasis 

(B) Bronchitis 

(C) Pulmonary embolus 

(D) Afferent loop syndrome 

(E) Pneumonia 

36. A 30-year-old male is admitted with frequent 
episodes of hypoglycemia. Biochemical investi- 
gations confirmed an insulinoma. Localization 
studies were carried out. A CT scan and magnetic 
resonance imaging (MRI) of the abdomen failed 
to reveal a tumor in the pancreas. An endoscopic 
ultrasound, however, localized a 2-cm insuli- 
noma in the tail of the pancreas. What should be 
the next step in the management of this patient? 



Questions: 30-39 



163 



37. 



38. 



(A) Somatostatin receptor scintigraphy 
(SRS) to confirm the insulinoma 

(B) Exploratory laparotomy and total 
pancreatectomy 

(C) Distal pancreatectomy 

(D) Whipple pancreaticoduodenectomy 

(E) Enucleation of the tumor 

A 66-year-old man with obstructive jaundice is 
found on ERCP to have periampullary carci- 
noma. He is otherwise in excellent physical 
shape and there is no evidence of metastasis. 
What is the most appropriate treatment? 

(A) Radical excision (Whipple procedure) 
where possible 

(B) Local excision and radiotherapy 

(C) External radiotherapy 

(D) Internal radiation seeds via catheter 

(E) Stent and chemotherapy 

A 74-year-old man complains of epigastric dis- 
comfort. There is no jaundice evident, but an 
enlarged gallbladder is palpated. The bilirubin 
level is 13 mg/dL, the alkaline phosphatase 
level is 410 U, and the hematocrit is 35%. CT 
scan and MRI findings are shown in Fig. 7—1. 



What is the most likely malignant tumor caus- 
ing extrahepatic obstructive jaundice? 

(A) Gallbladder 

(B) Common hepatic duct 

(C) Cystic duct 

(D) Periampullary area 

(E) Head of the pancreas 

39. A 25-year-old female presents with episodes of 
bizarre behavior, memory lapse, and uncon- 
sciousness. She also demonstrated previously 
episodes of extreme hunger, sweating, and tachy- 
cardia. During one of these episodes, her blood 
sugar was tested and was found to be 40 mg/dL. 
Which of the following would most appropri- 
ately indicate a diagnosis of insulinoma? 



(A) 

(B) 

(C) 
(D) 



(E) 



Demonstration of insulin antibodies in 

blood 

Abnormal glucagon level 

CT of the pancreas showing a mass 

Hypoglycemia during a symptomatic 

episode with relief of symptoms by 

intravenous glucose 

Decreased circulating C peptide in the 

blood 





Figure 7-1. 

A, CT scan shows dilated gallbladder, which in obstructive jaundice, suggests the presence of an underlying malignancy (Courvoisier's sign). 

B, MRI at a lower level than A shows tumor (anterior and medial to that of the right kidney). 



164 



7: Pancreas, Biliary Tract, Liver, and Spleen 



40. A 41-year-old woman is known to have multi- 
ple endocrine neoplasia syndrome. She has 
multiple family members who have had ade- 
noma tumors removed from the parathyroid, 
pancreas, and/or pituitary glands. She has 
severe diarrhea associated with low gastric acid 
secretion and a normal gastrin level. Which of 
the following serum assays would be best to 
evaluate the possible cause of the diarrhea? 

(A) Glucagon 

(B) Vasoactive intestinal peptide (VIP) 

(C) Cholecystokinin 

(D) Serotonin 

(E) Norepinephrine 

41 . A 45-year-old patient with chronic pancreatitis is 
suffering from malnutrition and weight loss sec- 
ondary to inadequate pancreatic exocrine secre- 
tions. Which is TRUE regarding pancreatic 
secretions? 

(A) Secretin releases fluid rich in enzymes. 

(B) Secretin releases fluid rich mainly in 
electrolytes and bicarbonate. 

(C) Cholecystokinin releases fluid, 
predominantly rich in electrolytes, and 
bicarbonate. 

(D) All pancreatic enzymes are secreted in 
an inactive form. 

(E) The pancreas produces proteolytic 
enzymes only. 

42. A 48-year-old woman presents with severe recur- 
rent peptic ulcer located in the proximal jejunum. 
Five years previously she underwent parathy- 
roidectomy for hypercalcemia. Her brother was 
previously diagnosed as having Zollinger-Ellison 
syndrome. To confirm the diagnosis of Zollinger- 
Ellison syndrome, blood should be tested for 
levels of which of the following? 

(A) Parathyroid hormone 

(B) Histamine 

(C) Pepsin 

(D) Gastrin 

(E) Secretin 

43. A 50-year-old patient develops severe peptic 
ulcer disease that recurs despite gastric resection 



and vagotomy operations. She now presents 
with melena from a peptic ulcer located in the 
third part of the duodenum. To localize the 
gastrin-producing tumor, she should have which 
of the following? 

(A) CT scan of the abdomen 

(B) Ultrasound of the abdomen 

(C) SRS 

(D) MRI of the abdomen 

(E) Barium meal and follow through 

44. A 42-year-old accountant presents with recur- 
rent RUQ pain of 3-year duration. He had 
undergone a laparoscopic cholecystectomy 
2-years ago for presumed symptomatic 
cholelithiasis, but the pain persisted. An upper 
GI endoscopy is normal. A sonogram and CT 
scan of the abdomen are normal. An ERCP is 
performed, and the pressure in the CBD is 45- 
cm saline (normal bile duct pressure is 10-18- 
cm saline). What is the most likely diagnosis? 

(A) Acalculous cholecystitis 

(B) Emphysematous cholecystitis 

(C) Biliary dyskinesia 

(D) Cancer of the gallbladder 

(E) Myasthenia gravis 

45. In the emergency department, blood is taken 
from a 42-year-old man who presents with cen- 
tral abdominal pain of 12-hour duration. There 
is no history of alcohol abuse or gallstones. The 
serum is noted to be lactescent (milky appear- 
ance). To help elucidate the significance of the 
abdominal pain, which of the following tests 
should be requested? 

(A) Amylase 

(B) Hemoglobin electropheresis 

(C) Creatinine kinase MB (CK-MB) 

(D) Lipase 

(E) Calcium 

46. A 67-year-old woman is evaluated for obstruc- 
tive jaundice. The cholangiographic findings 
indicate that she has a cancer of the lower end 
of the CBD. Clinical examination would most 
likely reveal which of the following? 



Questions: 40-51 



165 



(A) Enlarged gallbladder 

(B) Shrunken gallbladder 

(C) Enlarged pancreas 

(D) Shrunken pancreas 

(E) Palpable tumor 

47. A 73-year-old woman is evaluated for obstruc- 
tive jaundice after an injury to the CBD, 7 months 
previously at laparoscopic cholecystectomy. The 
alkaline phosphatase is elevated. In obstructive 
jaundice, which of the following statements is 
true regarding alkaline phosphatase? 

(A) Its level increases before that of bilirubin. 

(B) Its level is unlikely to be increased in 
pancreatic malignancy. 

(C) Its elevation indicates bone metastasis. 

(D) Its elevation excludes hepatic metastasis. 

(E) Its level falls after that of the bilirubin, 
following surgical intervention. 

48. A recently arrived emigrant from China 
develops jaundice, rigors, and high fever. 
Investigations revealed that he is suffering from 
oriental cholangiohepatitis. This condition is 
confirmed by detecting which of the following? 

(A) Schistosomiasis (Bilharzia) parasite 

(B) Ameba 

(C) Opistorchis (Clonorchis) sinensis 

(D) Hydatid cyst (Echinococcus) 

(E) Hookworm 

49. A 48-year-old female travel agent presents with 
jaundice. Radiological findings confirm the 
presence of sclerosing cholangitis. She gives a 
long history of diarrhea for which she has 
received steroids on several occasions. She is 
likely to suffer from which of the following? 

(A) Pernicious anemia 

(B) Ulcerative colitis 



50. 



(C) Celiac disease 

(D) Liver cirrhosis 

(E) Crohn's disease 

A 40-year-old man underwent laparoscopic 
cholecystectomy 2 years earlier. He remains 
asymptomatic until 1 week before admission, 
when he complains of RUQ pain and jaundice. 
He develops a fever and has several rigor 
attacks on the day of admission. An ultrasound 
confirms the presence of gallstones in the distal 
CBD. The patient is given antibiotics. Which 
of the following should be undertaken as the 
next step in therapy? 

(A) Should be discharged home under 
observation 

(B) Should be observed in the hospital 

(C) Undergo surgical exploration of the CBD 

(D) ERCP with sphincterotomy and stone 
removal 

(E) Anticoagulants 



51. A 43-year-old woman undergoes open chole- 
cystectomy. Intraoperative cholangiogram 
revealed multiple stones in the CBD. Exploration 
of the CBD was performed to extract gallstones. 
The CBD was drained with a #18 T-tube. After 10 
days, a T-tube cholangiogram reveals a retained 
CBD stone. This should be treated by which of 
the following? 



(A) 
(B) 
(C) 

(D) 



(E) 



Laparotomy and CBD exploration 
Subcutaneous heparinization 

Antibiotic therapy for 6 months and 

then reevaluation 

Extraction of the stone through the 

pathway created by the T-tube (after 

6 weeks) 

Ultrasound crushing of the CBD stone 



166 



7: Pancreas, Biliary Tract, Liver, and Spleen 



52. 



53. 



54. 



55. 



A 62-year-old woman who underwent chole- 
cystectomy and choledochoduodenostomy 
(CBD duodenal anastomosis) 5 years previ- 
ously is admitted to the hospital with a 3-day 
history of upper abdominal pain, chills, fever, 
and dark urine. These symptoms are sugges- 
tive of ascending cholangitis. What is the labo- 
ratory finding that supports a diagnosis of 
ascending cholangitis? 



(A) 



(B) 



(C) 

(D) 

(E) 



Amylase elevation with normal findings 

on liver studies 

Alkaline phosphatase elevation with 

normal or elevated normal bilirubin 

levels 

Elevated serum glutamic oxaloacetic 

transaminase (SGOT) levels 

Altered urea /creatinine ratio 

Urobilin in urine 



A 70-year-old male underwent a choledo- 
choduodenostomy for multiple common duct 
stones. The patient now presents with RUQ 
abdominal pain. What should be the initial test 
(least invasive with the best yield) to determine 
patency of the choledochoduodenostomy? 

(A) ERCP 

(B) Percutaneous transhepatic 
cholangiogram (PTC) 

(C) HIDAscan 

(D) CT scan of the abdomen 

(E) Ultrasound of the abdomen 

An 70-year-old male presents with a clinical 
diagnosis of acute cholangitis. Which organ- 
ism is most likely involved in the pathogenesis 
of ascending cholangitis? 

(A) CJonorchis sinensis 

(B) Escherichia coli 

(C) Salmonella 

(D) Staphylococcus aureus 

(E) Clostridia 

Following admission to the hospital for intes- 
tinal obstruction, a 48-year-old woman states 
that she previously had undergone cholecys- 
tectomy and choledochoduodenostomy. The 



most likely indication for the performance of 
the choledochoduodenostomy was: 

(A) Hepatic metastasis were present. 

(B) Multiple stones were present in the 
gallbladder at the previous operation. 

(C) Multiple stones were present in the CBD 
at the previous operation. 

(D) The common hepatic duct had a 
stricture. 

(E) The small intestine was occluded. 

56. In attempting to minimize complications 
during cholecystectomy, the surgeon defines 
the triangle of Calot during the operation. The 
boundaries of the triangle of Calot (modified) 
are the common hepatic duct medially, the 
cystic duct interiorly, and the liver superiorly. 
Which structure courses through this triangle ? 

(A) Left hepatic artery 

(B) Right renal vein 

(C) Right hepatic artery 

(D) Cystic artery 

(E) Superior mesenteric vein 

57. A 64-year-old man complains of abdominal 
pain, pruritus, 4-lb weight loss, and anorexia. 
There are multiple scratch marks on the skin 
of the extremities and flank. The bilirubin is 
1.0 mg/dL. To determine if the condition is 
due to cholestasis, blood should be tested for 
which of the following? 

(A) Direct and indirect bilirubin 

(B) Alkaline phosphatase 

(C) Serum glutamic-oxaloacetic 
transaminase (SGOT) 

(D) Serum glutamic-pyruvic transaminase 
(SGPT) 

(E) Bile pigments 

58. A 49-year-old African American woman born 
in New York is admitted with RUQ pain, fever, 
and jaundice (Charcot's triad.) A diagnosis of 
ascending cholangitis is made. With regard to 
the etiology of ascending cholangitis, which of 
the following is TRUE? 



Questions: 52-63 



167 



(A) It usually occurs in the absence of 
jaundice. 

(B) It usually occurs secondary to CBD 
stones. 

(C) It occurs frequently after 
chole docho duo deno stomy. 

(D) It does not occur in patients with 
cholangiocarcinoma. 

(E) It is mainly caused by the liver fluke. 

59. A 43-year-old man is admitted with jaundice of 
6-week duration. An ultrasound shows multi- 
ple small stones in the gallbladder and the pres- 
ence of a CBD stone. A preoperative ERCP 
followed by a laparoscopic cholecystectomy is 
planned. The international normalization ratio 
(INR) is elevated to 3.1 What is the next step in 
management? 

(A) Infusion of cryoprecipitate 

(B) Oral vitamin K tablets to decrease 
prolonged INR 

(C) Parenteral vitamin K to decrease 
prolonged INR 

(D) Demonstration that urobilinogen is 
increased in the urine 

(E) Demonstration that stercobilinogen is 
increased in the stool 

60. A 65-year-old woman is admitted with RUQ 
pain radiating to the right shoulder, accompa- 
nied by nausea and vomiting. Examination 
reveals tenderness in the RUQ and a positive 
Murphy's sign. A diagnosis of acute cholecys- 
titis is made. What is the most likely finding? 

(A) Serum bilirubin levels may be elevated. 

(B) Cholelithiasis is present in 40-60%. 

(C) Bacteria are rarely found at operation. 

(D) An elevated amylase level excludes this 
diagnosis. 

(E) A contracted gallbladder is noted on 
ultrasound. 

61. A surgeon is removing the gallbladder of a 
35-year-old obese man. One week previously 



the patient had recovered from obstructive 
jaundice and at operation, numerous small 
stones are present in the gallbladder. In addi- 
tion to cholecystectomy, the surgeon should 
also perform which of the following? 

(A) Intraoperative cholangiogram 

(B) Liver biopsy 

(C) No further treatment 

(D) Removal of the head of the pancreas 

(E) CBD exploration 

62. A 42-year-old man presents with recurrent 
RUQ pain for 2 years. A sonogram is negative 
for gallstones, and the CBD is normal. An 
upper GI endoscopy is also normal, and there 
is no peptic ulcer disease. Biliary dyskinesia is 
suspected, and the patient undergoes further 
evaluation. Which of the following will stimu- 
late contraction of the gallbladder? 

(A) Cholecystokinin 

(B) Vagal section 

(C) Secretin 

(D) Epinephrine 

(E) Gastrin 

63. A 57-year-old previously healthy business exec- 
utive presents with gradually increasing obstruc- 
tive jaundice. An ultrasound of the liver shows 
dilated intrahepatic ducts, but the CBD is 
normal. An ERCP shows a filling defect at the 
level of the common hepatic duct. Endoscopic 
brush biopsies are taken, and histology confirms 
cholangiocarcinoma. In discussing these find- 
ings, the surgeon should inform the patient that 

(A) This tumor affects men more commonly 
than women. 

(B) The tumor is a result of gallstones. 

(C) The tumor is best treated with a stent to 
relieve obstructive jaundice. 

(D) Weight loss is common in this condition. 

(E) The most common location of these 
tumors is at the ampulla of Vater. 



168 



7: Pancreas, Biliary Tract, Liver, and Spleen 



64. A 38-year-old male lawyer develops abdominal 
pain after having a fatty meal. Examination 
reveals tenderness in the right hypochondrium 
and a positive Murphy's sign. Which test is 
most likely to reveal acute cholecystitis? 

(A) HIDAscan 

(B) Oral cholecystogram 

(C) Intravenous cholangiogram 

(D) CT scan of the abdomen 

(E) ERCP 

65. A 55-year-old white female undergoes a laparo- 
scopic cholecystectomy for symptomatic 
cholelithiasis. The operation went well, and the 
patient was discharged home. One week later, 
she comes to your office for a routine postoper- 
ative follow-up. The final pathology report 
shows an incidental finding of a gallbladder car- 
cinoma confined to the mucosa. In further advis- 
ing the patient, you should inform her that 

(A) She should undergo radiation therapy. 

(B) She should undergo right hepatectomy 
to remove locally infiltrating disease. 

(C) She should undergo regional 
lymphadenec tomy 

(D) She requires systemic chemotherapy. 

(E) She does not require any further 
therapy. 

66. A 49-year-old man who recovered 7 years ago 
from acute viral hepatitis develops chronic 
active hepatitis and liver cirrhosis. He is seen in 
the office without any abdominal symptoms. 
An ultrasound reveals cholelithiasis and 
ascites. What treatment should be instituted? 

(A) He should undergo percutaneous 
dissolution of stones. 

(B) He should undergo cholecystectomy. 

(C) He should undergo cholecystostomy 

(D) He should be placed on a diet that 
avoids fatty foods and discouraged 
from undergoing elective 
cholecystectomy. 

(E) He should be treated with 
ursodeoxycholic acid. 



67. A 48-year-old man is admitted to the hospital 
with severe abdominal pain, tenderness in the 
right hypochondrium, and a WBC count of 
12,000. A HIDA scan fails to show the gall- 
bladder after 4 hours. Acute cholecystitis is 
established. After diagnosis, cholecystectomy 
should be performed within which of the 
following? 

(A) 3-60 minutes 

(B) The first 2-3 days following hospital 
admission 

(C) 8 days 

(D) 3 weeks 

(E) 3 months 

68. A 60-year-old diabetic man is admitted to the 
hospital with a diagnosis of acute cholecystitis. 
The WBC count is 28,000, and a plain film of 
the abdomen and CT scan show evidence of 
intramural gas in the gallbladder. What is the 
most likely diagnosis? 

(A) Emphysematous gallbladder 

(B) Acalculous cholecystitis 

(C) Cholangiohepatitis 

(D) Sclerosing cholangitis 

(E) Gallstone ileus 

69. A 60-year-old woman is recovering from a major 
pelvic cancer operation and develops severe 
abdominal pain and sepsis. Following a positive 
HIDA scan, laparotomy is performed. The gall- 
bladder is severely inflamed and removed. There 
is no evidence of gallbladder stones (acalculous 
cholecystitis). Cholecystectomy is performed. 
Which is true of acalculous cholecystitis? 

(A) It is usually associated with stones in 
theCBD. 

(B) It occurs in 10-20% of cases of 
cholecystitis. 

(C) It has a more favorable prognosis than 
calculous cholecystitis. 

(D) It is increased in frequency after trauma 
or operation. 

(E) It is characterized on HIDA scan by 
filling of the gallbladder. 



Questions: 64-76 



169 



70. 



71. 



72. 



Following recovery in the hospital from a frac- 
ture of the femur, a 70-year-old nursing home 
female patient develops RUQ abdominal pain 
and fever. She has tenderness in the right sub- 
costal region. There is evidence of progressive 
sepsis and hemodynamic instability. The WBC 
count is 24,000. A bedside sonogram confirms 
the presence of acalculous cholecystitis. What 
should treatment involve? 

(A) Intravenous antibiotics alone 

(B) ERCP 

(C) Percutaneous drainage of the 
gallbladder 

(D) Urgent cholecystectomy 

(E) Elective cholecystectomy after 3 months 

In designing a study related to gallbladder 
function, it should be noted that the healthy 
gallbladder mucosa selectively absorbs which 
of the following? 

(A) Bile pigment 

(B) Bile salts 

(C) Cholesterol 

(D) Sodium 

(E) Free fatty acids 

On a recent safari in Africa, a 39-year-old male 
engineer developed an acute diarrhea state 
requiring hospitalization and treatment with 
Flagyl. Six weeks after his return, he developed 
RUQ pain, fever and chills. A chest x-ray showed 
elevation of the right hemidiaphragm, and sono- 
gram showed a large abscess in the right lobe of 
the liver.Which of the following statements is 
TRUE regarding this disease process? 



(A) 



(B) 



(C) 
(D) 

(E) 



Satisfactory treatment is not readily 

available. 

Diagnosis is easily made by finding 

Entamoeba histolytica in stools in nearly 

all patients. 

Bloody diarrhea is always present. 

Anchovy-paste pus is usually present in 

the abscess cavity. 

Extensive surgical drainage is usually 

indicated. 



73. A 45-year-old male is suspected of having an 
amebic abscess of the liver. Serum bilirubin is 
mildly elevated. The WBC is 11,000 but there is 
eosinophilia. The initial line of treatment 
involves which of the following? 

(A) Cortisone 

(B) Metronidazole (Flagyl) 

(C) Surgical excision 

(D) Sulfonamides and penicillin 

(E) Colon resection 

74. In performing hepatic resection, a knowledge of 
the different lobes and segments of the liver is 
mandatory. The right and left lobes of the liver 
are separated by an imaginary plane (Cantlie's 
line) that passes between the the inferior vena 
cava (IVC) and which of the following? 

(A) Portal vein 

(B) Falciform ligament 

(C) Left margin of the quadrate lobe 

(D) Gallbladder 

(E) Left margin of the caudate lobe 

75. A 32-year-old diabetic woman who has taken 
contraceptive pills for 12 years develops RUQ 
pain. CT scan of the abdomen reveals a 5-cm 
hypodense lesion in the right lobe of the liver 
consistent with a hepatic adenoma. What 
should the patient be advised to do? 

(A) Undergo excision of the adenoma 

(B) Stop oral contraceptives only 

(C) Stop oral hypoglycemic medication 

(D) Undergo right hepatectomy 

(E) Have serial CT scans every 6 months 

76. A 35-year-old woman is seen in the office with 
focal nodular hyperplasia. This condition is sim- 
ilar to hepatic adenoma, in that it does what? 

(A) Frequently causes symptoms 

(B) Tends to lead to liver rupture 

(C) LFT and alpha fetoprotein (AFP) are 
normal 

(D) Easily detected by CT scan of the liver 

(E) Tends to undergo malignant changes 



170 



7: Pancreas, Biliary Tract, Liver, and Spleen 



77. 



78. 



79. 



80. 



A 64-year-old man has mild upper abdominal 
pain. On contrast CT scan, a 5-cm lesion in the 
left lobe of the liver enhances and then decreases 
over a 10-minute period from without to within. 
The most likely lesion is which of the following? 

(A) Congenital cyst 

(B) Hemangioma 

(C) Fungal abscess 

(D) Focal nodular hyperplasia 

(E) Hepatic adenoma 

A 16-year-old previously healthy male fell off 
his bicycle while riding back home from school. 
On examination there was mild tenderness in 
the RUQ. No other abnormality was detected. 
A sonogram showed a large solitary hypoe- 
chogenic cyst in the liver. The LFTs are normal, 
and there is no family history of cystic disease 
involving solid organs. What is the most likely 
cause? 

(A) Fungal abscess 

(B) Trauma 

(C) Developmental 

(D) Neoplastic 

(E) Pyogenic abscess 

A healthy 64-year-old woman had a cancer of 
the left colon resected 4 years previously. 
During follow-up, an increased carcinoembry- 
onic antigen (CEA) level lead to a CT scan of 
the abdomen, which revealed two discrete 
lesions in the left lateral lobe of the liver. Liver 
biopsy confirms that this is metastatic colon 
cancer. What is the most appropriate plan? 



(A) 



(B) 
(C) 

(D) 



Inform the patient that there is no treat- 
ment, and that her expectation of life is 
limited. 

Irradiation is recommended. 
Local cauterization of the cancer is 
recommended. 
Liver resection is recommended. 



(E) Chemotherapy is recommended. 

A 42-year-old man undergoes a liver transplan- 
tation. There is rapid deterioration after the com- 
pletion of the graft, and the patient dies within 
12 hours. What is the most likely cause of death? 



(A) Massive pulmonary embolus 

(B) Graft rejection 

(C) Fat embolus 

(D) Massive hemorrhage 

(E) Subphrenic abscess 

81. In discussing the treatment of a 42-year-old 
man with severe liver cirrhosis, the possibility 
of heterotopic transplantation is considered. 
Which statement about heterotopic liver trans- 
plantation is TRUE? 

(A) It implies removal of the recipient's 
liver. 

(B) It is preferable to orthotopic liver 
transplantation. 

(C) It should be done in the iliac vessels. 

(D) It is rarely associated with long-term 
survival. 

(E) Heterotopic auxiliary liver transplants 
require high-out flow pressures. 

82. A 43-year-old man develops chronic hepatitis, 
which was attributed to a complication result- 
ing from multiple blood transfusions for sickle 
cell anemia. He complains of chronic sweating, 
palpitation, and hunger attacks. What would 
be the most likely cause of these symptoms? 

(A) Hepatogenic hypoglycemia 

(B) Hemolytic anemia 

(C) Jaundice 

(D) Spontaneous hyperglycemia 

(E) Elevated bile salts in the blood 

83. A 42-year-old man is admitted with bleeding 
from esophageal varices. Investigation reveals 
that he has an occlusion of the portal vein. 
There is no evidence of liver cirrhosis. Which 
test will most likely reveal an underlying pre- 
disposing factor for this condition? 

(A) Hepatitis screening 

(B) Isoamylase 

(C) Intravenous pyelogram to exclude 
hydronephrosis 

(D) Coagulation tests to include 
antithrombin III 

(E) CT of abdomen 



Questions: 77-87 



171 



84. A 9-year-old girl had multiple episodes of upper 
GI bleeding. Contrast enhanced CT scan showed 
multiple cavernous malformation surrounding 
the portal vein (Fig. 7-2). She is admitted with 
severe hematemesis and melena. At birth, she 
had developed an infection around the umbili- 
cus. What is the most likely site of bleeding? 




Figure 7-2. 

Following portal vein thrombosis, massive cavernous malformations 
around the portal vein is demonstrated. Note large spleen. 



(A) Meckel's diverticulum 

(B) Esophageal varices 

(C) Peptic ulcer 

(D) Duodenal varices 

(E) Mallory- Weiss tear of the lower end of 
the esophagus 

85. A 49-year-old man with a history of cirrhosis is 
admitted with significant hematemesis. There 
is jaundice and clubbing of the fingers. His 
extremities are cold and clammy and the sys- 
tolic blood pressure drops to 84 mm Hg. The 
initial step in the management is to proceed 
with which of the following? 



(A) Urgent endoscopy and sclerotherapy 

(B) Sengstaken-Blakemore tube 

(C) Infusion of intravenous crystalloids 

(D) Intravenous pitressin 

(E) Surgery to stop bleeding 

86. A 42-year-old woman with a known history of 
esophageal varices secondary to hepatitis and 
cirrhosis is admitted with severe hematemesis 
from esophageal varices. Bleeding persists after 
pitressin therapy. What would the next step in 
management involve? 

(A) Emergency portacaval shunt 

(B) Emergency lienorenal shunt 

(C) Insertion of Sengstaken-Blakemore tube 

(D) Vagotomy 

(E) Transjugular intrahepatic portasystemic 
shunt (TIPS) 

87. A 12-year-old boy who underwent a previous 
splenectomy for thalassemia presents to the 
emergency room with fever, chills, and septic 
shock. The parents give a history of seemingly 
minor sore throat, which started only a few 
hours previously. The child is hypotensive and 
appears moribund. A diagnosis of overwhelm- 
ing postsplenectomy infection (OPSI) is made. 
Which of the following statements about OPSI 
is TRUE? 

(A) The condition is more common in 
children. 

(B) The condition is more common after 
splenectomy for trauma. 

(C) Prophylactic antibiotics have not been 
shown to improve outcome in children. 

(D) Prophylactic vaccination against 
Enterococcus should be performed. 

(E) The condition is very common after 
splenectomy. 



M2 



7: Pancreas, Biliary Tract, Liver, and Spleen 



88. A 43-year-old man with chronic hepatitis and 
liver cirrhosis is admitted with upper GI bleed- 
ing. He has marked ascites and shows multiple 
telangiectasias, liver palmar erythema, and 
clubbing. A diagnosis of bleeding esophageal 
varices secondary to portal hypertension is 
made. Portal pressure is considered elevated 
when it is above which of the following? 

(A) 0.15 mm Hg 

(B) 1.5mmHg 

(C) 12mmHg 

(D) 40mmHg 

(E) 105mmHg 

89. A 23-year-old male college student has a his- 
tory of liver cirrhosis due to Kimmelstiel- 
Wilson syndrome (abnormality in copper 
metabolism). He should be treated with which 
of the following? 

(A) Penicillamine as soon as the diagnosis is 
established 

(B) Penicillamine after variceal bleeding has 
occurred 

(C) A portocaval shunt 

(D) Sclerosis of the esophageal varices as a 
prophylactic measure 

(E) Splenorenal shunt 

90. A 24-year-old woman presents with menorrha- 
gia, an easy tendency toward bruising, and a 
history of prolonged bleeding after extraction of 
an impacted molar several years previously. A 
diagnosis of idiopathic thrombocytopenic pur- 
pura (ITP) is made after appropriate investiga- 
tions. Her disease has failed to respond to 
steroid and immunoglobin therapy. She is 
scheduled to undergo splenectomy in 1 week, 
but her platelet count is 22,000. What should be 
the treatment of choice? 

(A) She should be given platelets daily and 
be scheduled for splenectomy when her 
platelet count is more than 75,000. 

(B) She should undergo bone marrow 
transplantation. 

(C) She should be treated with steroids only, 
and the operation should be canceled. 



(D) She should receive transfusion with 3 U 
of packed cells. 

(E) She should not be given platelets rou- 
tinely before surgery. 

91. Following a successful splenectomy, for throm- 
bocytopenia, a 24-year-old patient notes that 
she was no longer prone to excessive bleeding. 
Her platelet count had become elevated. 
However, 2 years later, she developed further 
skin purpura, and her platelet count was 
reduced to 45,000. What should she undergo? 

(A) Radioactive technetium ( ,9m Tc) scan to 
see if a splenunculus is present 

(B) Radioactive (I 135 ) to see if a splenunculus 
is present 

(C) Exploratory laparotomy 

(D) Platelet transfusion 

(E) Red blood cell (RBC) fragility test 

92. A 28-year-old woman is diagnosed with TTP In 
addition to purpura and thrombocytopenia, 
studies will show which of the following? 

(A) Normal arterioles on biopsy of the 
spleen 

(B) Absence of infarction on biopsy of the 
spleen 

(C) Leukopenia 

(D) Elevated urea and creatinine levels 

(E) Suppression of reticulocytes 

93. A 24-year-old African American man has sickle 
cell disease. He is admitted to the hospital 
because of a sickle cell crisis. His hemoglobin is 
10 g/dL, and he complains of pain in the lower 
chest wall and legs. His further course of man- 
agement should include which of the following? 

(A) Emergency splenectomy 

(B) Elective splenectomy 

(C) Admission to the hospital for hydration 
and given dehydromorphine as required 

(D) Administer steroids 

(E) Exchange transfusions to keep his 
hemoglobin at a normal level 



Questions: 88-99 



173 



94. A 24-year-old woman from the Caribbean is 
admitted to the hospital for severe lower chest 
and upper abdominal pain. Her hemoglobin 
is 9 g/dL. The findings on ultrasound of the 
abdomen and chest x-ray are normal. Her 
father has sickle cell disease. For her physician 
to establish the diagnosis of sickle cell trait or 
disease, she must undergo which procedure? 

(A) A bone marrow study 

(B) Injection of radioactive RBCs 

(C) Red cell fragility studies 

(D) Studies to determine her response to 
erythropoietin 

(E) Blood smear and electrophoresis 

95. Splenectomy is often indicated in the manage- 
ment of which of the following? 

(A) Hereditary spherocytosis 

(B) Hereditary neurofibromatosis 

(C) Aplastic anemia 

(D) Pheochromocytoma 

(E) Hashimoto's disease 

96. A 2-year-old African-American boy is diag- 
nosed as having hereditary spherocytosis. His 
parents should be informed that this condition 
is which of the following? 

(A) It is not associated with a marked 
increase in gallstones. 

(B) It is transmitted as a recessive trait. 

(C) It is diagnosed by showing RBCs 
undergo lysis at a higher osmotic 
pressure. 

(D) It is characterized by a low reticulocyte 
count. 

(E) It is infrequently treated by splenectomy. 

97. A 67-year-old man is admitted to hospital with 
a diagnosis of polycythemia vera. He has con- 
siderable back pain and is diagnosed as having 
myeloid metaplasia. This condition is charac- 
terized by which of the following? 



(A) Decrease of the connective tissue in the 
spleen 

(B) Decrease in the blood elements of the 
spleen 

(C) Aplastic anemia 

(D) Deterioration after splenectomy 

(E) A favorable response to alkylating 
agents 

98. A 24-year-old woman with rheumatoid arthri- 
tis involving the sacroiliac joint and fingers is 
noted to have splenomegaly and neutropenia 
(Felty's syndrome). She is advised to have 
splenectomy, but she should be informed that 

(A) Large-joint disease symptoms will 
lessen. 

(B) Small-joint disease symptoms will 
lessen. 

(C) Neutropenia responds to splenectomy. 

(D) The joint symptoms will become worse. 

(E) All symptoms will lessen. 

99. A 10-year-old boy is hit by a truck while riding 
his bicycle home from school. A CT scan shows 
a tear of the spleen. His hematocrit is 32%, and 
he is in pain, although fully alert and oriented. 
His blood pressure is 110/60 mm Hg, and his 
heart rate is 104 bpm. The next step in man- 
agement should be which of the following? 

(A) Cross-match blood and transfuse 
appropriately 

(B) Perform splenectomy as soon as 
possible 

(C) Perform laparotomy, and suture the tear 
where possible 

(D) Perform angiographic embolization of 
the spleen 

(E) Avoid surgery, even if bleeding 
continues profusely after transfusion 



Answers and Explanations 



1. (B) Annular pancreas is a congenital anomaly; a 
band of pancreatic tissue encircles the second 
part of the duodenum. Annular pancreas is asso- 
ciated with Down syndrome as well as duode- 
nal stenosis or atresia. Duodenojejunostomy and 
gastrojejunostomy are acceptable treatments. 
Resection is not an acceptable choice due to the 
high incidence of fistula In adults, annular pan- 
creas usually presents with abdominal pain, 
nausea, and vomiting. 

2. (E) The patient has three Ranson's criteria at the 
time of admission. The expected mortality rate 
is 15% with 3-A Ranson's criteria. Amylase and 
lipase levels are not prognostic factors in acute 
pancreatitis. Calcium level <8 mg/dL within 
the first 48 hours is one of Ranson's criteria, as 
is arterial P0 2 <60 mm Hg. 

3. (B) Most gallbladder injuries are associated 
with other injuries, most often to the liver, large 
intestine, and/or small intestine. Isolated gall- 
bladder injuries are rare. A gallbladder injury 
can be treated with cholecystectomy or chole- 
cystostomy A nonbleeding liver laceration does 
not need further treatment. A careful search for 
injuries should be made during laparotomy. 

4. (C) Choledochal cysts can involve the intrahep- 
atic and/or extrahepatic biliary tree (see Fig. 7-3 
for classification). Choledochal cysts present 
more commonly in infants and children, but may 
present in adults. They are more common in 
females. The classic triad of jaundice, RUQ mass 
and abdominal pain is found in less than a third 
of patients. There is an association between 
choledochal cysts and hepatobiliary cancers, 
most commonly cholangiocarcinoma. For most 



types of choledochal cyst, excision of the cyst 
with a Roux-en-Y biliary enteric anastomosis is 
recommended. Laparoscopic cholecystectomy 
alone is not sufficient. 

5. (E) An upper GI series would not visualize the 
cyst. Ultrasound may diagnose a choledochal 
cyst, showing size and location, but is not always 
diagnostic. CAT scan and MRCP can show size, 
location, and extent of disease. ERCP visualizes 
the distal duct anatomy well, while PTC is better 
at visualizing the proximal ductal anatomy. 

6. (C) The intraoperative cholangiogram is sugges- 
tive of a CBD stone. Normal LFTs do not rule out 
choledocholithiasis. Patients with choledo- 
cholithiasis often have dilatation of the CBD on 
ultrasound; the stones may be visualized, but a 
normal ultrasound does not rule out CBD stones. 
A HIDA scan is unlikely to be helpful. An explo- 
ration of the CBD is indicated (either laparo- 
scopically or open) along with a cholecystectomy. 

7. (A) Gallstone ileus usually results from forma- 
tion of a cholecystoenteric fistula and is seen 
more often in elderly patients. Obstruction 
occurs most often at the terminal ileum. 
Treatment is laparotomy and removal of the 
stone through an enterotomy proximal to the 
obstruction; cholecystectomy should be done if 
the patient can tolerate the additional surgery. 

8. (D) Hemobilia should be suspected in a patient 
with a history of liver trauma who later devel- 
ops GI bleeding and abdominal pain. Hemobilia 
usually appears weeks after the injury; pain is 
often intermittent and melena or hematemesis 
may occur. In this case, the injury is the result of 



174 



Answers: 1-10 175 






Type IVa 



Type IVb 



Type V 



Figure 7-3. 

Classification of choledochal cysts. Type I, fusiform or cystic dilations of the extrahepatic biliary tree, are the most common type, making 
up over 50% of all choledochal cysts. Type II, saccular diverticulum of an extrahepatic bile duct, is rare, comprising <5% of choledochal 
cysts. Type III, bile duct dilations within the duodenal wall (choledochoceles), make up about 5% of choledochal cysts. Types IVa and IVb, 
multiple cysts, make up 5-10% of choledochal cysts. Type IVa affects both extrahepatic and intrahepatic bile ducts, while type IVb cysts 
affect the extrahepatic bile ducts only. Type V, intrahepatic biliary cysts, are very rare and make up only about 1% of choledochal cysts. 
(Reproduced, with permission, from Brunicardi FC et al.: Schwartz's Principles of Surgery, 8th ed. 1210. McGraw-Hill, 2005.) 



the melena and hematemesis may occur. In this 
case, the injury is the result of the biopsy. The 
other diseases listed are less likely to explain all 
of the findings listed. 

(C) Once again hemobilia should be suspected, 
with the history of trauma to the liver and 
guaiac positive stools and RUQ abdominal 
pain. Angiography can be diagnostic as well as 
therapeutic. The source of bleeding can be iden- 
tified and embolized. Ultrasound is unlikely to 
identify the bleeding source; it would identify 
cholelithiasis or a liver tumor. A CAT scan like- 
wise would identify a tumor. A HIDA scan doc- 
uments patency of the cystic duct and would 



not be useful in this case. Laparoscopy would 
be unlikely to identify the communication 
between a hepatic vessel and the biliary tree. 

10. (E) Tru-cut needle liver biopsy allows patho- 
logic diagnosis of liver lesions. Needle biopsy 
is contraindicated if hemangioma is suspected 
and in adenomas, because of the risk of bleed- 
ing. Other potential complications of percuta- 
neous needle biopsy are pain, pneumothorax, 
and bile peritonitis. Needle biopsy can diag- 
nose posthepatic and postnecrotic cirrhosis, 
malignant tumors, and hepatitis, and can 
determine the need for treatment in hepatitis C. 



176 



7: Pancreas, Biliary Tract, Liver, and Spleen 



11. (D) Pringle's maneuver is occlusion of the porta 
hepatis. The portal vein, hepatic artery, and the 
CBD are the structures of the porta hepatis. 

12. (D) Hepatitis B vaccine is made from geneti- 
cally engineered hepatitis B surface antigen par- 
ticles. Vaccination produces hepatitis B surface 
antibodies but not hepatitis B core antibodies. 
Hepatitis B surface antigen will not be present. 

13. (B) A laceration to the parenchyma of the spleen 
1-3 cm deep is a class II injury. A class I injury 
is a nonexpanding subcapsular hematoma 
involving less than 10% of the surface area of 
the spleen. Nonoperative management may be 
attempted for both of these injuries. This patient 
is hemodynamically stable and does not require 
emergency laparotomy. A class III injury is a 
major parenchymal injury. Prophylactic trans- 
fusion is not indicated. Delayed splenic rup- 
ture may occur within 2 weeks or more of a 
blunt splenic injury in 10-15% of patients. 

14. (E) Staging of Hodgkin's disease is often done 
nonoperatively. Staging laparotomy consists of 
wedge biopsy of the liver, splenectomy, exam- 
ination and biopsy of peraortic lymph nodes, as 
well as biopsy of mesenteric and hepatoduo- 
denal nodes. Stage I Hodgkin's lymphoma is 
limited to one anatomic area, while Stage II 
involves 2 or more areas of the same side of the 
diaphram. Stage III disease involves both sides 
of the diaphram limited to lymph nodes, 
Wal dyer's ring or the spleen. Stage IV disease 
involves organs other than lymph nodes, 
Wal dyer's ring, or the spleen. Splenectomy 
may improve thrombocytopenia and allow 
chemotherapy to be administered. 

15. (A) WDHA or vasoactive intestinal polypeptide 
(VIPoma) is characterized by voluminous diar- 
rhea, 5 L or more daily rich in potassium, which 
looks like watery tea. The diarrhea is secretory 
and if refractory to antidiarrheal agents. Patients 
are weak, with metabolic acidosis and 
hypokalemia. Octreotide decreases diarrhea 
volume. The pancreatic tumor should be excised. 
Secretory diarrhea also occurs in some patients 
with Zolliger-Ellison syndrome (ZES), and is the 
only complaint in less than 10% of ZES patients. 



More than 90% of ZES patients have peptic ulcer 
disease. Unlike the diarrhea associated with ZES, 
the diarrhea of WHDA continues with fasting 
and continuous nasogastric tub suctioning. 15% 
of patients with glucagonoma have diarrhea; 
glucagonoma is associated with migratory necro- 
tizing dermatitis. 

16. (C) Gastrinoma, or Zollinger-Ellison syndrome, 
should be suspected in patients with peptic ulcer 
disease refractory to medical treatment, or in 
patients with multiple ulcers or ulcers in uncom- 
mon locations. Gastrin secretion by the tumor, 
most commonly found in the pancreas, results in 
hypersecretion of gastric acid. Common patient 
complaints are epigastric pain, melena, 
hematemesis, diarrhea, and weight loss. ZES 
may occur as part of the MEN-1 syndrome; this 
patient presents with only atypical peptic ulcer 
disease. The treatment of choice involves the 
identification and resection of the gastrinoma. 
Preoperative treatment may include treatment 
of the ulcers with omeprazole. 

17. (B) Multiple endocrine neoplasia syndrome 
type 1 (MEN-1, or Werner's syndrome), and 
autosomal dominant disorder, involves tumors 
or hyperplasia of two or more glands, most 
commonly parathyroid, pancreas, and pituitary 
glands. Hyperparathyroidism is most common, 
followed by various pancreatic isle cell tumors 
and pituitary adenomas. MEN-2A (Sipple's 
syndrome) consists of pheochromocytoma, 
medullary carcinoma of the thyroid, and often 
hyperparathyroidism. MEN-2B is character- 
ized by medullary carcinoma of the thyroid, 
pheochromocytoma, neuromas, and marfinoid 
body habitus. MEN 2- A and 2-B are also auto- 
somal dominant. 

18. (B) Hereditary spherocytosis is the most 
common symptomatic familial hemolytic 
anemia, and is transmitted as an autosomal dom- 
inant trait. A defect in the red cell membrane 
causes increased trapping in the spleen and 
hemolysis. Anemia, jaundice, and splenomegaly 
are clinical findings. Splenectomy is the only 
treatment. Thalassemia is transmitted as a dom- 
inant trait; anemia is the result of a defect in 
hemoglobin synthesis. Thalassemia major, or 



Answers: 11-26 



177 



homozygous thalassemia, is associated with 
anemia, icterus, splenomegaly, and early death. 
Transfusions are usually required. Splenectomy 
may reduce hemoloysis and transfusion require- 
ments. Sickle cell anemia is hereditary hemolytic 
anemia. Serum bilirubin may be mildly elevated. 
Splenomegaly often precedes autoinfraction. 
Splenectomy may be indicated for chronic hyper- 
splenism or acute splenic sequestration. 

19. (A) In thalassemia, intracellular hemoglobin 
precipitates, or Heinz bodies, damage red cells 
and contribute to early destruction. Cells are 
small, thin, misshapen, and resistant to osmotic 
lysis. Diagnosis is made by peripheral smear. 
Nucleated red cells, or target cells, are present. 
Distorted red cells, or target cells, are present. 
Distorted red cells of different shapes and sizes 
are found. In sickle cell disease, characteristic 
sickle cells are seen on peripheral smear. In 
hereditary spherocytosis, the peripheral smear 
shows small, thick, nearly spherical red cells. 
Cells have increased osmotic fragility. 

20. (E) The triad of rheumatoid arthritis, splen- 
omegaly, and neutropenia is known as Felty's 
syndrome. Gastic achlorhydria is common. 
Thrombocytopenia and mild anemia are some- 
times seen. Splenectomy is sometimes used to 
treat the neutopenia in patients with serious 
infections, anemia requiring transfusions, or 
severe thrombocytopenia. 

21. (E) Breast cancer commonly metastasizes to 
bone, lung, soft tissues, liver, and brain. The 
patient should be worked up for local recur- 
rence as well as other distant metastasis. The 
presence of masses in the liver should lead to 
the diagnosis of metastatic cancer. 

22. (A) Benign liver cysts can be single or multiple. 
Solitary nonparasitic cysts usually contain clear, 
watery fluid. These cysts are more common in 
the right lobe. They are most likely congenital 
and most are asymptomatic; many are found 
incidentally. An anechoic area on ultrasound 
is suggestive. Hydatid cysts, caused by 
Echinococcus, are also more common in the right 
lobe. The colorless fluid in the cyst is under 
high pressure, unlike parasitic cysts. Ultrasound 



will show internal echoes. Hemangiomas can 
have a variable echogenic pattern on ultra- 
sound; focal nodular hyperplasia is often hypo- 
dense. Hepatocellular carcinoma and metastasis 
have a characteristic sonographic appearance 
different from benign nonparasitic cysts. 

23. (C) Ranson's criteria allow for early identification 
of patients who have severe pancreatitis. 
Mortality increases with increasing number of 
Ranson's criteria score. The five criteria of poor 
prognosis at the time of admission are age >55, 
WBC >16,000, blood glucose >200 mg/dL, AST 
>250, LDH >350. During the following 48 hours, 
six additional criteria may develop. These 
include hypoxemia with arterial PO, <60 mm on 
room air, base deficit >4, fluid requirement >6 L, 
hematocrit fall >10%, blood urea nitrogen (BUN) 
increase >8 mg/dL, and serum Ca <8 mg/dL. 
Amylase and lipase elevation may focus atten- 
tion on the appropriate diagnosis, but amylase 
levels fail to correlate with prognosis 

24. (A) Pseudocysts frequently are encountered on 
ultrasound examination early after an acute 
attack of pancreatitis. In most cases, the pseudo- 
cyst resolves, but if it enlarges, it may compress 
the stomach anteriorly. An enlarging pseudocyst 
is an indication to attempt percutaneous 
drainage. If percutaneous drainage is unsuc- 
cessful, internal drainage into the stomach 
should be performed at an appropriate interval 
to allow the pseudocyst wall to mature (Fig. 7-4). 

25. (B) In pancreatitis, the serum amylase level may 
be normal. The causes include: (a) hyperlipi- 
demia, which interferes with chemical deter- 
mination of amylase; (b) increased urinary 
excretion of amylase; and (c) near complete 
destruction of pancreatic parenchyma as a 
result of chronic pancreatitis. On the other hand, 
the serum amylase level may be elevated in the 
absence of pancreatitis (for example, perforated 
peptic ulcer, gangrenous cholecystitis, small- 
bowel strangulation or chronic renal failure.) 

26. (C) If a large pseudocyst is present, it may cause 
displacement of the transverse colon, duode- 
num, or stomach (anteriorly). Other radiologic 
signs in pancreatitis include pseudocyst on 



178 



7: Pancreas, Biliary Tract, Liver, and Spleen 




Figure 7-4. 

After cyst evacuation, the opening is enlarged to 3- to 4-cm diame- 
ter. Adherent posterior gastric and anterior cyst wall is sewn with 
nonabsorbable suture. (Reproduced with permission, from Maingot's 
Abdominal Operations, 10th ed. 2023. Appleton & Lange, 1996.) 



ultrasound or CT scan, downward displacement 
of transverse colon, dilated pancreatic duct on 
pancreatogram, and smooth tapering of the 
CBD on cholangiogram (if the head of the pan- 
creas is diseased). The irregular tapering of the 
common duct is suggestive of neoplasm. The 
looping of the colon in the RUQ is seen with sig- 
moid volvulus. 

27. (E) True epithelial-lined cysts in the pancreas are 
extremely rare. They should not be confused 
with the more common pseudocyst (no epithe- 
lial lining), benign cystadenoma, or malignant 
cystadenoma of the pancreas. Pseudocysts are 
more common in men, but cystadenocarcinoma 
occurs more frequently in women. 

28. (A) The presence of an epigastric mass 2-3 
weeks after the onset of acute pancreatitis 
strongly favors a pancreatic pseudocyst. The 
history of alcoholism points to pancreatitis as a 
possible etiologic factor in the differential diag- 
nosis. Pseudocysts develop in 10% of patients 
following acute pancreatitis. Most of these, 
however, resolve spontaneously. They may also 
develop in patients with chronic pancreatitis 
or after pancreatic trauma. 



29. (B) Fibrosis in the head of the pancreas as a result 
of chronic inflammation may lead to compres- 
sion of the CBD. In pancreatitis, the narrowing of 
the CBD is smooth on x-ray studies. There is no 
association with pancreatitis and sclerosing 
cholangitis. Alcoholic hepatitis is the most 
common cause of jaundice, but it most frequently 
is not of an obstructive nature. Pseudocysts and 
carcinoma of the head of the pancreas are other 
recognized causes of obstructive jaundice in 
patients with chronic pancreatitis. 

30. (B) The passage of small stones through Vater's 
ampulla often results in pancreatitis. It is impor- 
tant to perform cholecystectomy after pancre- 
atitis has subsided but during the same hospital 
stay in patients with documented gallstone pan- 
creatitis (to avoid recurrence of symptoms). 
Smooth tapering of the common duct is usually 
seen with stones obstructing the common duct. 
Pancreatic intraductal calcification is consistent 
with chronic pancreatitis, and air in the biliary 
tree is consistent with gallstone ileus. 

31. (A) A recent increase in alcohol consumption 
explains the jaundice secondary to alcoholic 
hepatitis in the majority of such patients. 
Carcinoma of the pancreas is relatively rare but 
often causes difficulty in the differentiation 
from pancreatitis. A pseudocyst measuring 
4 cm is not likely to be associated with nonob- 
structive jaundice in this patient. 

32. (D) Patients who develop acute pancreatitis as a 
result of cholelithiasis should have gallbladder 
surgery performed during the same hospital stay 
to avoid recurrence. An assessment of the bile 
ducts should be performed either preoperatively 
or intraoperatively after the resolution of the 
pancreatitis. Elective cholecystectomy should be 
avoided during the actual phase of pancreatitis. 

33. (D) Because of its protected retroperitoneal 
location, pancreatic injury occurs with deep 
penetrating wounds or with significant blunt 
trauma to upper abdomen. Blunt trauma 
accounts for less than 20-30% of all pancreatic 
injuries. The most common site of injury is at 
the neck of the pancreas where the pancreatic 
tissue is compressed against the spine. 



Answers: 27-39 



179 



Associated visceral and vascular injuries occur 
commonly and together with the delay in diag- 
nosis account for the high morbidity and mor- 
tality. Fistulae, pseudocyst, infection, and 
secondary (delayed) hemorrhage are common 
complications. Pancreatic injuries frequently 
are overlooked initially, and their detection 
requires a high index of suspicion. Elevation of 
amylase after trauma is nonspecific. 

34. (A) If the pancreatic duct is dilated and symp- 
toms persist, a longitudinal pancreaticoje- 
junostomy (Puestow) is performed (Fig. 7-5). In 
this operation, the pancreatic duct is slit open 
and anastomosed side-to-side to the cut end of 
the divided jejunum with a Roux-en-Y anasto- 
mosis. Resection of the pancreas is reserved for 
patients without a dilated duct (<6 mm). In 
these cases, a distal pancreatectomy is per- 
formed when the disease primarily involves 
the body and tail of the pancreas; whereas, a 



Whipple operation is performed when the dis- 
ease is confined to the head. 

35. (A) Atelectasis is partly due to a factor released 
from the pancreas that alters pulmonary sur- 
factant. The other conditions listed are not 
specifically related to pancreatitis. 

36. (E) Most insulinomas are small (<2 cm), solitary, 
and benign. Therefore, simple enucleation is ade- 
quate. Less than 10% of cases are malignant and 
require resection in the form of either pancreati- 
coduodenectomy or distal pancreatectomy 
(depending upon the location of the tumor). Ten 
percent of insulinomas are associated with MEN 
I syndrome, and in these cases, the tumors are 
multiple. Partial pancreatic resection may be 
required for these patients. Total pancreatectomy 
is almost never required for the removal of insuli- 
nomas. Somatostatin receptors are not always 
present on insulinoma cells, and, therefore, SRS is 
less useful for localization of this tumor. 




Pancreatic duct 



Figure 7-5. 

Lateral pancreaticojejunostomy (Puestow) for 
chronic pancreatitus. (Reproduced, with per- 
mission, from Doherty GM: Current Surgical 
Diagnosis and Treatment, 12th ed. 618, 
McGraw-Hill, 2006.) 



37. (A) Carcinoma of the head of the pancreas is 
treated with radical excision of the head of the 
pancreas along with the duodenum. Continuity 
of the biliary and GI tract is established by per- 
forming hepaticojejunostomy, pancreaticoje- 
junostomy, and gastrojejunostomy (Fig. 7-6). 
The 5-year survival rate is higher for peri- 
ampullary carcinoma (30%) than that for pan- 
creatic head lesions (10%). Most centers do not 
give irradiation routinely before or after sur- 
gery because pancreatic cancers do not respond 
well to radiotherapy. Endoscopically placed 
stents alone are used only in palliative circum- 
stances in patients with limited life expectancy. 

38. (E) Cancer of the head of the pancreas is the 
most common cause of obstructive jaundice. 
In cholangiocarcinoma of the common hepatic 
duct, the gallbladder will be empty and not 
distended. Anemia may occur as a result of 
bleeding into the duodenum in periampullary 
cancer, but this is relatively rare. Carcinoma of 
the gallbladder results in jaundice only after 
the tumor invades the adjacent biliary tree. 

39. (D) The characteristic features of insulinomas 
include: (a) hypoglycemic symptoms; (b) 



180 7: Pancreas, Biliary Tract, Liver, and Spleen 



Tumor 





Figure 7-6. 

Pancreaticoduodenectomy (Whipple procedure). A: Preoperative anatomic relationships showing a 
tumor in the head of the pancreas. B: Postoperative reconstruction showing pancreatic, biliary, and 
gastric anastomoses. A cholecystectomy and bilateral truncal vagotomy are also part of the proce- 
dure. In many cases, the distal stomach and pylorus can be preserved, and vagotomy is then unnec- 
essary. (Reproduced, with permission, from Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 623. McGraw-Hill, 2006.) 



40. 



41. 



blood glucose <50 mg/dL during the sympto- 
matic episodes; and (c) relief of symptoms by 
intravenous injection of glucose (Whipple's 
triad). Diagnosis is confirmed by demonstra- 
tion of fasting hypoglycemia in the presence of 
inappropriately elevated levels of insulin in 
the blood. A ratio of plasma insulin/glucose 
>0.3 is diagnostic. Circulating levels of C- 
peptide are usually elevated in patients with 
insulinoma but not in patients with such other 
causes of hypoglycemia as tumors of mes- 
enchymal origin and liver tumors. Patients 
who surreptitiously administer insulin develop 
insulin antibodies. 

(B) VIP producing tumors (VIPomas) are usually 
malignant, although benign tumors and hyper- 
plasia may also occur. Increase of VIP results in 
the WDHA syndrome. Diarrhea is severe and 
results in fluid and electrolyte disturbances. 
Treatment is directed to removal of the pancreatic 
tumor. Gastrinoma is more common but is asso- 
ciated with increased gastrin level in the blood. 

(B) Secretin releases fluid rich mainly in elec- 
trolytes and bicarbonate. Both cholecystokinin 
and vagal stimulation result in fluid with a 
high content of enzymes. Among the pancreatic 



enzymes, amylase and lipase are released in 
their active forms; whereas, the proteolytic 
enzymes (trypsinogen, chymotrypsinogen) are 
secreted as inactive zymogens. Their activation 
occurs in the duodenum, where the zymogens 
are exposed to enterokinase. 

42. (D) Zollinger-Ellison syndrome is caused by 
secretion of excessive amounts of gastrin by 
islet cells of the pancreas (gastrinoma). It 
should always be thought of in patients with 
peptic ulcer disease, whose ulcers are severe, 
refractory to management, recurrent or located 
distally, beyond the first part of the duodenum. 
Gastrin levels in the blood are increased 
markedly and can be raised further by secretin 
injection (paradoxical response). The source of 
gastrin level in the blood may arise from hyper- 
plasia, adenoma, or most commonly carcinoma 
of the islets. Most gastrinomas are sporadic, 
but 25% of patients have a family history of 
multiple endocrine neoplasia. 

43. (C) Because most gastrinomas are small, pre- 
operative localization of the tumor may be dif- 
ficult. A nuclear scan may be performed using 
radiolabeled somatostatin (octreotide) ana- 
logue. This binds with the somatostatin receptors 



Answers: 40-52 



181 



present on the gastrin-producing cells which 
identifies the tumor. Endoscopic (not transcu- 
taneous) ultrasound is also useful in localizing 
these lesions in the pancreas and in the duo- 
denum. The combined accuracy of SRS and 
endoscopic ultrasound in preoperative local- 
ization of gastrinomas is 93%. 

44. (C) Patients with biliary dyskinesia present 
with typical symptoms of gallstone disease, 
but investigations fail to reveal cholelithiasis 
or choledocholithiasis. Ironically many patients 
will have undergone cholecystectomy for inci- 
dentally found gallstones but without relief of 
pain. ERCP with measurement of sphincter 
pressure will reveal basal sphincter pressure 
above 40 cm of water. Calcium channel block- 
ers may be tried initially to relieve the spasm of 
the sphincter of Oddi, but many patients will 
require an endoscopic sphincterotomy. 

45. (D) Lactescent serum is sometimes seen soon 
after an acute attack of pancreatitis. Lipase level 
should be elevated to show pancreatitis as the 
cause of the abdominal pain. Hypertrigly- 
ceridemia artificially lowers serum amylase 
levels. If the blood specimen appears milky 
the serum should be diluted; after dilution, 
serum amylase levels may become elevated. 
Other uncommon causes of pancreatitis 
include steroids, thiazide diuretics, lasix, sul- 
fonamides, protein deficiency hypercalcemia, 
familial, traumatic, idiopathic, and anatomic 
anomalies such as stricture, or pancreas divi- 
sum of the pancreatic duct. 

46. (A) The gallbladder is enlarged (Courvoisier's 
sign) in most cases of obstructive jaundice attrib- 
utable to malignancy. In obstructive jaundice 
attributable to gallstones, the gallbladder is usu- 
ally shrunken, owing to the previous inflam- 
matory condition affecting the gallbladder. 

47. (A) Alkaline phosphatase level usually is more 
sensitive than the bilirubin level for indicating 
cholestatic jaundice. It also is more likely to fall 
before the bilirubin level when the obstruction 
has been relieved. If an unexplained alkaline 
phosphatase elevation exists (even in the pres- 
ence of a normal bilirubin), biliary pathology 



must be excluded. Elevation of the alkaline 
phosphatase from a possible source in bone dis- 
ease can be excluded by measuring isoenzymes. 

48. (C) Oriental cholangiohepatitis is thought to be 
caused by the Chinese liver fluke (C. sinensis). It 
is encountered mainly in China (Canton) and 
Hong Kong, and among Chinese who have emi- 
grated elsewhere. There are multiple strictures 
in the biliary tree, and the intrahepatic ducts 
are dilated. Secondary infection supervenes. 
Schistosomiasis causes liver fibrosis, ameba 
causes liver abscess. Echinococcns, causes hydatid 
liver cysts, and hookworm causes anemia. 

49. (B) Sclerosing cholangitis is rare and occurs 
mainly in the third and fourth decades of life. 
Unlike most autoimmune disorders, it affects 
men more commonly. It may occur without 
any other abnormal pathology or may be asso- 
ciated with ulcerative colitis or retroperitoneal 
fibrosis. The CBD is converted to a thickened 
cord whose lumen is almost completely oblit- 
erated. The prognosis is guarded, and the mean 
survival is only 5-6 years. 

50. (D) The patient described has the features of 
Charcot's triad-jaundice, abdominal pain, and 
rigors, which indicates the presence of ascending 
cholangitis in a patient with obstructive jaun- 
dice. The patient should be treated with broad 
spectrum IV antibiotics and undergo ERCP, 
sphincterotomy, and stone extraction. If this fails, 
surgical exploration of the CBD will be required. 

51. (D) If a stone is detected, the T tube should be left 
in place for 6 weeks to allow the tract to mature. 
At this time, the T tube can be removed, and the 
stone can be extracted by using a Dormia basket 
under fluoroscopy. This approach is indicated 
only when a T-tube larger than 16 has been 
inserted. If this approach is not feasible, the stone 
can be extracted by retrograde endoscopic tech- 
niques or CBD exploration. 

52. (B) In the presence of previous gallbladder sur- 
gery the possibility of cholestatic jaundice must 
be excluded. Elevation of alkaline phosphatase 
(with normal or elevated bilirubin level) 
strongly supports this diagnosis. The dark urine 



182 



7: Pancreas, Biliary Tract, Liver, and Spleen 



results from increase in conjugated bilirubin 
(regurgitated jaundice). Urobilin is excreted in 
the urine in hepatocellular jaundice but is 
absent in the urine in obstructive jaundice, 
because this pigment forms only if bile reaches 
the small intestine. 

53. (C) A HIDA scan will show excretion of the 
radiolabeled isotope into the biliary tree, but 
there will be no flow into the duodenum, indi- 
cating that the biliary-enteric anastomosis is 
occluded. If an upper GI study with barium is 
performed, visualization of the common bile 
duct would indicate patency of the choledocho- 
duodenal anastomosis. 

54. (B) Gram-negative bacilli including E. coli, 
Klebsiella, and Proteus are the organisms most 
commonly involved in ascending cholangitis. 
Anaerobic bacteroids should also be excluded, 
especially in elderly patients. Intravenous 
hydration and early institution of appropriate 
antibiotics is indicated. The antibiotics selected 
should be effective against the isolated organ- 
isms. Combined therapy with an aminoglyco- 
side, penicillin, and an antibiotic targeted 
specifically against anaerobic organisms should 
be administered initially until blood culture 
results are available. 

55. (C) Multiple stones were present in the CBD at 
the previous operation. During exploration of 
the CBD, most stones can be removed by using 
Desjardin's forceps or under direct vision using 
a choledochoscope and Dormia basket. 
However, if there are multiple stones impacted 
in the lower part of the CBD, a drainage pro- 
cedure may be indicated. The CBD must be 
dilated before considering performing a chole- 
dochoduodenostomy at the time of gallbladder 
surgery (Fig. 7-7). If a stone is present in a 
dilated CBD after previous cholecystectomy, a 
choledochoduodenostomy is performed, 
because the rate of recurrent jaundice is high 
(>20%). Alternatively ERCP and sphinctero- 
tomy could be considered. 

56. (D) The cystic artery courses through the tri- 
angle of Calot. The identification of the triangle 



is therefore important in the performance of a 
cholecystectomy. 

57. (B) Pruritus occurs frequently in untreated 
obstructive jaundice. Bile salt elevation is a pos- 
sible cause of pruritus. Patients with general- 
ized pruritus should have alkaline phosphatase 
levels determined; if levels are elevated, the 
possibility of cholestatic jaundice should be 
considered. Bilirubin is not always elevated in 
obstructive jaundice. 

58. (B) Any obstruction to the biliary tree (stones 
and benign, malignant, or anastomotic stric- 
tures) can lead to infection and cholangitis. It 
may also occur after trauma to the biliary tree. 
In ascending cholangitis, there is fever, jaun- 
dice, and rigors (Charcot's triad). Suppurative 
cholangitis is suspected when additional signs 
of deterioration in mental status and hypoten- 
sion are present in addition (Reynold's pentad). 
This entity requires immediate biliary decom- 
pression either endoscopically or surgically. C. 
sinensis, the liver fluke, causes suppurative 
cholangitis in the Far East. 

59. (C) Vitamin K requires bile salts for efficient 
absorption from the gut, as do the other fat- 
soluble vitamins — A, D, and E. Therefore, the 
oral route is not suitable to administer patients 
with obstructive jaundice. If intramuscular 
vitamin K is given, correction will occur if there 
has been no hepatocellular damage. When 
emergency surgery is required in this circum- 
stance, the coagulation defect due to hepatic 
disease may be corrected with fresh-frozen 
plasma (FFP). Urobilinogen usually is absent in 
the urine in obstructive jaundice, because its 
presence depends on a patent biliary-enteric 
circulation. Stercobilinogen will be absent in 
fecal examination. 

60. (A) Stones are found in the gallbladder in over 
90% of patients with cholecystitis. Bacteria are 
cultured in bile in about half the patients under- 
going surgery; however, many patients have 
previously received antibiotics. The gallbladder 
is usually distended in patients with acute chole- 
cystitis but contracted in chronic cholecystitis. 



Answers: 53-60 183 






Figure 7-7. 

Treatment for invasive gallbladder cancer is cholecystectomy and a wedge resec- 
tion of the liver along with a regional lymphadenectomy. The wedge resection of the 
liver is illustrated. Segments 4 and 5 together with the lymph node regions should 
be removed. (Reproduced, with permission, from Greenfield: Surgery: Scientific 
Principles & Practice, 2nd ed. 957. Lippincott, 1996.) 



184 



7: Pancreas, Biliary Tract, Liver, and Spleen 



61. (A) If there is a recent history of jaundice, 
although the CBD is not dilated, intraoperative 
cholangiography must be performed to exclude 
CBD stones. Other indications for intraopera- 
tive cholangiogram include a recent history of 
ascending cholangitis, dilated CBD on preop- 
erative sonogram, or suspicion of a "missing" 
stone in the gallbladder (i.e., as detected by 
ultrasound or other observations). Elevated 
bilirubin and alkaline phosphatase are other 
indications that a CBD stone may be present. 

62. (A) A cholecystokinin stimulated HIDA scan 
should be performed. Failure of the gallbladder 
to contract after stimulation by cholecystokinin 
may suggest dyskinesia. This is an indication 
for cholecystectomy, even though stones are 
not demonstrated. Secretin is the duodenal hor- 
mone that stimulates exocrine pancreatic secre- 
tion. Gastrin, released mainly from the antrum, 
increases gastric acid secretion that is high in 
bicarbonate and electrolytes. 

63. (A) Unlike most biliary disease conditions, 
cholangiocarcinoma condition affects men more 
commonly than women. Primary sclerosing 
cholangitis, C. sinensis, and choledochal cysts 
may play an etiological role in some cases, but 
gallstones are not involved in the pathogenesis 
of this tumor. Patients present with obstructive 
jaundice; pain, and weight loss are less common. 
Proximal tumors (Klatskin) are most common, 
and they require excision of hepatic duct bifur- 
cation and reconstruction with a Roux-en-Y limb 
of jejunum. Tumors of the distal duct can be 
resected by performing a Whipple pancreato- 
duodenectomy. Patients who are not operative 
candidates (those with advanced disease or 
those who cannot withstand a major operation) 
should undergo palliative endoscopic stent 
placement to relieve the obstruction. 

64. (A) The HIDA scan is most accurate in estab- 
lishing a diagnosis of acute cholecystitis. After 
injection, the technetium-labeled imminodi- 
acetic acid radioisotopes are taken up by the 
liver and excreted into the biliary tree. If the 
cystic duct is obstructed (as in patients with 
acute cholecystitis) the gallbladder will not 
be visualized. Ultrasound may show ductal 



dilation, the presence of wall thickening (<3 
mm), or pericholecystic fluid, which is highly 
suggestive of acute cholecystitis. 

65. (E) She does not require any further therapy. In 
instances where gallbladder carcinoma is dis- 
covered incidentally during cholecystectomy 
and is shown to have only invaded the mucosa 
and submucosa it is classified as stage I. The 
5-year survival for these patients is 100% and 
no further treatment is required as for more 
advanced lesions, that is, those penetrating the 
muscular layer or with lymph node involve- 
ment (stages II & III). Here there is a higher 
incidence of local and regional spread to the 
liver and porta hepatis lymph nodes, respec- 
tively. For these patients an en bloc resection of 
segments 4 and 5 of the liver is performed 
along with dissection of celiac axis and porta 
hepatis lymph nodes. For more advanced 
lesions (stage IV), the prognosis is very poor, 
and further resection is not indicated. 
Gallbladder carcinoma responds poorly to 
radiotherapy or chemotherapy. 

66. (D) The morbidity and mortality of cholecys- 
tectomy is markedly increased in the presence 
of cirrhosis. The prognosis is particularly grave 
in patients with decompensated liver disease. 
Most gallstones in patients with cirrhosis are 
pigment stones, and hence dissolution with 
ursodeoxycholic acid is not an acceptable 
option of treatment. 

67. (B) Early after the onset of acute cholecystitis, 
the plane of dissection may be facilitated 
because of early inflammatory response. 
Between the seventh and fourteenth day after 
admission, surgery may be extremely difficult 
because of resolving infection and adhesions. 
Where possible surgery should be avoided 
during this period. 

68. (A) Emphysematous cholecystitis is caused by 
gas-forming organisms. On a plain x-ray of the 
abdomen, gas may be seen within the wall of the 
gallbladder. Clinically, the patient has rapidly 
progressive sepsis, RUQ pain, fever, and hemo- 
dynamic instability. The disease primarily affects 
diabetic men. Treatment with laparotomy and 



Answers: 61-76 



185 



cholecystectomy is urgent to avoid complica- 
tions. Air within the biliary tree (not gallbladder 
wall) may be seen in gallstone ileus, after biliary- 
enteric anastomosis or after sphincterotomy. 

69. (D) Acute acalculous cholecystitis is most com- 
monly encountered in critically ill patients after 
trauma, other unrelated surgical operations, 
burns, sepsis, and multiorgan failure. The 
HIDA scan fails to visualize the gallbladder, 
and a sonogram may show a distended gall- 
bladder with wall thickening and perichole- 
cystic fluid. Acalculous cholecystitis carries a 
mortality rate of 10-30%. Delay in diagnosis 
and hence treatment is accompanied by severe 
complications, such as gangrene and perfora- 
tion of the gallbladder in a patient who usually 
has other debilitating illnesses. 

70. (C) Obstruction of the cystic duct may be caused 
by factors other than stones. Acalculous chole- 
cystitis carries a high mortality, because it 
occurs in patients who are already critically ill. 
Furthermore, the establishment of the diagnosis 
is often delayed. Urgent cholecystostomy should 
be performed. In recent years, percutaneous 
cholecystostomy under CT or ultrasonography 
(US) guidance is performed more commonly 
than surgical cholecystectomy, because it carries 
a lower operative mortality rate. In a stable 
patient, cholecystectomy may be considered. 

71. (D) Sodium chloride and water are selectively 
absorbed by the gallbladder mucosa. Bile salts 
and pigments are concentrated in the bile. 
Mucus also is secreted into the bile to function 
in a protective capacity. The presence of cho- 
lesterol crystals in biliary drainage material 
warrants further investigation, although the 
biliary system is normal. 

72. (D) This patient has an amebic liver abscess. In 
most patients, the antecedent intestinal phase 
has subsided by the time patient presents with 
fever, chills, and a painful, tender enlarged liver. 
Amoebae are found in examination of fresh 
stools in 15% of cases, but the indirect hemag- 
glutination test is almost always positive. 
Amebic abscess responds rapidly to treatment 
with metronidazole (Flagyl). Surgery should be 



avoided when possible and is indicated only 
when medical treatment has failed or complica- 
tions, such as perforation, have occurred. 

73. (B) Amebic liver abscess almost always 
responds to treatment with metronidazole 
(Flagyl). Occasionally, percutaneous aspiration 
is required when there is no response to Flagyl 
or if the abscess is secondarily infected. Amebic 
lever abscess affects mainly middle-aged men. 
Complications of amebic liver abscess include 
secondary infection in 20% and rupture into 
pleural, peritoneal, or pericardial cavity in 10% 
of cases. 

74. (D) The hepatic artery, portal vein, and hepatic 
bile duct are distributed equally between both 
lobes of the liver divided by Cantlie's line. This 
line passes between the inferior vena cava pos- 
teriorly and the gallbladder fossa anteroinferi- 
or ly. The falciform ligament does not divide 
the liver into a right and left lobe; it divides the 
true left lobe into medial and lateral segments. 
The caudate and quadrate lobes are part of the 
left lobe, and, thus, Cantlie's line passes along 
their right (and not left) margins. 

75. (A) Hepatic adenomas are associated with an 
increased incidence in patients receiving oral 
contraceptives, diabetes, and pregnancy. Most 
patients are symptomatic with pain and bleed- 
ing. Because of the real risk of intraperitoneal or 
intratumoral bleeding as well as malignant trans- 
formation, excision of the adenoma is recom- 
mended. Tumors are removed by enucleation or 
with a narrow rim of normal parenchyma, and 
major liver resection is not required. 

76. (C) Unlike hepatic adenomas, these lesions do 
not usually cause symptoms. Unlike hepatic 
adenomas, focal nodular hyperplasia does not 
tend to cause intramural bleeding with rup- 
ture into the peritoneal cavity. CT or US scan 
may frequently miss the lesion, because it is so 
dense. There is no definite relationship with 
oral contraceptives. Focal nodular hyperplasia 
lesions are not well encapsulated and have a 
central stellate scar. Malignant changes have 
not been reported. LFT and AFP are normal in 
both conditions. 



186 



7: Pancreas, Biliary Tract, Liver, and Spleen 



77. (B) Hemangioma is the commonest nodule in 
the liver. On intravenous contrast CT or MRI, a 
liver hemangioma shows initial centripetal 
enhancement followed by decrease in dye 
over 10 minutes from without to within. 
Hemangiomas occur more frequently in women. 
Most lesions are asymptomatic, discovered inci- 
dentally and require no treatment. Larger 
hemangiomas may cause pain because of stretch- 
ing of liver capsule or thrombocytopenia due to 
platelet trapping. These tumors may occasionally 
require resection. 

78. (C) Congenital cysts are more frequently 
encountered than those that are acquired, 
which are caused by trauma, inflammation, or 
parasitic disease. Most congenital cysts tend to 
be asymptomatic and require no treatment. 
Larger cysts may cause pain and occasionally 
require radiologically guided percutaneous 
drainage or operative unroofing to prevent 
recurrence. Fungal abscesses, encountered 
mainly in immunosupressed patients, tend to 
be multiple. Pyogenic abscesses tend to be 
symptomatic with fever and pain, whereas, 
tumors are generally not hypoechoic. 

79. (D) Before performing the left hepatic lobec- 
tomy, any extrahepatic metastasis should be 
ruled out. If lung, bone, adrenal, or skin metas- 
tasis were present, then subjecting the patient 
to a major operation would not be warranted in 
most cases. Moreover, before proceeding with 
surgery, it must be ascertained that control of 
the primary tumor has been achieved and that 
the patient's physical condition will allow such 
a major operation. Surgical excision of hepatic 
metastasis results in 25%, 5-year survival. 
Patients not treated by hepatic resection do not 
usually survive into the first year after clinical 
detection. Chemotherapy would be offered if 
resection were not indicated. 

80. (D) Massive hemorrhage. Hemorrhage is a 
major cause of death after liver transplanta- 
tion. Subphrenic infection and other intra- 
abdominal and intrahepatic infections may 
occur later in the postoperative period. Graft 
rejection is mainly a problem at a later period. 



81 . (D ) Is rarely associated with long-term survival. 
Heterotopic (to a remote position) auxiliary 
transplantation is only occasionally indicated 
where orthotopic transplantation cannot be car- 
ried out. Long-term survival with this proce- 
dure is limited (2 of 69 cases). Hetrotopic 
auxiliary liver transplants require low outflow 
pressure and are, therefore, most likely to suc- 
ceed if placed proximally as close to the heart as 
possible. One advantage of this procedure is 
that the procedure is technically easier, because 
the patient's liver is not disturbed. 

82. (A) The liver plays a role in glucose formation 
from various glucogenic amino acids and other 
substances. Hepatic disease removes this 
source of glucose supply. In insulin hypo- 
glycemia, there is enhanced rapid uptake of 
glucose by fat tissue and muscle. 

83. (D) Antithrombin III counteracts excess of 
thrombin formation. The excess of thrombin 
facilitates conversion of fibrinogen to fibrin. 
Portal vein thrombosis will lead to portal 
hypertension but not hepatic congestion, as 
seen in Budd-Chiari syndrome. Portal vein 
thrombosis may occur in cirrhosis, trauma, in 
patients on contraceptive tablets, and in those 
who have an increased propensity for throm- 
bus formation. It is also a direct complication of 
periumbilical infection in the neonate. 

84. (B) Umbilical infection at birth is associated with 
ascending infection along the remnant of the 
left umbilical vein in the round ligament. This 
vein communicates with the left portal vein. 
Portal hypertension occurs because of portal 
vein thrombosis. In general, LFTs are normal, 
because the site of portal obstruction is outside 
the liver. Other causes of portal vein thrombosis 
include chronic pancreatitis, carcinoma of the 
pancreas, surgical intervention in this region, 
and diseases associated with an increased ten- 
dency toward clot formation. (See Answer 65.) 

85. (C) As in any patient with upper GI bleeding, 
the initial intervention following clinical eval- 
uation requires appropriate resuscitation. 
Blood transfusion may be required. Liver func- 
tions must be assessed, and coagulopathy 



Answers: 77-92 



187 



should be corrected with FFP or vitamin K 
injection. After resuscitation is completed, 
every attempt should be made to perform an 
upper GI endoscopy as soon as possible. These 
patients may be bleeding from varices, portal 
hypertensive gastropathy, peptic ulcer, or 
Mallory-Weiss tear, and early endoscopy will 
provide a higher diagnostic yield as to which 
lesion is actually bleeding. 

86. (E) TIPS refers to an implantable, expandable 
metal stent placed radiologically through the 
hepatic parenchyma to establish a tract 
between the hepatic and portal vein. A portal 
systemic shunt is, therefore, created, and the 
varices are decompressed. Because of the high 
incidence of complications (esophageal perfo- 
ration, aspiration, airway obstruction) associ- 
ated with the Sengstaken-Blakemore tube, it is 
only used as a last ditch attempt to control 
exsanguination. In >50% of cases, bleeding 
recurs after the tube is deflated. 

87. (A) The condition is more common in children. 
Splenectomy predisposes the patient to OPSI 
characterized by fulminant bacteremia, menin- 
gitis, or pneumonia. The mortality of this condi- 
tion is high. The risk is greatest in children under 
4 and for those undergoing splenectomy for tha- 
lassemia or lymphoma. The risk is lower in 
adults and those undergoing splenectomy for 
trauma than for ITP All patients undergoing 
elective splenectomy should receive vaccination 
against pneumococcus and H. Influenzae about 
2 weeks before surgery. Vaccination should be 
repeated every 5 years. In addition, children 
should be given penicillin prophylactically until 
they are 18 years of age. Postsplenectomy 
patients should seek medical attention at the first 
sign of even seemingly mild upper respiratory 
tract infection and should be advised to wear a 
Medic Alert tag indicating their asplenic state. 

88. (C) Portal hypertension is suspected clinically 
if esophageal varices are detected, hyper- 
splenism occurs, or ascites develop. Normal 
portal venous pressure is 5-10 mm Hg. 
Pressure may be measured indirectly by using 
hepatic venous wedge pressure (occlusive 



hepatic wedge pressure). About two-thirds of 
patients with portal hypertension will develop 
varices of which one-third will bleed. 

89. (A) Penicillamine counteracts the adverse 
effects of copper on the liver in patients with 
Kimmelstiel-Wilson syndrome. This has been 
demonstrated in both humans and animals 
afflicted with this disease. Portocaval shunt 
and esophageal varices are not indicated 
prophylactically. 

90. (E) Platelets should not be given before splenec- 
tomy, but arrangements should be made to 
have them available immediately before the 
operation. They should be used only if bleed- 
ing occurs and after the spleen has been 
removed. ITP is a hemorrhagic disorder char- 
acterized by a low platelet count with bone 
marrow findings that show normal or 
increased megakaryocytes. The female/male 
ratio is 3:1. This diagnosis implies that no other 
systemic disease or past history of drug intake 
could account for these changes. Some cases 
may be caused by an autoimmune response. 

91. (A) Radioactive technetium (" 9m Tc) scan to see if 
a retained accessory spleen (splenunculus) is 
present, which may account for postoperative 
thrombocytopenia. Radioactive technetium 
(not I 135 ) is used to localize splenic tissue. 
Patients with ITP have petechiae, ecchymosis, 
and/or bleeding. Splenectomy performed ini- 
tially for ITP is likely to be successful in 80% of 
patients, but is less effective in older patients. 

92. (D) Features of TTP include fever, thrombocy- 
topenic purpura, hemolytic anemia, neurolog- 
ical manifestations, and renal disease. The exact 
cause of TTP has not been determined. 
Histologically, there is diffuse hyalinization of 
arterioles and capillaries, with occlusion and 
infarction. The disease may follow a rapid and 
fulminant course, with death occurring sec- 
ondary to cerebral hemorrhage or renal failure. 
Treatment includes steroids, plasmapheresis, 
and splenectomy. Approximately, 1/20 cases 
occur in pregnancy, but unlike ITP, TTP is not 
improved by termination of pregnancy. 



188 



7: Pancreas, Biliary Tract, Liver, and Spleen 



93. (C) Sickle cell disease is relatively common in 
African- Americans and certain ethnic commu- 
nities in the United States. Most patients 
with sickle cell disease respond favorably to 
rehydration and analgesia for each attack. The 
patient must avoid unnecessary exposure to 
infections, hypoxemia, and dehydration. In 
most patients with sickle cell disease, there is 
autoinfarction of the spleen. Splenectomy is 
rarely indicated, except for patients with sickle 
cell disease with a massively enlarge spleen, 
where trapping of RBCs is demonstrated. 

94. (E) Sickle cell disease is diagnosed by periph- 
eral smear showing sickle-shaped red cells and 
HbS on electrophoresis. The pathogenesis of 
the disease is characterized by microinfarction 
in different parts of the body. This can lead to 
serious (and in some instances fatal) outcome. 

95. (A) In hereditary spherocytosis, the abnormally 
shaped erythrocytes fail to pass through the 
splenic pulp and are more prone to earlier 
destruction. In hereditary elliptocytosis, the ery- 
throcyte membrane also is abnormal. Children 
with spherocytosis should undergo splenectomy 
around their fourth birthday. Other less common 
hematological indications for splenectomy are 
thalassemia, sickle cell anemia, autoimmune 
anemia, and an enlarged spleen that becomes a 
major site of red cell sequestration. 

96. (C) Characterized by RBCs that undergo lysis at 
a higher osmotic pressure. Gallstones are fre- 
quently encountered as a result of increased pro- 
duction of bilirubin. Hereditary spherocytosis 



is transmitted as an autosomal-dominant trait. 
Because of a fault in the RBC membrane, the 
cells are smaller and round and undergo lysis in 
a minor vessel, which results in a relative 
obstruction to flow. 

97. (E) Alkalating agents must be given cautiously, 
because patients with myeloid metaplasia are 
sensitive to these agents. The connective and 
hemopoietic tissues in the spleen and liver are 
increased. Polycythemia vera, myelogenous 
leukemia, and idiopathic thrombocytosis must 
be excluded. Splenectomy is often of value. 

98. (C) Felty's syndrome is characterized by 
splenomegaly, neutropenia, and rheumatoid 
arthritis. Steroids are used initially, but their 
effect usually is transient. Splenectomy favor- 
ably alters the leukocyte count; it does not alter 
the clinical course of rheumatoid arthritis. As 
with all patients undergoing elective splenec- 
tomy, this patient must be given pneumovax, as 
well as haemophilus and meningiococcal vac- 
cines before surgery. 

99. (A) The risk of infection after removal of the 
spleen as well as the good results of conserva- 
tive treatment should encourage a nonopera- 
tive approach in children. In adults, surgery is 
usually recommended, but when possible, the 
spleen should be repaired and not removed. If 
the spleen is to be removed on an elective 
basis,pneumovax and prophylactic vaccine 
against H. influenza are given about 2 weeks 
before surgery. (See Answer 69.) 



CHAPTER 8 



Hernia 

Max Goldberg and Nanakram Agarwal 

Questions 



DIRECTIONS (Questions 1 through 21): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 

1. A 6-month-old boy presents with an inguinal 
hernia, first noticed 2 weeks after birth. What is 
the best treatment choice? 

(A) Observation 

(B) Laparotomy 

(C) Surgical repair when the child is fully 
grown 

(D) Surgical repair of the affected side 

(E) Surgical repair of the affected side and 
exploration of the nonaffected side to 
search for and repair a sac that was not 
previously detected by clinical means 

2. A 60-year-old male presents with an inguinal 
hernia of recent onset. Which of the following 
statements are TRUE? 

(A) The hernia is more likely to be direct 
than indirect. 

(B) Presents through the posterior wall of 
the inguinal canal, lateral to the deep 
inguinal ring. 

(C) Is covered anteriorly by the transversalis 
fascia. 

(D) Is more likely than a femoral hernia to 
strangulate. 

(E) The sac is congenital. 



3. A 70-year-old cigarette smoker presents with a 
right inguinal mass that has enlarged and has 
caused discomfort in recent months. He com- 
plains of recent difficulty with micturition and 
nocturia. The swelling, which does not extend 
to the scrotum, reduces when resting. What is 
the likely diagnosis? 

(A) Direct inguinal hernia 

(B) Strangulated indirect inguinal hernia 

(C) Hydrocele 

(D) Aneurysm of the femoral artery 

(E) Cyst of the cord 

4. A 65-year-old female requires emergency sur- 
gery for a strangulated inguinal hernia. Which 
of the following is correct? 

(A) The sac is formed by an unobliterated 
processus vaginalis. 

(B) The hernia is direct rather than indirect. 

(C) Such herniae never contain small 
intestine. 

(D) Strangulation never results in bowel 
ischemia and gangrene requiring 
resection. 

(E) Indirect inguinal herniae are never 
found in female patients. 



789 



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190 



8: Hernia 



5. An otherwise healthy, 60-year-old male has 
been advised to undergo surgical treatment for 
a left ingunial hernia. Which of the following 
are acceptable standards of surgical treatment? 

(A) Traditional surgical repair under general 
or local anesthesia 

(B) Repair of the hernia and ipsilateral 
orchiectomy, in order to better assure 
closure of the inguinal canal and reduce 
the possibility of recurrence 

(C) Laparotomy to perform a retroperitoneal 
repair 

(D) Surgical exploration of the contralateral 
groin to search for an occult hernia sac 
and to remove it before a hernai 
develops 

(E) The patient should be advised to wear a 
truss postoperatively, in order to reduce 
the incidence of recurrence 

6. A 62-year-old male presents with an irreducible 
swelling and severe pain in the left groin. He 
had a known reducible hernia for 15 years prior 
to this. He had a bowel movement while in the 
emergency room. At surgery, a Richter's hernia 
was found. Which of the following statements 
is TRUE? 

(A) It presents lateral to the rectus sheath. 

(B) It presents through the lumbar triangle. 

(C) It presents through the obturator 
foramen. 

(D) It contains a Meckel's diverticulum. 

(E) It may allow normal passage of stool. 

7. At surgery for a right inguinal hernia, a 
72-year-old man is found to have a hernia sac 
that is not independent of the bowel wall. The 
cecum forms part of the wall of the sac (Fig. 8-1). 
Such a hernia is properly referred to as which 
of the following? 

(A) Incarcerated 

(B) Irreducible 

(C) Sliding 

(D) Richter's 

(E) Interstitial 




Peritoneal cavity 



Figure 8-1. 

Hernia has entered internal inguinal 
ring. Note that one-fourth of the hernia 
is not related to the peritoneal sac. 
(Reproduced, with permission, from 
Way LW: Current Surgical Diagnosis & 
Treatment, 10th ed. 176. Appleton & 
Lange, 1994.) 



8. The following structures may be injured during 
surgery to repair an inguinal hernia: 



(A) 



(B) 
(C) 
(D) 

(E) 



The ilioinguinal, genitofemoral, 

iliohypogastric, and lateral femoral 

cutaneous nerves 

The femoral nerve 

The popliteal nerve 

The nerve to the psoas major muscle 

The pudendal nerve 



9. Which of the following structures would be 
encountered during repair of an inguinal 
hernia in a male? 



(A) 



(B) 
(C) 
(D) 
(E) 



Spermatic cord, cremaster muscle, 

transversalis fascia, deep epigastric 

vessels, conjoined tendon 

Round ligament 

Obturator nerve 

Symphysis pubis 

Nerve to the adductor muscles of the 

thigh 



10. In repair of a femoral hernia, the structure most 
vulnerable to major injury lies: 

(A) MediaUy 

(B) Laterally 

(C) Anteriorly 

(D) Posteriorly 

(E) Superficially 



Questions: 5-17 



191 



11. A 28-year-old professional football player has 
sudden pain and swelling in the right groin 
when attempting to intercept a pass. He is 
admitted to the local emergency department. 
On examination, there is a tender swelling 
in the right groin. The scrotum and penis show 
no abnormality. What is the next step in 
management? 

(A) Needle aspiration to exclude hematoma 

(B) Forceful manual reduction 

(C) Laparotomy within 20 minutes 

(D) Preoperative preparation and exploration 
of the groin with hernia repair 

(E) Morphine and reevaluation within 
12 hours 

Questions 12 and 13 

A 70-year-old woman presents with a tender irre- 
ducible mass immediately below and lateral to the 
pubic tubercle. Plain abdominal x-ray shows intes- 
tinal obstruction. 

12. What is the likeliest diagnosis? 

(A) Small-bowel carcinoma 

(B) Large-bowel carcinoma 

(C) Adhesions 

(D) Strangulated inguinal hernia 

(E) Strangulated femoral hernia 

13. Treatment with a nasogastric tube and intra- 
venous fluids is initiated. What is the next step 
in treatment? 

(A) Sedation to relax the patient and allow 
spontaneous reduction of the mass 

(B) Sedation and surgery scheduled for the 
next elective surgical appointment 

(C) Sedation and manual taxis (reduction) 

(D) Emergency surgery on the left groin 

(E) Emergency laparotomy for intestinal 
obstruction and hernia repair from the 
peritoneal cavity 

14. A 2-year-old African American boy presents 
with a reducible umbilical hernia, under 2-cm 
diameter. This is best managed by: 



(A) Immediate surgery and repair with mesh 

(B) Immediate surgery repair without mesh 

(C) Laparoscopic repair with mesh 

(D) Laparoscopic repair without mesh 

(E) Periodic observation and evaluation 

15. A 55-year-old woman, who recently had been 
dieting with a weight loss of 20 lb, presents 
with a small-bowel obstruction and pain, which 
radiates down the inside of her thigh to the knee. 
She has no past history of abdominal surgery. 
Which of the following is the likely diagnosis? 

(A) Strangulated obturator hernia 

(B) Obstructing neoplasm of the ileum 

(C) Gallstone ileus 

(D) Strangulated femoral hernia 

(E) Fracture of the pubic bone 

16. A 50-year-old man presents with a complaint of 
a 1-cm moderately painful, tender mass situ- 
ated one-third of the way between the xiphis- 
ternum and the umbilicus (Fig. 8-2). What is 
the most likely diagnosis? 

(A) Fibrosarcoma of the abdominal wall 

(B) Omphalocele 

(C) Spigelian hernia 

(D) Fat necrosis 

(E) Epigastric hernia 

17. A 70-year-old, moderately obese, male pres- 
ents with a large, midline incisional hernia. 
One year previously, he underwent a colon 
resection for adenocarcinoma. Colonoscopy, 
metastasis workup and carcinoembryonic anti- 
gen (CEA) are normal. Which of the following 
statement is TRUE? 

(A) Repair with mesh can be performed 
laparoscopically 

(B) Strangulation is uncommon because the 
neck is narrow. 

(C) Recurrence is common, even with the 
use of mesh of improved quality. 

(D) Surgical repair is simple to perform 
under local anesthesia. 

(E) Patients remain very uncomfortable, 
even with an adequate repair. 



192 



8: Hernia 




Figure 8-2. 

Epigastric lesion. (Reproduced, with permission, from 
Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 774. McGraw-Hill, 2006.) 



18. Following laparoscopic preperitoneal repair of 
an inguinal hernia, a 50-year-old male com- 
plains of severe burning pain, which radiates 
down the lateral side of the ipsilateral thigh. 
The most likely cause is injury to which of the 
following: 

(A) Ilioinguinal nerve 

(B) Iliohypogastric nerve 

(C) Genitofemoral nerve 

(D) Femoral nerve 

(E) Lateral femoral cutaneous nerve 

19. A male neonate is born with an omphalocele 
(shown in Fig. 8-3). This entity can be distin- 
guished from gastroschisis, because in an 
omphalocele, the protrusion is: 

(A) Not covered by a sac 

(B) A defect in the abdominal musculature 

(C) Associated with an umbilicus attached 
to the abdominal wall musculature 

(D) Associated with partial or complete 
malrotation of the bowel 

(E) Really contains abdominal viscera 




Figure 8-3. 

Giant omphalocele in a newborn male. (Reproduced, with per- 
mission, from Brunicardi FC et al.: Schwartz's Principles of 
Surgery, 8th ed. 1503. McGraw-Hill, 2005.) 

20. What is true of Spigelian hernia? 

(A) It occurs exclusively in males. 

(B) It involves part of the circumference of 
the bowel wall. 

(C) It is best repaired by the classical Bassini 
technique of inguinal ligament repair. 

(D) It occurs at the lateral edge of the linea 
semilunaris. 

(E) It always contains the vermiform 
appendix. 

21. A 56-year-old man is scheduled to have a left 
indirect hernia repaired. He is asymptomatic. 
Before surgical treatment, he should have 
which of the following? 

(A) Rectal examination alone 

(B) Rectal examination and sigmoidoscopy 

(C) Barium enema 

(D) Colonoscopy 

(E) Intravenous pyelogram 



Answers and Explanations 



1. (E) Inguinal hernias in infancy are almost 
always congenital and indirect and are often 
bilateral. Bilateral exploration is recommended, 
except when the surgery is performed for 
incarceration. 

2. (A) Hernias, which present in adult life are most 
often direct and aquired, rather than indirect. 
They protrude through the transversalis fascia, 
which forms the medial half of the posterior wall 
of the inguinal canal and is located medial to the 
deep inguinal ring and deep epigastric vessels. 
Strangulation of direct inguinal herniae is uncom- 
mon, probably because the neck of the sac tends 
to be wide, rather than narrow and constricting 

3. (A) Direct hernias are more common in older 
patients. There is an increased incidence in 
patients with a chronic cough and prostatic 
obstruction. They are rarely encountered in 
children and women. This type of hernia does 
not extend to the scrotum and rarely under- 
goes strangulation. 

4. (A) Indirect inguinal hernia sacs are found less 
commonly in female patients. They are formed 
by the unobliterated processus vaginalis of the 
peritoneum and allow for the entry of intraperi- 
toneal viscera, such as loops of small intestine, 
omentum, and the likes. Compromise of blood 
supply by constriction leads to strangulation. 

5. (A) Traditional hernia repair is performed 
under local or general anesthesia. Laparoscopic 
repair, in general, is performed under general 
anesthesia. Combinations of local anesthesia 
and intravenous sedation are in routine use. 
Orchiectomy, though occasionally used in 



special circumstances, is by no means a routine 
part of hernia repair. Exploration of the oppo- 
site groin, though recommended in infants, 
does not apply to adults. 

6. (E) In Richter's hernia, part of the bowel wall is 
entrapped in the hernia sac. This results in a par- 
tial occlusion of the lumen and bowel movement 
remains possible, despite strangulation and gan- 
grene of the entrapped portion. Evaluation at 
surgery, of the viability of the full-bowel wall 
must always be carried out before returning the 
entrapped segment to the peritoneal cavity. 

7. (C) The term sliding refers to the peritoneum 
that slides along with the hernia in its passage 
along the cord (Fig. 8^). The viscus forms part 
of the wall of the sac. The peritoneum should 
not be removed from the bowel wall, because 
devascularization may occur. 




Peritoneal cavity 



Figure 8-4. 

Note cecum and ascending colon slid- 
ing on fascia of posterior abdominal 
wall. (Reproduced, with permission, 
from Doherty GM: Current Surgical 
Diagnosis and Treatment, 12th ed. 771. 
McGraw-Hill, 2006.) 



193 



194 



8: Hernia 



8. (A) Any of these nerves may be devided, 
crushed, or entrapped by suture or mesh 
during repair of a groin hernia. The lateral 
femoral cutaneous nerve is vulnerable espe- 
cially during laparoscopic hernia repair. 

9. (A) All are normal and constant anatomic struc- 
tures of the inguinal canal. 

10. (B) The femoral vein lies immediately lateral 
to the femoral canal. Careful attention to this 
structure is essential in repair of femoral 
herniae. 

11. (D) Unexplained recent onset of swelling in the 
groin, that is not reducible, should be consid- 
ered to be a strangulated inguinal or femoral 
hernia until proved otherwise. Needle aspira- 
tion may cause fecal perforation and forceful 
manual reduction may result in the return of 
gangrenous bowel to the peritoneal cavity. 

12. (E) Strangulated femoral hernia is located 
below and lateral to the pubic tubercle and is 
more common in females. Inguinal hernias 
occur in similar frequency in females, but com- 
pared to femoral hernias, they are less likely to 
undergo strangulation. 

13. (D) This patient has a strangulated femoral 
hernia. Emergency surgery after appropriate 
resuscitation is the correct treatment. Gangrene 
of strangulated bowel may be present. No 
attempt at manual reduction should be made, 
because gangrenous bowel may be returned to 
the peritoneal cavity. 

14. (E) As many as 90% of umbilical herniae up to 
1.5 cm in diameter will not be clinically evi- 
dent by the age of 5 years. 

15. (A) Strangulation of a bowel loop may occur at 
the obturator fossa, classically following weight 
loss, which results in loss of the fat pad that 
covers the area, superiorly, where the obturator 
membrane is deficient. This allows entry and 
strangulation of a bowel loop. Compression of 
the obturator nerve causes the pain down the 
medial side of the thigh. CT scan with contrast 
may show the level of obstruction. 




Figure 8-5. 

Radiograph shows large swelling due to gastroschisis. 
(A: Multiple loops of bowel lying on the right side and outside 
of the abdomen. B: Bowel loops wrapped in synthetic bag to 
reduce bowel sequentially.) 

16. (E) Epigastric hernia is a defect in the linea alba 
between the umbilicus and the xiphisternum. It 
usually contains preperitoneal fat rather than 
omentum or bowel. It may cause pain and is 
commonly encountered in older patients. 
Sometimes it is located on either side of the 
midline. Spigelian hernia occurs lateral to the 
linea semilunaris. 



Answers: 8-21 



195 



17. (A) Repair can be performed laparoscopically, 
under general anesthesia, following adequate 
preoperative medical preparation. Patients are 
more comfortable following adequate repair. 
Modern mesh is of much improved quality and 
recurrence has become much less common. 

18. (E) The lateral femoral cutaneous nerve is vis- 
ible in the laparoscopic approach to hernia 
repair. This nerve can be injured in placement 
of the mesh used for repair, especially if staples 
are used. Great care must be taken to avoid 
this injury, which causes severe burning pain 
and paresthesia of the thigh and is very dis- 
abling. Injury is not likely if staples are not 
inserted lateral to the deep inguinal ring. 

19. (D) In omphalocele (see Fig. 8-5), the swelling 
is covered by a membrane formed by the peri- 
toneum, Wharton's jelly, and amnion. The 
membrane is transparent, and underlying 
intestine can be seen. The other features listed 
are characteristic of gastroschisis. In gas- 
troschisis, the protrusion is not covered by a 
membrane and the other features listed apply 



20. (D) Spigelian hernia occurs at the semilunar 
line, which extends along the lateral border of 
each rectus abdominis muscle. The posterior 
rectus sheath is deficient at the level of the arcu- 
ate line (semicircular line) about one-third of the 
distance between the umbilicus and the pubic 
symphysis; this is the most common site for 
Spigelian hernia to occur through the linea semi- 
lunaris. It occurs in both sexes. The Bassini tech- 
nique refers to inguinal hernias only. A hernia 
that involves part of the bowel wall is known as 
a Richter's hernia. The appendix may or may 
not form part of the contents of the sac. 

21. (B) Patients who have symptoms suggestive 
of change in bowel habits will require a barium 
enema or colonoscopy. It is important not to 
overlook an underlying carcinoma, which 
could cause the patient to strain and induce a 
hernia. Carcinoma and/or polyps may be over- 
looked if this approach is ignored. 



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CHAPTER 9 



Male and Female Genitourinary 

Systems 

Sean Fullerton and Albert Samadi 

Questions 



DIRECTIONS (Questions 1 through 59): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 

Questions 1 and 2 

1. A 62-year-old African American male attorney 
presents to a prostate-screening clinic during 
National Awareness Week. On careful ques- 
tioning, he has noted slight urgency frequency 
nocturia, and a decrease in the force of mic- 
turition. He is referred to have blood tests to 
include which of the following? 

(A) Carcinoembryonic antigen (CEA) 

(B) Prostatic acid phosphatase 

(C) Alkaline phosphatase 

(D) Prostate-specific antigen (PSA) 

(E) Lactic dehydrogenase (LDH) 

2. General examination from his urologist is non- 
contributory A rectal examination reveals hem- 
orrhoids and a left-sided irregular mass in the 
prostate. Following normal blood tests, he 
should have which of the following? 

(A) Computed tomography (CT) scan of the 
pelvis 

(B) Magnetic resonance image (MRI) of the 
prostate 

(C) Colonoscopy and biopsy of the prostate 
under general anesthetic 



(D) Biopsy of the nodule 

(E) Bone scan 

3. A 62-year-old postal officer develops minimal 
urinary symptoms. His PSA level is elevated 
and continues to increase during a 6-month 
period of observation. The next step in evalu- 
ation, if transrectal ultrasound (TRUS) prostate 
biopsy (Fig. 9-1) were positive for adenocarci- 
noma of prostate, would be: 

(A) Refer to oncologist for chemotherapy 

(B) Metastatic evaluation including CT and 
bone scans 

(C) Repeat PSA and biospy 

(D) Evaluation by radiation oncologist 

(E) Start hormonal ablation treatment 

4. Because of positive biopsy findings and nega- 
tive workup, he undergoes a radical prostate- 
ctomy. The pathology report reveals Gleason 
score 9/10 and involvement of several pelvic 
lymph nodes. Which is the most likely site for 
prostatic cancer metastasis? 

(A) Liver 

(B) Kidney 

(C) Lung 

(D) Bone 

(E) Brain 



197 



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198 



9: Male and Female Genitourinary Systems 




7.0 r* 
IFOCL 1-6 Cr- 

Itransverse 

" SUPINE/PROr 

Istep 0.5 cc 

STEP INC. 
STEP DEC. 
WRITE 
ERASE 




(Reproduced, with permission, from Doherty GM: Current Surgical Diagnosis & Treatment, 12th ed. 1047. McGraw-Hill, 2006 



Figure 9-1. 

Transrectal ultrasound of the prostate. Sagittal plane showing large hypoechoic prostate cancer at arrows. (Reproduced, 
with permission, from Way LW: Current Surgical Diagnosis & Treatment, 10th ed. Appleton & Lange, 1994.) 



5. A 79-year-old man is examined for severe pain 
in the iliac crest. Metastatic disease from pro- 
static cancer is confirmed. What is the treat- 
ment offered initially to most patients with 
metastatic prostatic cancer? 

(A) Cortisone and pituitary ablation 

(B) Radical prostatectomy 

(C) Luteinizing releasing hormone (LRH) 
agonist (Leuprolide) 

(D) Local irradiation and testosterone 

(E) Hyperthermia 

6. During her eighth month of pregnancy, a 
29-year-old woman is noted to have polyhy- 
dramnios. Further testing shows anencephalus. 
Polyhydramnios in this patient is caused by 
which of the following? 

(A) Impairment of the fetus's swallowing 
mechanism 

(B) Tumor of the fetus's brain 

(C) A secretory peptide from the placenta 

(D) Excess antidiuretic hormone (ADH) 
from the fetus 

(E) Renal agenesis 

7. Several weeks after lifting a heavy object, a 
previously healthy 34-year-old man continues 
to complain of heaviness in his left groin. 
Which of the following statements is true of 
testicular cancer? 



(A) It is the most common solid tumor in 
men over 50 years of age. 

(B) It is not associated with a higher 
incidence of infertility. 

(C) It presents as a painless mass in the 
scrotum in more than 70% of patients. 

(D) It accounts for 10% of malignant tumors 
in men. 

(E) It rarely metastasizes. 

During a workup for infertility, a 34-year-old 
man is noted to have a solid tumor in the ante- 
rior aspect of his right testis. What is the most 
likely diagnosis? 

(A) Torsion of the testis 

(B) Cyst of the epididymis 

(C) Lipoma of the cord 

(D) Cancer of the testis 

(E) Epididymo-orchitis 

Improved survival after lymphadenectomy for 
testicular tumors occurs after which of the fol- 
lowing? 

(A) Seminoma 

(B) Embryonal cell carcinoma 

(C) Ley dig cell tumor 

(D) Sertoli cell tumor 

(E) Lymphoma 



Questions: 5-17 



199 



10. A 38-year-old woman presents with shortness 
of breath and abdominal distention. Workup 
reveals presence of ascites and hydrothorax. 
What is the name of this condition? 

(A) Brenner tumor 

(B) Dysgerminoma 

(C) Wolffian duct remnant 

(D) Krukenberg's tumor 

(E) Meigs's syndrome 

11. A 41-year-old man requests information con- 
cerning vasectomy for sterilization. In this 
prcedure, which of the following statements 
is true? 

(A) The incidence of sexual dysfunction is 
not influenced in those with dependent 
personalities. 

(B) The success rate in reestablishing 
continuity of the vas deferens is greater 
than 80% at 10 years. 

(C) The failure rate occurs in 1/400 patients. 

(D) Recanalization of the vas deferens does 
not occur. 

(E) The procedure is difficult and requires 
laparotomy. 

12. A 6-month-old boy was born with hypospa- 
dias. This condition is due to failure in the 
development of which of the following? 

(A) Urogenital fold 

(B) Mullerian system 

(C) Genital tubercle 

(D) Urachus 

(E) Vitelline duct 

13. A 64-year-old woman notes an ulcer on her left 
labia majora. Biospy reveals squamous cell car- 
cinoma. What is the treatment? 

(A) Wide local excision 

(B) Radiotherapy 

(C) Preoperative radiotherapy followed by 
wide local excision 



(D) Wide excision and unilateral groin 
dissection 

(E) Radical vulvectomy and bilateral groin 
dissection 

14. A 6-year-old healthy appearing girl is brought 
for evaluation of bloody vaginal discharge. The 
most likely diagnosis is: 

(A) Squamous cell carcinoma 

(B) Sarcoma botryoides 

(C) Carcinosarcoma 

(D) Clear cell adenocarcinoma 

(E) Lymphoma 

15. A healthy appearing, 8-year-old boy is evalu- 
ated for an abdominal mass, felt by his mother 
during a bath. What is the most likely diagnosis? 

(A) Lymphoma 

(B) Rhabdomyoscarcoma 

(C) Wilms' tumor 

(D) Neuroblastoma 

(E) Renal cell carcinoma 

16. In repair of a third-degree perineal laceration, 
which structure shown in Fig. 9-2 is least likely 
to be divided? 

(A) Bulbocavernosus muscle 

(B) Vaginal mucosa 

(C) Superficial transverse perineal lmuscle 

(D) External anal sphincter 

(E) Ischiocavernosus muscle 

17. A 24-year-old man had been treated for gonor- 
rhea 2 months previously. He developed an 
ulcerative lesion in the glands of the penis that 
is noted to be condylomata lata. The etiology of 
condylomata lata is which of the following? 

(A) Mixture of organisms 

(B) Haemophilus ducreyi 

(C) Herpesvirus hominis, type II 

(D) Treponema pallidum 

(E) Neisseria gonorrhoeae 



200 



9: Male and Female Genitourinary Systems 



Ischiocavernosus 
muscle 



Bulbocavernosus 
muscle 



Bulb of 
vestibule 



Adipose 
tissue 



External 

anal 

sphincter 



Anococcygeal 
ligament 




Superficial 
transverse 
perineal 
muscle 



Levator 
ani muscle 



Gluteus maximus 
muscle 



Coccyx 

Figure 9-2. 

Skin and subcutaneous tissues removed to reveal structures in perineum. (Reproduced, with permis- 
sion, from DeCherney AH et a!.: Current Diagnosis & Treatment Obstetrics & Gynecologic, 10th ed. 
McGraw-Hill, 2007.) 



18. A 23-year-old woman has a cesarean section in 
which a Pfannenstiel incision (Fig. 9-3) is used. 
In the Pfannenstiel incision, which of the fol- 
lowing is TRUE? 

(A) The recti and fascia are separated 
transversely. 

(B) The recti and fascia are separated 
vertically. 

(C) Fascia lata graft is used. 



(D) A prosthetic graft is used. 
The uppe 
explored. 



/\ prostnetic gratt is usea. 
(E) The upper abdomen can readily be 
exolored. 



19. 




20. 



21. 



Figure 9-3. 



Pfannenstiel incision. 



What is the most common cause of failure of 
radiotherapy for stage II cervical carcinoma? 

(A) Liver metastasis 

(B) Bone metastasis 

(C) Para-aortic node metastasis 

(D) Resistance of the central tumor 

(E) Undifferentiated tumor histology 

Twelve years after menopause, a 60-year-old 
woman undergoes laparotomy for an ovarian 
carcinoma. The ovarian tumor that is most 
likely to respond to radiotherapy is which of 
the following? 

(A) Dysgerminoma 

(B) Krukenberg's tumor 

(C) Arrhenoblastoma 

(D) Granulosa cell tumor 

(E) Brenner tumor 

A 24-year-old woman has been unsuccessful 
becoming pregnant. She is admitted with abdom- 
inal pain; her blood pressure is 90/60 mm Hg, 



Questions: 18-27 



201 



her pulse rate is 102 beats per minute (bpm), and 
her hematocrit (HCT) is 28%. Features of ectopic 
pregnancy include which of the following? 

(A) Elevated blood pressure on assuming an 
erect position 

(B) Pulsus paradoxus 

(C) Tenderness below the right subcostal 
margin (Murphy's sign) 

(D) Pain referred to the supraclavicular 
region 

(E) Ecchymosis around the umbilicus 

22. After undergoing a partial cystectomy for car- 
cinoma of the rectum, a 76-year-old woman 
develops a vesicovaginal fistula. The repair will 
have a higher chance of success if which of the 
following occurs? 

(A) Scare tissue is not excised 

(B) The bladder wall is closed under tension 

(C) Repair is performed more than 

6 months after the causative operation 

(D) Repair is performed within 7-14 days of 
the onset of symptoms 

(E) Urethral catheters removed within 7 days 

23. After being treated for ovarian carcinoma, a 
65-year-old woman develops complications 
attributed to cisplatin (czs-diamminedichloro- 
platinum). What is a common side effect of 
cisplatin? 

(A) Multiple lipoma 

(B) Ankylosing spondylitis 

(C) Megaloblastic anemia 

(D) Pulmonary fibrosis 

(E) Peripheral neuropathy 

24. A 33-year-old woman is seen for evaluation of 
infertility. She complains of dyspareunia. On 
vaginal examination, tender nodularity along 
the uterosacral ligaments is noted. What is the 
diagnosis? 

(A) Adenomyosis 

(B) Diethylstilbestrol (DES)-related disease 

(C) Subserosal fibroids 



(D) Endometriosis 

(E) Adrenogenital syndrome 

25. Following a radical nephrectomy, a 60-year- 
old, diabetic male develops necrotizing fasci- 
itis. After treating the infection, the plastic 
surgeon places an omental graft, which is based 
on blood supply from which of the following? 

(A) Omental branch of the abdominal aorta 

(B) Middle colic artery 

(C) Gastroepiploic artery 

(D) Middle sacral artery 

(E) Epigastric artery 

26. An otherwise healthy, 30-year-old man is 
brought to the emergency department after 
being thrown off the back of a motorcycle. 
During the assessment, blood is noted at the 
urethral meatus. Which of the following state- 
ment is TRUE? 

(A) A foley catheter should be inserted 
immediately. 

(B) Dislocation of the sacroiliac joint is 
usually associated with a fracture of the 
pubic ramus or separation of the 
symphysis. 

(C) Open lavage is a useful indication for 
the need to perform laparotomy. 

(D) Fracture of the coccyx requires surgical 
excision in most patients. 

(E) Pain is relieved on walking. 

27. A 62-year-old woman with cardiac disease 
undergoes a pudendal nerve block to remove a 
tumor from the vulva. Fibers forming the 
pudendal nerve originate from which of the 
following? 

(A) L2-L4 

(B) L3-L5 

(C) L4, L5, SI 

(D) S1-S3 

(E) S2-S4 



202 



9: Male and Female Genitourinary Systems 



28. 



29. 



A 42-year-old man has recurrent cystitis. 
Cystoscopic examination and biopsy confirm 
the presence of locally muscle invasive (T2) 
carcinoma of the bladder (Fig. 9—4)? 

(A) Repeat cystoscopic resection 

(B) Cystoscopic fulguration 

(C) Partial cystectomy 

(D) Radical cystoprostatectomy 

(E) Radiotherapy 



30. 




31. 



32. 



Figure 9-4. 

Excretory urogram showing space-occupying lesion 
(transitional cell carcinoma) on the left side of the blad- 
der. The upper tracts are normal. (Reproduced, with per- 
mission, from Doherty GM: Current Surgical Diagnosis 
and Treatment, 12th ed. 1043. McGraw-Hill, 2006.) 



A healthy, 45-year-old woman undergoing 
abdominal hysterectomy and salpingo- 
oophrectomy for benign disease. The right 
ureter is accidentally cut. To minimize injury to 
the ureter, the surgeon should recognize what 
about this structure? 

(A) It enters the pelvis at the level of the 
aortic bifurcation. 

(B) It passes posterior to the iliac vessels. 

(C) It passes above the uterine artery. 



33. 



(D) It enters the pelvis 4-cm medial to the 
bifurcation of the common iliac artery. 

(E) It enters the pelvis immediately distal to 
the common itiac artery bifurcation. 

A 56-year-old woman is admitted to the 
emergency department complaining of upper 
abdominal pain. An ultrasound of the abdomen 
reveals a thin-walled gallbladder filled with fluid 
and a solid, left renal mass. What should be the 
next test ordered? 

(A) Hydroxy iminodiacetic acid (HIDA) 
scan 

(B) Intravenous pyelogram (IVP) 

(C) CT scan of the abdomen and pelvis 

(D) Oral cholecystogram 

(E) Upper gastrointestinal (GI) series 

A kidney graft between identical twins is likely 
to survive for which period of time? 



(A) 


1-6 weeks 


(B) 


7-52 weeks 


(C) 


1-10 years 


(D) 


11-25 years 


(E) 


more than 25 years 



A 32-year-old woman with chronic renal failure 
undergoes successful renal transplantation. 
Tests carried out after the operation indicates 
the presence of cytomegalovirus (CMV). What 
is TRUE of this condition? 

(A) It cannot be measured by 
immunofluorescent assay. 

(B) It is detected in most patients after 
surgery. 

(C) It should not cause additional problems 
with regard to tissue rejection. 

(D) It results in infection that usually is fatal. 

(E) CMV infection occurs only in CMV 
positive donor. 

A 4-year-old girl has a yellow, blood-tinged, 
foul-smelling, vaginal discharge. On examina- 
tion, the external genitalia are red, and a mal- 
odorous, blood-tinged discharge is noted. The 
most likely cause of these findings are: 



Questions: 28-40 



203 



(A) Chlamydia trachomatis 

(B) Gonorrhea 

(C) Treponema 

(D) Foreign body 

(E) Vaginal cancer 

34. A 46-year-old man is on a waiting list to secure 
a renal transplant. The genetic locus of trans- 
plant antigens in humans is known as which? 

(A) Rhesus (Rh) 

(B) Ig (Immunoglobulin) A and IgM 

(C) Human leukocyte antigen (HLA) 

(D) ABO 

(E) Hepatitis B surface antigen (HBsAg) 

35. A 64-year-old man underwent transplantation, 
which was complicated by graft-versus-host 
reaction. He had undergone a transplantation 
of which of the following? 

(A) Kidney 

(B) Skin 

(C) Bone marrow 

(D) Cornea 

(E) Liver 

36. In evaluating the role of the autonomic nervous 
system related to urinary incontinence that 
developed in a 67-year-old man after prostate- 
ctomy, it is determined that the sympathetic 
nerves are injured. What is the natural hor- 
mone in the catecholamine pathway? 

(A) Norepinephrine 

(B) Dopamine 

(C) Vasoactive intestinal peptide (VIP) 

(D) Isoproterenol 

(E) Acetylcholine 

37. During evaluation of the cause of varicocele in 
a 36-year-old man, attention is directed to the 
method of drainage of the left testicular vein, 
which usually enters which of the following? 



(A) Left adrenal vein 

(B) Left renal vein 

(C) Left inferior mesenteric vein 

(D) Inferior vena cava (IVC) 

(E) Left inferior epigastric vein 

38. A 42-year-old man presents with cancer of 
the left testis. To exclude lymphatic metasta- 
sis, which is the site that should be initially 
examined? 

(A) Vertical chain of inguinal glands 

(B) Horizontal chain of inguinal glands 

(C) Retrorectal glands 

(D) Para-aortic glands 

(E) Obturator nodes 



39. 



As a result of a motor vehicle crash, a 42-year- 
old female has a pelvic fracture, confirmed on 
x-ray of the pelvis. What does she require? 

(A) Surgical repair under local anesthesia 

(B) Open lavage and, if positive, immediate 
laparotomy 

(C) Immobilization of the pelvis in a plaster 
cast 

(D) Analgesics and observation 

(E) Skeletal traction 



40. A 42-year-old woman involved in a traffic acci- 
dent presents to the emergency room com- 
plaining of flank pain and gross hematuria, she 
is hemodynamically stable. The next step in 
management is: 

(A) Exploratory laparotomy 

(B) Open lavage and, if positive, immediate 
laparotomy 

(C) Immobilization of the pelvis 

(D) Computed axial tomography (CAT) scan 
with the use of intravenous contrast 

(E) Skeletal traction 



204 



9: Male and Female Genitourinary Systems 



41. A 62-year-old woman with metastatic cancer 
had mild chronic renal disease. Renal excre- 
tion of antineoplastic drugs is least likely to be 
affected by which of the following? 

(A) Nonsteroidal anti-inflammatory drugs 
(NSAIDs) 

(B) Probenecid 

(C) Aspirin 

(D) Alkalinizing urine 

(E) Aminoglycosides 

42. A 62-year-old farmer had received chemother- 
apy for cancer of the head and neck. He has 
developed classical multidrug resistance (MDR) 
to which of the following? 

(A) Alkylating agents 

(B) Antimetabolites 

(C) Bleomycin 

(D) Vinca alkaloid 

(E) Cyclosporine 

Questions 43 and 44 

A 32-year-old female has chronic pyelonephritis with 
chronic renal failure. She is scheduled to have a renal 
transplantation. The donor kidney will be obtained 
from her brother-in-law, and left laparoscopic 
nephrectomy is planned. The donor kidney operation 
will be performed in a separate operating room 
under general anesthesia. 

43. Where will the donor kidney be placed? 

(A) In the groin 

(B) Right iliac fossa 

(C) At site of bifurcation of aorta 

(D) Into the portal system 

(E) Inferior vena cava 

44. With reference to the donor kidney which of 
the following statement is TRUE? 

(A) The left side is preferred, because the 
left renal artery is larger than that on the 
right. 

(B) The left renal vein passes posterior to 
the aorta. 



(C) Renal arteries are end arteries. 

(D) Anomalous arteries are a contraindication 
for elective use in transplantation. 

(E) Renal fascia separates segments of 
kidney. 

45. A 64-year-old male is admitted to the emer- 
gency department following a car accident. His 
pulse is 94 bpm, blood pressure 95/60 mm Hg, 
and HCT 30%. Severe hematuria is evident. 
Following resuscitation, his blood pressure is 
elevated to 120/80 mm Hg. A CT scan reveals 
extensive contusion confined to the left kidney 
and perirenal fat. His blood pressure declines 
to 80/40 mm Hg, and urgent laparotomy is 
performed via? 

(A) Through a left flank incision 

(B) Through a midline abdominal incision 

(C) Through an Gibson incision 

(D) Through a thoracoabdominal incision 

(E) Through an inguinal incision 

46. A 42-year-old male presents with a solid swelling 
in the left testis of 2-month duration. Biopsy 
reveals this to be a Leydig cell tumor. The func- 
tion of the Leydig cell is to produce what? 

(A) Follicle-stimulating hormone (FSH) 

(B) Inhibin 

(C) Testosterone 

(D) Luteinizing hormone (LH) 

(E) Progesterone 

47. A 63-year-old male has had declining ability to 
achieve an erection over the past 18 months. 
He received a prescription of sildenafil (Viagra), 
which works via which route? 

(A) It prevents the breakdown of cyclic 
guanosine monophosphate (cGMP). 

(B) It is a nonspecific inhibitor of 
phosphodiesterase. 

(C) It stimulates the production of nitric 
oxide, a gaseous neurotransmitter. 

(D) It enhances proerectile signaling in the 
brain. 

(E) It inhibit phosodiesterase (PDE)-2. 



Questions: 41-53 



205 



48. A 65-year-old male patient complains of loss of 51. 
libido and is found to have a low free and total 
testosterone level. Treatment is commenced 

with testosterone supplemental therapy. What 
is the next step in management after testos- 
terone administration? 

(A) Check PSA levels 

(B) Testosterone levels are decreased 

(C) Decrease in size of benign prostatic 
tissue lesions occurs 

(D) Decrease in size of prostatic cancer occurs 

(E) Anemia occurs 

49. A 45-year-old male CIA employee presents 

with a 3-week history of a tumor in the scro- 52. 

turn. The patient has a known history of dia- 
betes controlled by diet. There is minimal 
discomfort. On examination, the lesion is 
located posteriorly and does not transillumi- 
nate to light. Both testes are clinically normal. 
What is the most likely diagnosis? 

(A) Spermatocele 

(B) Teratoma 

(C) Adenomatoid lesion of the epididymis 53 

(D) Varicocele 

(E) Torsion of a testicular appendiceal cyst 

50. A 63-year-old man undergoes a peripheral vas- 
cular procedure under general anesthesia. A 
decrease in urine formation and excretion are 
noted. Decreased urine flow under general anes- 
thesia occurs because of which of the following? 

(A) Vasopressin 

(B) Aldosterone suppression 

(C) Depression of glucocorticoid 

(D) Depression of thyroid function 

(E) Specific effect of anesthesia on renal 
tubules 



A 32-year-old athletic long distance runner 
complains of severe pain in the left flank. 
There is no radiation of the pain to the groin. 
Examination reveals mild tenderness in the left 
flank. Investigations confirm the presence of 
renal calculi. The stone is most likely which of 
the following? 

(A) Cystine 

(B) Ammonium magnesium phosphate 
(struvite) 

(C) Calcium oxalate 

(D) Uric acid 

(E) Calcium phosphate 

What characteristic of struvite (ammonium 
magnesium phosphate) stones makes antibiotics 
ineffective when treatment is being performed? 

(A) Resistant bacteria 

(B) Poor excretion of antibiotics 

(C) Ineffective antibiotics 

(D) Bacteria inaccessible to antibiotics 

(E) Antibiotics inactivated by the stone 

Following nonsurgical management of the 
stone, the patient is readmitted with severe col- 
icky pain radiating to the left groin. There is 
minimal tenderness in the left abdomen. An x- 
ray shows a stone in the ureter at the level of 
the L-5 vertebra. Surgical intervention should 
be considered for which reason? 

(A) For all ureteric stones 

(B) If analgesics are required 

(C) If urinary tract infection is present 

(D) For uric acid stones 

(E) If impaired renal function occurs 



206 



9: Male and Female Genitourinary Systems 



Questions 54 and 55 

A 42-year-old female seeks advice concerning dys- 
pareunia, dysuria, and urinary incontinence. 
Symptoms were mild for the past 3 years but have 
become more troublesome in the past 6 months. 
She has had five full-term deliveries. Symptoms 
are worse with coughing and sneezing. Pelvic exam 
reveals a suburethral mass, which is confirmed on 
transvaginal sonogram. 

54. Which of the following statements is true con- 
cerning this condition? 

(A) It occurs in 5% of woman over the age 
of 50. 

(B) It is most likely due to interstitial cystitis. 

(C) It causes urgency incontinence if due to 
a urinary fistula. 

(D) It is suggestive of a urethral diverticulum 
if a suburethral mass is present. 

(E) Kegel pelvic muscle exercises would 
aggravate this condition. 

55. Treatment for urinary incontinence for this 
41-year-old involves which of the following? 

(A) Should exclude Kegel pelvic muscle 
exercises 

(B) Kegel pelvic muscle exercises, involving 
exclusively the thigh and abdominal wall 
muscles 

(C) Is by routine hysterectomy 

(D) Includes cholinergic drugs 

(E) Is by transabdominal or transvaginal 
surgical repair 

56. A 32-year-old female had been unable to become 
pregnant for 6 years. Three weeks previously, 
she missed her period. She was admitted to hos- 
pital with left-side lower abdominal pain and 
nausea. Her B subunit human chorionic 
gonadotropin (HCG) and pelvic ultrasound con- 
firms an ectopic pregnancy. Treatment includes 
which of the following? 

(A) Immediate laparotomy and 
salpingectomy 

(B) If unruptured, the fallopian tube should 
be spared 



(C) Avoid incidental appendectomy 

(D) If stable, avoid surgery 

(E) Transfer embryo to uterus 

57. A 34-year-old woman who is G4P2 complains 
of abdominal pain, nausea, and vomiting. 
During her first trimester of pregnancy, labo- 
ratory findings reveal elevated levels of Bata 
HCG (>100,000 mlU/dL) and pelvic ultra- 
sound shows a "snowstorm" appearance. 
Which of the following statements is TRUE 
about gestational trophoblastic disease? 

(A) It always leads to malignancy. 

(B) It is more common in multiple pregnancy. 

(C) Gestational trophoblastic disease has 
complete moles that are diploid and 
have a 20% risk of malignancy. 

(D) Gestational trophoblastic disease has 
partial moles that are triploid and 
always undergo neoplasia. 

(E) Gestational trophoblastic disease with 
hydatiform mole is then treated by 
hysterectomy. 

58. Which of the following changes would be most 
consistent with the diagnosis of choriocarci- 
noma? 

(A) Increased B-HCG 

(B) Increased alpha-fetoprotein (AFP) 

(C) Increased thyroid-stimulating hormone 
(TSH) 

(D) Decreased AFP 

(E) Decreased thyroxine (T4) 

59. In evaluating the menstrual cycle, which is 
TRUE? 

(A) Estrogen secretion predominates during 
week prior to menstruation. 

(B) Ovulation follows a surge in LH. 

(C) Progesterone predominates the first 
week after menstruation. 

(D) FSH is released at midcycle. 

(E) Basal body temperature raises during 
mild follicular phase. 



Questions: 54-67 



207 



DIRECTIONS (Questions 60 through 70): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. Each lettered option 
may be selected once. 

Questions 60 through 63 



(A 
(B 
(C 
(D 
(E 
(F 
(G 
(H 
(I 
(J 



Ulcerative colitis 
Rheumatoid arthritis 
Hemolytic anemia 
Cancer of the thyroid 
Crohn's disease 
Behcet's syndrome 
Glomus tumor 
Renal agenesis 
Granuloma inguinale 
Schistosomiasis (Bilharzia) 



60. A 44-year-old woman complains of pain in the 
perineum. On vaginal examination, she is noted 
to have a 2-cm ulcer on the posterior wall of the 
vagina. The most likely cause of vulvar ulcer 
with associated perineal fistula and/or a weep- 
ing pustular lesion is? SELECT ONE. 

61. A 45-year-old man presents with two painless 
beefy red ulcers in the inguinal region, a biopsy 
and Giemsa stain reveal Donovan bodies, these 
findings are most consistent with? SELECT ONE. 

62. A 35-year-old male presents with painful oral 
ulcers, photophobia and hazy vision along with 
ulcers of the penis and scrotum, he has been 
treated with topical corticosteroids which pro- 
vide temporary symptomatic relief, his symp- 
toms are most consistent with? SELECT ONE. 

63. A 65-year-old man from Egypt presenting with 
gross hematuria is diagnosed with squamous 
cell carcinoma of the bladder. The most likely 
cause is? SELECT ONE. 

64. A 46-year-old man has a swelling in the scro- 
tum. It shows clear transillumination anterior 



to the testis when a light is applied to the scro- 
tum in a dark room. This physical exam is most 
consistent with? 

(A) Cyst of the epididymis 

(B) Torsion of testis 

(C) Hydrocele 

(D) Direct inguinal hernia 

(E) Hematocele 

65. A 25-year-old male diagnosed with testicular 
cancer undergoes radical orchiectomy followed 
by retroperitoneal lymphadenectomy com- 
plains of azoospermia, his symptoms ae most 
likely secondary to? 

(A) Impotence 

(B) Failure of ejaculation 

(C) Loss of sensation in the scrotum 

(D) Absent bulbocavernous reflex 

(E) Splanchnic nerve denervation 

66. A 20-year-old female complains of vaginal bleed- 
ing. Diagnostic workup reveals clear cell adeno- 
carcinoma of the vagina. A maternal history 
should be obtained for use of? 

(A) Thalidomide 

(B) OralDES 

(C) Loss of sevsation in the scrotum 

(D) absent bulbocavernous refl 

(F) Richter's hernia 

(G) torsion of testis 

(H) Fournier's gangrene of the scrotum 

67. A 42-year-old premenopausal woman noted to 
have a questionable pelvic mass on examina- 
tion. Ultrasound revealed a small left ovarian 
cyst. Plan x-rays show no evidence of calcifi- 
cation. The most likely cause is? 

(A) Hydatid cyst 

(B) Psuedocyst 

(C) Corpus luteum 

(D) Dermoid cyst 

(E) Granulosa-theca cell tumors 



208 



9: Male and Female Genitourinary Systems 



68. A 55-year-old man with history of alcohol abuse 
recently started on oral medication for benign 
prostatic hyperplasia, after several weeks of use 
he complains of decrease in his semen volume. 
Which of the following medications is respon- 
sible for ejaculatory dysfunction? 

(A) Doxazosin 

(B) Finasteride 

(C) Tamsulosin 

(D) Dutasteride 

(E) Alfuzosin 

69 . A 65-year-old man with history of hypertension 
(blood pressure-130/90 mm Hg) is recently 
diagnosed with benign prostatis hyperplasia. 
Which of the following a-blockers does not 
lower blood pressure in men and uncontrolled 
hypertensison 



(A) Terazosin 

(B) Doxazosin 

(C) Tamsulosin 

(D) Prazosin 

(E) Phenoxybenzamine 

70. A 75-year-old man with history of benign pro- 
static hyperplasia, hypertension, and diabetes, 
on finasteride (proscar) for 2 years with a PSA 
level of 4 ng/mL would most likely if he were 
not taking finasteride, have a PSA value of: 



(A) 
(B) 
(C) 
(D) 

(E) 



2 ng/mL 
6 ng/mL 
8 ng/mL 
12 ng/mL 
4 ng/mL 



Answers and Explanations 



1. (D) According to American Cancer Society, all 
men over the age of 50 years should undergo 
annual PSA measurement and digital rectal 
examination (DRE). This recommendtion is fur- 
ther supplemented by the guidelines from 7. 
American Urological Association to start screen- 
ing 10 years earlier in high-risk individuals (Cau- 
casians with family history of prostate cancer 

and African Americans). 

2. (D) At any time during prostate cancer screen- 
ing, if either the PSA or the DRE is abnormal, 
recommendation is referral to a urologist to 
perform TRUS guided biopsy of prostate. 

3. (B) Typical workup after a positive TRUS biopsy 8. 
would be evaluating the common metastatic 

sites (pelvic lymph nodes and bone). CT scan of 
abdomen and pelvis with and without contrast 
is performed to also rule out other GU abnor- 
malities (i.e., renal mass, renal stone, and so forth) 
in addition to pelvic lymphadenopathy Bone 
scan, however, is typically not indicated for PSA 
<20 mg/mL. 

9. 

4. (D) Bone metastasis is a characteristic feature 
of prostatic cancer. The lesions are typically 
osteoblastic on x-ray, and the serum acid phos- 
phatase level becomes elevated. 

5. (C) Previously, androgen ablation was achieved 
by bilateral orchiectomy. However, total andro- 
gen ablation is accomplished by oral adminis- 10. 
tration of antiandrogens for 2 weeks followed 

by injection of LRH angonist. 

6. (A) Anencephalus is due to failure of the cephalic 
part of the neural tube to close off. This condition 



happens in 1/1000 pregnancies, is four times 
more common in whites than blacks, and is four 
times more common in females than males. 

(C) Testicular cancer accounts for 1-2% of all 
malignant tumors in men. There are two cate- 
gories of testicular tumors — lymphomas 
(which occur in individuals <10 or >50 years of 
age) and nonhematogenous tumors, that is 
germ cell and nongerm cell tumors (which 
occur in 15-35 year old individuals). Typically, 
the patient presents few weeks or months after 
a vague recollection of heavy activity or local 
trauma. 

(D) Nonhematogenous testicular tumors are 
divided into two categories — germ cell tumors 
(seminoma, nonseminoma, i.e., embryonal, 
choriocarcinoma, teratoma, teratocarcinoma, 
yolk sac tumors) and nongerm cell tumors 
(Ley dig cell or Sertoli cell). There is no mass 
within the testis with torsion. Epididymitis 
presents within painful tender testis. 

(B) Embryonal cell carcinoma should be treated 
by retroperitoneal lymph node dissection 
(RPLND), if tumor is not spread beyond peri- 
toneal cavity. About 30% of patients will have 
lymph node metastasis at the time of diagnosis. 
Seminoma and embryonal cell carcinomas 
account for about 70% of all testicular tumors. 

(E) This patient is suffering from Meigs's syn- 
drome. Treatment would be removal of a benign 
ovarian fibroma. Brener tumor is a fibroepithelial 
tumor of the ovary with low -malignant potential. 
Dysgerminomas contain germ cells and infiltra- 
tion with lymphocytes. Krukenberg's tumor is 



209 



210 



9: Male and Female Genitourinary Systems 



metastasis of a primary alimentary tract adeno- 
carcinoma to the ovary. 

11. (C) The failure rate of 1/400 patient has been 
reported. Since there is no alteration in the level 
of testosterone production, there is no reported 
sexual dysfuntion attributed to vasectomy. The 
success rate for reversal of vasectomy greatly 
depends on the time since the vasectomy was 
performed. Failure rates for vasovasostomy has 
been reported to be >80% after 10 years. 

12. (A) Embryologically the genital tubercule devel- 
ops into the penis. The edge of the cloacal mem- 
brane forms the urogenital fold and by the 
process of invagination forms the urethral 
groove and finally the penile urethera. The sever- 
ity of hypospadias depends on the location of the 
anomalous opening onto the penile urethra. The 
mildest degree is where the opening is on the 
glans and the most severe form at the peno- 
scrotal junction. 

13. (E) Similar to penile cancer, radical vulvectomy 
and bilateral groin dissection have improved 
survival in patients with carcinoma of the 
vulva. The deep and superficial nodes are 
removed. If the lymph nodes are not involved, 
the cure rate exceeds 70%. The overall survival 
is approximately 50%. Radiotherapy has not 
offered additional benefit pregnancy. 

14. (B) Sarcoma botryoides usually occurs as a 
grape-like polypoid mass in the vagina of young 
girls. Clear-cell adenocarcinoma occurs at an 
older age, in the second decade of life. It is asso- 
ciated with the aclrninistration of DES to patient's 
mother's during pregnancy. Squamous carci- 
noma is the most common tumor of the vagina 
in postmenopausal patients. However, malig- 
nant tumors of the vagina are rare in children. 

15. (C) Typically Wilms' tumor is noted in well 
appearing children in the second half of their 
first decade of life. These masses are usually 
felt or visually noted by parents during routine 
daily activities. Children with neuroblastoma 
are usually younger and appear quite sick. 
Although unlikely, renal cell carcinoma has 
been reported in children and diagnosis is only 



based on final pathology results. Lymphoma 
should be ruled out based on CT scan findings 
and subsequent needle-guided biopsy, since 
treatment is usually nonsurgical. 

16. (E) Ischiocavernous muscle is not involved in 
third degree perineal lacerations. This muscle 
originates at the ischial tuberosity and inserts at 
the base of the clitoris. 

17. (D) Condylomata lata are a manifestation of 
secondary syphilis. The treatment is intramus- 
cular injection of penicillin. They are distin- 
guished from condylomata acuminata; in that 
the latter are velvety and filiform in appear- 
ance and are result of infection with human 
papilloma virus (HPV). 

18. (B) In the Pfannenstiel incision, the rectus mus- 
cles and the peritoneum are separated in a ver- 
tical fashion after the skin is incised transversely. 

19. (C) In stage II cervical cancer, the incidence of 
nodal involvement is 25%-40%. Most tumors 
are not radioresistant, and distant metastasis 
(i..e., a more advanced stage) are a late compli- 
cation of more advanced stages of the disease. 

20. (A) Dysgerminoma (like seminoma in men) is 
very radiosensitive. The Krukenberg's tumor is 
a metastatic tumor to the ovary and is not 
treated by radiation. The other tumors are best 
treated by surgery. The Brenner tumor is most 
often a benign tumor. Arrhenoblastomas and 
granuloso cell tumors are hormone-producing 
tumors. 

21. (D) Free bleeding in the peritoneal cavity 
results in pain referred to the right supraclav- 
icular region due to diaphragmatic irritation. 
Patients who present with abdominal pain and 
(usually) a history of missed menstruation 
should undergo a pregnancy test after hospital 
admission. 

22. (C) Repair of vesicovaginal fistula is recom- 
mended after enough time has passed, to allow 
a reduction in the inflammatory reaction and 
even spontaneous closure to occur. To promote 
spontaneous closure, a Foley catheter is inserted 



Answers: 11-32 



211 



for bladder drainage. It is advised to perform 
meticulous repair, excision of previous fistulous 
tract, and tension-free anastomosis. Frequently 
an omental interposition helps to separate over- 
lapping suture lines. 

23. (E) Peripheral neuropathy, ototoxicity, and 
nephrotoxicity may be encountered following 
cisplatinum treatment. Nephrotoxicity can be 
minimized by hydrating the patient well prior 
and during the treatment. 

24. (D) Tender uterosacral ligament usually are a 
sign of endometriosis. Although the other con- 
ditions listed may be associated with some 
form of pelvic pain, they do not produce tender 
uterosacral ligaments. 

25. (C) The greater omentum is supplied by the 
right and left gastroepiploic arteries. There is 
no omental branch from the aorta. The middle 
sacral artery is a pelvic artery that does not 
supply the omentum, and the epigastric arter- 
ies supply the anterior abdominal wall. 

26. (B) Initially, advanced trauma life support 
(ATLS) protocol requires that airway, breathing, 
and circulation (ABC) to be maintained. Blood 
at the urethral meatus is an indication of lower 
urinary tract (bladder, urethra, penis) injury. 
Foley catheter should not be inserted until the 
integrity of urethra is assessed (usually by per- 
forming a retrograde urethrogram). Trauma x- 
ray panel includes a pelvic study to evaluate the 
extent of injury to to pelvic brim and pubic sym- 
physis. Fracture of the pubic rami or diastasis of 
pubic symphysis are commonly associated with 
dislocation of the sacroiliac joint as well as direct 
or indirect injury to the bladder and bulbous 
urethra. 

27. (E) The pudendal nerve is formed from the 
fibers of S2-S4. In males, this nerve supplies the 
scrotum and penis. In females, the clitoris, 
distal vigina, and more than 80% (posterior 
part) of the vulva are innervated by the 
pudendal nerve. Pudendal nerve block with 
local anesthetic infiltration may be offered to 
patients during vaginal delivery and /or repair 
of episiotomy 



28. (D) The main type of bladder cancer in this coun- 
try is trasitional cell carcinoma (TCC). Persistent 
irritative voiding symptoms in men and women, 
as well as microscopic hematuria, should prompt 
the physician to refer the patient for more 
detailed workup including cystoscopic evalua- 
tion. Any bladder lesion must be appropriately 
biopsied and removed (usually by either cold- 
cup biopsy and transurethral resection of bladder 
tumor [TURBT]). Muscle invasive bladder cancer 
is usually treated with radical cystoprostatec- 
tomy (in men) or anterior exenteration (in 
women). Extensive pelvic lymph node dissec- 
tion should be performed at the time of surgery 
for appropriate staging purposes. 

29. (E) It is very important to be familiar with the 
ureter's course in the pelvis, in order to be able 
to minimize injury to this structure during 
pelvic and colon operations. The ureter enters 
the pelvis immediately distal to the bifurcation 
of the common iliac artery. It then passes (pos- 
terior to the ovary) towards the bladder, where 
it travels inferior to the uterine artery (water 
under the bridge) — about 12 mm lateral to the 
cervix and upper vagina. 

30. (C) The ultrasound findings of the gallbladder 
are normal. However, the renal mass requires 
further imaging. Pre- and postcontrast CT scan 
of abdomen and pelvis will indicate if the 
tumor enhances and is thus more likely to be 
malignant. Hilar lymphadenopathy and possi- 
bility of metastatic disease can also be assessed. 

31. (E) Immunosuppression will not be required 
after grafting between identical twins (isograft). 
These grafts have survived the longest. Although 
with current immunosuppressive agents the sur- 
vival of renal allografts have improved, cadav- 
eric grafts still have the highest rejection rate 
followed by living unrelated, living related (par- 
ents and children), and siblings. 

32. (C) CMV infection may cause serious disease in 
immunosuppressed patients. In general, the 
CMV titer is elevated before transplantation in 
the recipient and only occasionally is attribued to 
transmission from the donor kidney. Although 
over one-half of patients with kidney allografts 



272 



9: Male and Female Genitourinary Systems 



have a positive CMV titer, only a small fraction 
develops serious disease. 

33. (D) The possibility of sexual assault must 
always be considered in the differential diag- 
nosis of a child presenting with an unexplained 
vaginal discharge. 

34. (C) HLA was one of the first studied antigens. 
The transplant antigen is located on the surface. 
The strongest transplant antigen is known as 
the major histocampatibility complex (MHC) 
and is found in humans on chronomosome 6. 
The higher the number of MHC matches, the 
better chance of survival for the allograft. 
However, zero MHC-matched grafts have been 
placed due to overwhelming demands. On the 
other hand, mismatch in ABO and Rh group 
results in hyperacute rejection are elevated. 

35. (C) Normal bone marrow cells are destroyed 
readily by drugs and ionizing irradiation; the 
red blood cell (RBC) stem cell in particular is 
sensitive to damage. The marrow is not 
destroyed by the host if transplanted into an 
immunosuppressed host. The transplanted bone 
marrow develops mature stem cells, which have 
immunologic competence that now reject those 
of the host (graft-versus-host reaction). Diarrhea, 
dermatitis, weight loss, and infection occur. 

36. (A) The metabolic pathway of catecholamines 
is initiated by conversion of tyrosine to dopa, 
which in turn, forms dopamine. Dopamine 
forms norepinephrine, which is the precursor 
of epinephrine. Epinephrine is the main amine 
secreted during life and is concerned with the 
"fight or flight" reaction. 

37. (B) The left testicular vein empties into the left 
renal vein, and the right testicular vein emp- 
ties into the IVC. Partial occlusion of the right 
renal vein is an uncommon cause of varicocele 
and may signify an associated retroperitoneal 
malignancy. 

38. (D) The right testis lymphatic drainage is to 
paracaval, interaortocaval, and para-aortic 
nodes. Lymphatic drainage is crucial to the 



understanding of metastatic spread of testicular 
cancer. The left testis drains mainly to the para- 
aortic and interaortic lymph nodes. However, 
crossover drainage from right to left is more 
common and, therefore, the right testis drains to 
paracaval, interaortocaval, preaortic, and para- 
aortic lymph nodes. The right testicular vein 
drains directly into the vena cava and the left 
vein into the left renal vein. Both testicular arter- 
ies arise from the aortia between the renal and 
mesenteric arteries. 

39. (B) The patient that has a hemoperitoneum fol- 
lowing a pelvic fracture need to be explored 
immediately. Surgical repair under local anes- 
thesia is not feasible nor is immobilization and 
a plaster cast. Anelgesics and observation 
might be possble if the patient were a child and 
a CAT scan revealed a clinical and a liver injury. 
Local traction would not be effective in stop- 
ping the bleeding. 

40. (D) In all patients in automobile accidents, the 
pelvis should be examined for local tenderness, 
and appropriate x-rays should be ordered 
when a fracture is suspected. Open lavage in 
fracture of the pelvis does not differentiate 
between a simple pelvic fracture and one asso- 
ciated with visceral injury. CAT scan with the 
use of intravenous contrast material is the pre- 
ferred imaging study for renal trauma. In all 
patients in automobile accidents, the pelvis 
should be examined for local tenderness, and 
appropriate x-rays should be ordered when a 
fracture of the pelvis does not differentiate 
between a simple pelvic fracture and one asso- 
ciated with visceral injury. 

41. (A) NSAIDs may decrease renal blood flow. 
Probenecid and aspirin inhibit excretion of 
methotrexate. 

42. (D) The hallmark of classic MDR is the develop- 
ment of cross-resistance to several drugs after 
exposure to a single drug such as dactinomycin, 
anthracycline, vinca alkaloid, or doxorubicin; the 
mechanism is a glycoprotein transmitter (Pgp) 
that is a result of the MDR-1 gene. Cyclosporine 
and verapamil block the effect of Pgp. 



Answers: 33-52 



213 



43. (B) In general, the left external iliac vessels of 
the recipient are chosen for anastomosis of the 
renal artery and renal vein of the recipient. The 
ureter of the donor kidney is anastomosed 
directly to the bladder. 

44. (C) In general, there are five segmental arter- 
ies supplying each kidney Segmental arteries 
are end arteries and, therefore, occlusion of a 
segmental will lead to infarction of the affected 
segment. The segmental arteries arise from the 
main renal artery. In about 70% of normal kid- 
neys, there is a single renal artery arising from 
the aorta to supply each kidney. In 30%, mul- 
tiple arteries arise from the aorta. In 10% of 
cases, there are at least two veins draining into 
the IVC on the right side. Duplication of 
venous drainage on the left side occurs much 
less frequently. The left renal vein passes ante- 
rior to the aorta and is of longer length, which 
offers advantage for the selection of the left 
kidney as a donor organ. If a kidney is in an 
abnormal location, vascular anomalies are 
encountered more frequently. 

45. (B) After entering the abdominal cavity the infe- 
rior mesenteric vein is isolated to the left of the 
fourth part of the duodenum and Treitz's sus- 
pensary ligament. An incision is made between 
the fourth part of the duodenum and the infe- 
rior mesenteric vein lateral to the aorta. This 
approach exposes the left renal hilum and allows 
early and accurate exposure and control of the 
left renal hilum. The approach allows exposure 
of the left kidney and enables the surgeon to 
determine if a renal repair or nephrectomy is 
needed. It also allows exposure to the opposite 
kidney. 

46. (C) LH released from the anterior pituitary 
acts on Ley dig cells to synthesize testosterone. 
Testosterone is a paracrine mediator and with 
FSH acts on the Sertoli cells to promote sper- 
matogenesis. Testosterone inhibits release of 
Gn RH from the hypothalamus. It also has a 
direct effect in preventing release of LH from 
the anterior pituitary. The Sertoli cells releases 
inhibin, which inhibits FSH secretion from the 
anterior pituitary. 



47. (A) Sildenafil citrate (viagra) is a selective 
inhibitor of PDE-5, the enzyme that breaks 
down cGMP. Sildenafil enhances the effect of 
nitric oxide on corporeal arterial and sinusoidal 
smooth muscle by inhibiting catabolism of 
cGMP by PDE-5. When nitric oxide enters a 
vascular smooth muscle cell it stimulates the 
enzyme guanylate cyclase to convert cGTP to 
cGMP 

48. (A) PSA levels can increase because both 
benign and malignant prostatic tissue are sen- 
sitive to testosterone (hormonal) therapy. There 
is increased prostatic growth with elevation of 
PSA and possible polycythemia. 

49. (C) Adenomatoid is the most common tumor 
of the epididymis. The epididymis is posterior, 
and a cyst of the epididymis transilluminates to 
light. A hydrocele also transilluminates, but it 
is anterior to the testis. A cyst of the testis is a 
remnant of the proximal part of the para- 
mesonephros (M tiller's) duct. In the presence 
of a normal FSH, testicular biopsy would most 
likely confirm normal sperm formation. 

50. (A) The ADH vasopressin (released from the pos- 
terior pituitary) is secreted to a large extent when 
a patient is under anesthesia. Thus, urine forma- 
tion is suppressed. The metabolic response to 
anesthesia and surgery tends to be retention of 
fluids; therefore, one must be careful to avoid 
administering large amounts of fluid to patients 
with early or overt heart failure during this period. 

51. (C) More than 70% of renal calculi are calcium 
oxalate stones. Nearly half of calcium oxalate 
stones contain phosphate in addition to oxalate. 
Calcium containing stones are radiopaque and 
can be visualized on plain x-rays. Struvite 
(ammonium magnesium phosphate) and cys- 
tine stones may also be radiopaque. 

52. (D) Bacteria inaccessible to antibiotics. Stuvite 
calculi harbor infective bacteria within their 
interstices. Effective therapy must be directed 
to eradicate associated infection. Struvite stones 
are the second most common type of renal cal- 
culi after calcium oxalate stone. 



274 



9: Male and Female Genitourinary Systems 



53. (E) Surgical intervention by endoscopic percu- 
taneous or open surgical procedure is indicated 
for stones more than 5 mm in diameter that 
cause persistent obstruction, intractable pain, 
impaired renal function, or persistent urinary 
tract infection. In over 90% of cases, a ureteric 
stone <4 mm will pass naturally. 

54. (D) Patients with urethral diverticulum show a 
triad of dysuria, dyspareunia, and dribbling of 
urine The commonest form of urinary inconti- 
nence, called stress incontinence, is due to mul- 
tifactorial causes, and frequently there is an 
anatomic defect of the bladder neck. Urge 
incontinence is attributed to detrusor bladder 
instability and may be associated with neuro- 
logical causes such as Parkinson's disease. The 
urethral syndrome and intestitial cystitis are 
sensory bladder disorders usually occurring in 
younger patients who do not have urinary 
infection. 

55. (E) Initial treatment for urinary incontinence 
revolves around well-planned Kegel pelvic 
floor muscles and sympathomimetic drugs (to 
increase urethral pressure). Surgery includes 
the Marshall Marchetti retropubic urethropexy. 
Transvaginal correction is equally effective. 

56. (B) If unruptured the fallopian tube should be 
spared; laparoscopic surgery is indicated, on 
the side of the ectopic pregnancy. An incision is 
made into superior (antimesenteric) border of 
the fallopian tube and the products of concep- 
tion removed by gentle traction. Preserving the 
fallopian tube may improve the chances of 
future conception. The appendix should be 
removed to avoid possible confusion of the 
diagnosis at a subsequent date. 

57. (C) Complete moles are diploid and have a 20% 
risk of malignancy. Partial moles are triploid and 
do not as a rule undergo malignant change. 
Gestational trophoblastic disease is divided in 
(a) hydatiform mole (partial or complete); and (b) 
gestational trophoblastic neoplasia. Hydatiform 
moles are from paternal and maternal origin. 
Hydatiform moles are treated by suction curet- 
tage through the cervix. 



58. (A) Gestational trophoblastic disease may 
involve hydatidiform mole, choricarcinoma, or 
placental trophoblastic tumor. Trophoblastic 
tissue produces B-HCG and thus B-HCG is ele- 
vated in all these conditions. AFP is increased in 
neural tube defect setting when screening at 
15-18 weeks gestation. AFP may be decreased 
in Down syndrome. 

59. (B) The proliferative (follicular) phase (estro- 
gen) is between the first days of menstrual 
bleeding to ovulation. If fertilization does not 
take place, progesterone release results in the 
endometrial proliferative phase. FSH stimu- 
lates the cycle of follicular proliferation. 

60. (E) Crohn's disease usually causes perineal fis- 
tulas, and suppurative hidradenitis can cause 
weeping pustular lesions. Carcinoma, syphilis, 
Crohn's disease, hidradenitis, granuloma 
inguinale, and Behcet's syndrome are some of 
the more common causes of ulcerative lesions 
of the vulva. 

61. (I) Granuloma inguinale is a lesion related to 
a contagious, sexually transmitted disease. 
Identification of Donovan bodies in tissue pre- 
pared with Giemsa stain establishes the diag- 
nosis. Treatment is with tetracycline. 

62. (E) Behcet's syndrome is characterized by oral 
and genital ulcers, ocular inflammation, disor- 
ders of the skin resembling erythema nodosum 
or multiforme, and disturbances of the central 
nervous system (CNS). Arthritis and throm- 
bophlebitis are not commonly associated with 
this condition. The etiology is not well under- 
stood, and it may be an autoimmune disease. 
Cortisone has been used as treatment with vari- 
able results. 

63. (J) In Egypt, the majority of these tumors are asso- 
ciated with schistosoniasis infection. Squamous 
cell Ca, usually presents as a higher clinical stage 
lesion and prognosis is generally poorer than 
transitional cell Ca. 

64. (C) In adults, this is diagnostic, but in children, 
transillumination is also seen in an indirect 



Answers: 53-70 



215 



inguinal hernai. As epididymal cyst may tran- 
silluminate but is posterior to the the testis. 

65. (B) Infertility and failure of ejaculation occur 
because of sympathetic denervation. Infertility 
is found in many patients with testis cancer. In 
retroperitoneal dissection (and any surgery in 
the region of the aortic bifurcation or promon- 
tory of the sacrum), the sympathetic branches 
to the hypogastric plexus must be identified 
and preserved when possible. In the case dis- 
cussed here, the patient's ability to have an 
erection should not be interfered with, because 
the pelvic splanchnic nerves are remote from 
the operating site. 

66. (B) Oral DES was given to patients who were 
unable to conceive. Fortunately, this complica- 
tion is unlikely to occur, because DES has been 
withdrawn as a drug used for this purpose. 

67. (C) Acorpus luteum cyst is functional and 
uusally regresses within one menstrual cycle. 
If a cyst is larger than 5-6 cm, one should 



reevaluate the patient in 4-6 weeks before sug- 
gesting laparotomy. Dermoid cysts are benign 
variations of teratomas. They usually are cured 
by simple excision, but the opposite ovary may 
be involved in 10% of cases. 

68. (C) The treatment related incidence of abnor- 
mal ejaculation observed in 0.4 mg of tamsu- 
losin is 11% and 0.8 mg of tamsulosin is 18%. 

69. (C) Tamsulosin has the advantage of not low- 
ering blood pressure in men who are hyper- 
tensive at baseline over the other a-blockers. 

70. (C) Finasteride (a 5-a-reductase inhibitor for 
treatment of BPH) at 5 mg has been shown to 
lower PSA levels by 50% after 12 months of 
treatment. Men who are to be treated with 
finasteride should have a baseline PSA meas- 
urement before starting therapy. If the PSA 
value does not decrease by 50%, or if there is a 
rise in PSA value when the patient is taking 
finasteride, these men should be suspected of 
having an occult prostate cancer. 



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CHAPTER 10 



Vascular 

Nilesh N. Balar and Mayank V. Patel 

Questions 



DIRECTIONS (Questions 1 through 59): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 



A 56-year-old male has history of leg pain at 
rest. Patient also has history of severe coronary 
artery diseases. He cannot walk two flights of 
steps without getting short of breath. He under- 
went evaluation and was noted to have com- 
plete aortoiliac occlusive disease. He needs 
surgery. Which one of the following options is 
acceptable? 

(A) Aortobililiac bypass 

(B) Aortobifemoral bypass 

(C) Aortoiliac angioplasty and stent 
placement 

(D) Axillobifemoral bypass 

(E) Axilloiliac 



2. 



A 65-year-old female on her routine examina- 
tion was noted to have a pulsatile abdominal 
mass. She has been otherwise healthy with his- 
tory of hypertension with no other history 
except family history of father dying of rup- 
tured abdominal aortic aneurysm. What are 
the acceptable reasons to operate on abdominal 
aortic aneurysms in 65-year-old female with 
5-cm infrarenal aneurysm? 

(A) Presence of aneurysm 

(B) Aneurysm with intramural thrombus 

(C) Asymptomatic aneurysm 5.5 cm 



(D) Associated 2-cm iliac aneurysm 

(E) Patient with splenic artery aneurysm 
1.5 cm 

3. An 89-year-old male presents with asympto- 
matic 8-cm abdominal aneurysm. He has a 
recent history of myocardial infarction (MI) and 
is not a candidate for coronary artery bypass. 
What should the treatment options include? 



(A) 
(B) 



(C) 



(D) 



(E) 



Conservative treatment observation 

Computerized axial tomography (CAT) 

scan to evaluate eligibility for 

endovascular repair 

Open repair without any further 

workup 

Axillofemoral bypass and coil 

embolization of aneurysm 

/3-blocker therapy 



A 70-year-old male underwent an open abdom- 
inal aortic aneurysm repair for ruptured 
aneurysm. He was stable during the procedure. 
In intensive care unit he was noted to have no 
urine output and was also noted to have large 
bloody bowel movement on first postoperative 
day. The next step for investigation includes: 

(A) Reexploration 

(B) Arterial blood gas evaluation for acidosis 

(C) CAT scan abdomen 

(D) Sigmoidscopy/colonoscopy 

(E) Antibiotics and hydration 



217 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



218 



10: Vascular 



5. A 69-year-old man was noted to have abdom- 
inal pain in left flank with severe hypotension 
and pulsatile mass in abdomen. He was taken 
to the operating room after he coded in the 
emergency room. Which of the following state- 
ments regarding ruptured abdominal aortic 
aneurysm is TRUE? 

(A) 10% of patient with ruptured aneurysm 
reach the Hospital. 

(B) Mortality is about 10%. 

(C) Aortic control is usually obtained by 
thoracotomy. 

(D) It cannot be treated by endovascular 
means. 

(E) Mortality following a code for ruptured 
AAA is 100%. 

6. A 82-year-old female presented with history of 
loss of vision in right eye for about 15 minutes 
and it cleared up. She has a history of diabetes 
and hypertension. She had which showed old 
infarct on right side. Carotid duplex showed 
that patient had 99% carotid artery stenosis. 
Which one of the following statements is 
TRUE? 

(A) 60% chance that extra cranial carotid 
artery stenosis is the cause of transient 
ischemic attack (TIA). 

(B) It is always due to platelet emboli. 

(C) 25% may be intracranial bleed. 

(D) 0.5 to 10% may have cardiac and other 
causes of TIA. 

(E) It is always due to thrombosis. 

7. A 63-year-old male was noted to have a recent 
TIA. Patient was having recurrent episodes of 
TIA despite of being on aspirin and clopidogrel 
bisulfate. He does have a history of unstable 
angina. His workup includes magnetic reso- 
nance angiography (MR A) and carotid duplex. 
What are the appropriate treatment options? 

(A) Carotid endarterectomy for 50% carotid 
stenosis on MRA 

(B) Carotid endarterectomy for 60% stenosis 
on MRA without any treatment of 
unstable angina 



(C) Carotid endarterectomy for 90% stenosis 
with coronary artery bypass graft 
(CABG) at the same time 

(D) Start patient on heparin therapy and 
treat conservatively for carotid stenosis 
of 80% 

(E) Coronary angiogram with possible 
coronary intervention and simultaneous 
carotid angiogram and angioplasty and 
stenting 

8. A 62-year-old man had right carotid endarterec- 
tomy 7 years ago. Now he has presented with 
80% stenosis on the same side. He has no symp- 
toms from the stenosis. He has carotid artery 
stenosis on the opposite side of 80%. He does 
not have any history of TIA. What is the appro- 
priate treatment for the patient? 

(A) Medical management with aspirin 

(B) Carotid artery redo surgery and patch 
angioplasty 

(C) Angiogram and angioplasty and stenting 

(D) Left carotid endarterectomy 

(E) Anticoagulation of the patient to 
prevent stroke 

9 . A 60-year-old male patient with bilateral carotid 
artery stenosis 90%, with history of right-sided 
weakness with resolution of symptoms in 15 
minutes. How would you treat the patient? 

(A) Right carotid endarterectomy 

(B) Left carotid endarterectomy 

(C) Right carotid angioplasty and stenting 

(D) Start patient on aspirin 

(E) Start patient on heparin 

10. A 72-year-old patient is noted to have neuro- 
logical deficit following elective carotid 
endarterectomy in recovery room. What is the 
most appropriate treatment at this time? 

(A) Carotid duplex 

(B) CAT scan of brain 

(C) Angiogram of cerebral vessels 

(D) Heparin drip 

(E) Exploration of the same side 



Questions: 5-14 



219 



11. A 63-year-old man has had a cyanotic painful 
left fourth toe for 2 days. The dorsalis pedis 
and posterior tibial arteries are palpable on both 
sides. There is no history of cardiac or vascular 
disease. What is the most likely diagnosis? 

(A) Cardiac embolus 

(B) Atheroembolism 

(C) Lupus vasculitis 

(D) Digital atherosclerosis 

(E) Raynaud's syndrome 

12. A 40-year-old chronic smoker presents with 
ulceration of the tip of the right second, third, 
and fourth toes. He gives a history of recur- 
rent migratory superficial phlebitis of the feet 
occurring a few years ago. Physical examina- 
tion findings are remarkable for absent bilateral 
posterior tibial and dorsalis pedis pulses with 
palpable popliteal pulses. What is the single 
most important step in management? 

(A) Multiple toe amputations 

(B) Long-term anticoagulant therapy 

(C) Immediate operative intervention 

(D) Angiography followed by bypass surgery 

(E) Cessation of smoking 

13. A middle-aged man is found to have a small 
pulsating mass at the level of the umbilicus 
during a routine abdominal examination. What 
is the best initial test to establish the diagnosis? 

(A) Aortography 

(B) Ultrasound 

(C) Computed tomography (CT) 

(D) Magnetic resonance imaging (MRI) 

(E) Plain films of the abdomen 

14. A 58-year-old woman is found to have a right 
carotid bruit on routine examination. She is 
completely asymptomatic. A carotid duplex 
scan and carotid arteriogram (Fig. 10-1) reveal 
a right carotid stenosis. Which of the following 
statements is true? 




Figure 10-1. 

Preoperative carotid arteriogram show- 
ing stenosis of the proximal internal 
carotid artery (immediately distal to 
the bifurcation of common carotid 
artery). (Reproduced, with permission, 
from Doherty GM: Current Surgical 
Diagnosis and Treatment, 12th ed. 825. 
McGraw-Hill, 2006.) 



(A) Operative treatment is indicated if the 
stenosis is greater than 80%, even if the 
patient is asymptomatic. 

(B) The incidence of stroke can be decreased 
by prophylactic carotid endarterectomy 
in patients with as little as 40% stenosis. 

(C) Aspirin is always a superior treatment 
to surgery regardless of the degree of 
stenosis. 

(D) If symptoms eventually develop, they 
are invariably TIAs, not stroke. 

(E) Neither surgery nor aspirin is indicated, 
because the patient is asymptomatic. 



220 



10: Vascular 



15. A 57-year-old male smoker is referred to you 
because of two episodes of right upper extrem- 
ity weakness over the past 6 months, each last- 
ing for 10-15 minutes. Findings on CT scan of 
the head are negative. An angiogram shows a 
75% stenosis of the left carotid artery. What is 
the most appropriate treatment? 

(A) Antiplatelet therapy 

(B) Oral anticoagulants 

(C) Carotid endarterectomy 

(D) Carotid artery bypass to vertebral system 

(E) Surgery only if a stroke develops 

16. A 24-year-old man complains of progressive 
intermittent claudication of the left leg. On 
examination, the popliteal, dorsalis pedis, and 
posterior tibial pulses are normal; but they dis- 
appear on dorsiflexion of the foot. What is the 
most likely diagnosis? 

(A) Embolic occlusion 

(B) Thromboangiitis obliterans 

(C) Atherosclerosis obliterans 

(D) Popliteal artery entrapment syndrome 

(E) Cystic degeneration of the popliteal 
artery 

17. Four days after undergoing hysterectomy, a 30- 
year-old woman develops phlegmasia cerulea 
dolens over the right lower extremity. What is 
the most appropriate treatment? 

(A) Bed rest and elevation 

(B) Systemic heparinization 

(C) Venous thrombectomy 

(D) Prophylactic vena caval filter 

(E) Local urokinase infusion 

18. A 21-year-old woman is referred to your office 
because of multiple lower extremity varicose 
veins. She has large varicosities in the distri- 
bution of the long saphenous vein. What is the 
next step in management? 

(A) A ligation and stripping operation 

(B) Ligation of both the long and short 
saphenous system 



(C) Sclerotherapy 

(D) Duplex evaluation along with clinical 
correlation as an essential initial step 

(E) Compression stockings and 
anticoagulation therapy 

19. A 45-year-old woman undergoes cardiac 
catheterization through a right femoral approach. 
Two months later, she complains of right lower 
extremity swelling and notes the appearance of 
multiple varicosities. On examination, a bruit is 
heard over the right groin. What is the most 
likely diagnosis? 

(A) Femoral artery thrombosis 

(B) Superficial venous insufficiency 

(C) Arteriovenous (AV) fistula 

(D) Pseudoaneurysm 

(E) Deep vein insufficiency 

20. A young basketball player develops an acute 
onset of subclavian vein thrombosis (effort 
thrombosis) after heavy exercise. What is the 
next step in management? 

(A) Active exercise of the limb 

(B) Anti-inflammatory drugs 

(C) Thrombolytic therapy 

(D) Antibiotics 

(E) First-rib resection 

21. A middle-aged man undergoes a left below- 
knee amputation for left-foot gangrene sec- 
ondary to arterial occlusive disease. Which of 
the following statements is true after the below - 
knee amputation? 

(A) There is less efficient function than after 
a through-knee amputation. 

(B) Stump prognosis can be judged by 
transcutaneous oxygen monitoring. 

(C) Poor prognosis is inevitable if Doppler 
fails to record a pulse at that level. 

(D) The fibula and tibia are of equal length. 

(E) The level of transection is 5 cm above 
the medial malleolus. 



Questions: 15-28 



221 



22. 



23. 



A 72-year-old retired banker complains of left- 
leg intermittent claudication while playing golf. 
An angiogram shows occlusion of the superfi- 
cial femoral artery and reconstitution of the 
popliteal artery below the knee. What is the 
treatment of choice? 

(A) A vigorous exercise program 

(B) Endarterectomy of the superficial 
femoral artery 

(C) Femoropopliteal bypass with expanded 
polytetrofluoroethylene (PTFE) graft 

(D) In situ femoropopliteal bypass 

(E) Femoropopliteal bypass with reversed 
saphenous vein graft 

A 40-year-old patient undergoes a CT scan of 
the abdomen for nonspecific abdominal pain. A 
splenic artery aneurysm is incidentally identi- 
fied. What is true of the splenic artery aneurysm? 

(A) It requires splenectomy for optimal 
treatment. 

(B) It is more common in men. 

(C) It is caused by atherosclerosis in most 
cases. 

(D) It may rupture during pregnancy. 

(E) It is rarely calcified on an abdominal 
x-ray. 



24. A 70-year-old man with a long-standing history 
of diabetes develops gangrene of the right 
second toe. What is true of his diabetic foot? 

(A) Dorsalis pedis and posterior tibial 
arteries are always absent. 

(B) Gangrene of the toe always requires 
urgent below-knee amputation. 

(C) Arterial reconstruction is invariably 
required. 

(D) His right femoral artery is most proba- 
bly occluded or stenosed. 

(E) Trophic ulcers are sharply demarcated. 

25. Eleven years after undergoing right modified 
radical mastectomy, a 61-year-old woman 
develops raised red and purple nodules over 
the right arm. What is the most likely diagnosis? 



(A) Lymphangitis 

(B) Lymphedema 

(C) Lymphangiosarcoma 

(D) Hyperkeratosis 

(E) Metastatic breast cancer 

26. Four days after undergoing subtotal gastrec- 
tomy for stomach cancer, a 58-year-old woman 
complains of right leg and thigh pain, swelling 
and redness, and has tenderness on examina- 
tion. The diagnosis of deep vein thrombosis is 
entertained. What is the initial test to establish 
the diagnosis? 

(A) Venography 

(B) Venous duplex ultrasound 

(C) Impedance plethysmography 

(D) Radio-labeled fibrinogen 

(E) Assay of fibrin/fibrinogen products 

27. A middle-age woman has right leg and foot 
nonpitting edema associated with dermatitis 
and hyperpigmentation. The diagnosis of 
chronic venous insufficiency is made. What is 
the treatment of choice? 

(A) Vein stripping 

(B) Pressure-gradient stockings 

(C) Skin grafting 

(D) Perforator vein ligation 

(E) Valvuloplasty 

28. A 55-year-old woman has bilateral leg edema 
associated with thick, darkly pigmented skin. A 
Trendelenburg's test is done, and results are 
interpreted as positive/positive. What does 
this patient have? 

(A) Competent varicose veins/competent 
perforators 

(B) Competent varicose veins/incompetent 
perforators 

(C) Deep vein thrombosis (DVT) 

(D) Incompetent varicose veins/competent 
perforators 

(E) Incompetent varicose veins/incompetent 
perforators 



222 



10: Vascular 



29. 



30. 



31. 



32. 



A middle-aged man known to have peptic 
ulcer disease is admitted with upper gastroin- 
testinal (GI) bleeding. During his hospital stay, 
he develops DVT of the left lower extremity. 
What is the most appropriate management? 

(A) Anticoagulation 

(B) Observation 

(C) Thrombolytic therapy 

(D) Inferior vena cava (IVC) filter 

(E) Venous thrombectomy 

A 70-year-old executive is complaining of 
three-block intermittent claudication of both 
legs. What is the percentage chance of his 
developing limb-threatening gangrene? 



(A) 


Less than 10% 


(B) 


20% 


(C) 


45% 


(D) 


60% 


(E) 


More than 75% 



Thirty-six hours after undergoing an abdomi- 
nal aortic aneurysm repair, a 70-year-old 
woman develops abdominal distension associ- 
ated with bloody diarrhea. What is the most 
likely diagnosis? 

(A) Aortoduodenal fistulas 

(B) Diverticulitis 

(C) Pseudomembranous enterocolitis 

(D) Ischemic colitis 

(E) Acute hepatic failure 

A 65-year-old man is referred to you because of 
an incidental finding of a 3-cm left popliteal 
aneurysm (Fig. 10-2). The patient is completely 
asymptomatic and has normal pulses. How 
should the aneurysm be treated? 

(A) It should be observed. 

(B) It should be repaired because it may 
lead to spontaneous rupture. 

(C) It should be repaired only if it is larger 
than 5 cm. 




Figure 10-2. 

Arteriogram showing aneurysm of the popliteal artery 
(arrow), (Reproduced, with permission, from Doherty 
GM: Current Surgical Diagnosis and Treatment, 12th ed. 
809. McGraw-Hill, 2006.) 

(D) It should be repaired because of its 
tendency to either undergo thrombosis 
or embolize distally 

(E) It should be repaired because of its 
tendency to cause nerve compression if 
it enlarges. 

33. A 72-year-old woman falls at home after an 
episode of dizziness. She had been complaining 
of low -back pain for 3 days before the fall. In the 
emergency department, she is hypotensive and 
has cold, clammy extremities. A pulsating 
mass is palpable on abdominal examination. 
Following resuscitation, the next step in the man- 
agement should involve which of the following? 

(A) Peritoneal lavage 

(B) Immediate abdominal exploration 



Questions: 29-41 



223 



(C) CT scan of the abdomen 

(D) Abdominal aortogram 

(E) Abdominal ultrasound 

34. A 60-year-old man complains of dizziness, ver- 
tigo, and mild right-arm claudication. On phys- 
ical examination, there is decreased pulse and 
blood pressure of the right upper extremity. 
What is the treatment of choice? 

(A) Anticoagulation 

(B) Repair of coarctation of the aorta 

(C) Ligation of vertebral artery 

(D) Carotid endarterectomy 

(E) Carotid subclavian bypass 

35. An 18-year-old man develops a painful, swollen 
leg while training for the New York Marathon. 
There is tenderness in the calf and ecchymosis 
is present. What is the most likely diagnosis? 

(A) Cellulitis 

(B) DVT 

(C) Superficial thrombophlebitis 

(D) Tear of the plantaris muscle 

(E) Medical lemniscus tear 

Questions 36 and 37 

Four days after suffering MI, a 78-year-old woman 
suddenly develops severe diffuse abdominal pain. 
Her electrocardiogram (ECG) shows atrial fibrilla- 
tion. On examination, the abdomen is soft, minimally 
tender, and slightly distended. Hyperactive bowel 
sounds are present. 

36. What is the most likely diagnosis? 

(A) Mesenteric embolus 

(B) Nonocclusive ischemic disease 

(C) Perforated peptic ulcer 

(D) Congestive heart failure (CHF) 

(E) Digoxin toxicity 

37. The most appropriate initial examination con- 
sists of which of the following? 

(A) Gastrografin upper GI series 

(B) White blood cell (WBC) counts and serial 
abdominal examination 



38. 



(C) Colonoscopy 

(D) Diagnostic peritoneal lavage 

(E) Angiography 

A 28-year-old woman has new -onset hyper- 
tension and a bruit on abdominal examination. 
An arteriogram shows fibromuscular dysplasia 
(FMD) of the right renal artery. What is the best 
treatment option? 

(A) Aortorenal saphenous vein bypass 

(B) Patch angioplasty of the renal artery 

(C) Percutaneous transluminal angioplasty 
(PTA) 

(D) Transaortic renal endarterectomy 

(E) Hepatorenal bypass 



Questions 39 through 41 

A 60-year-old man with a history of atrial fibrilla- 
tion is found to have a cyanotic, cold right lower 
extremity. 

39. The embolus is most probably originating from 
which of the following? 

(A) An atherosclerotic plaque 

(B) An abdominal aortic aneurysm 

(C) Heart 

(D) Lungs 

(E) Paradoxical embolus 

40. Which is the most common site at which an 
arterial embolus lodges? 

(A) Aortic bifurcation 

(B) Popliteal artery 

(C) Tibial arteries 

(D) Common femoral artery 

(E) Iliac artery 

41. What is the most appropriate management? 

(A) Embolectomy 

(B) Lumbar sympathectomy 

(C) Bypass surgery 

(D) Amputation 

(E) Arteriography 



224 



10: Vascular 



42. An elderly patient with ischemic rest pain is 
found to have combined aortoiliac and 
femoropopliteal occlusive disease. What is the 
treatment of choice? 

(A) Aortofemoral bypass 

(B) Femoropopliteal bypass 

(C) Aortofemoral and femoropopliteal bypass 

(D) Lumbar sympathectomy 

(E) Vasodilator therapy 

43. A 66-year-old woman has a 5.5-cm infrarenal 
abdominal aortic aneurysm. What is the most 
common manifestation of such an aneurysm? 

(A) Abdominal or back pain 

(B) Acute leak or rupture 

(C) Incidental finding on abdominal 
examination 

(D) Atheroembolism 

(E) Spontaneous thrombosis 

44. A 72-year-old man complains of bilateral thigh 
and buttock claudication of several months 
duration. He was told by his physician that the 
angiogram revealed findings indicating that he 
has Leriche syndrome. What does this patient 
have? 

(A) Abdominal aortic aneurysm 

(B) Aortoiliac occlusive disease 

(C) Iliac artery aneurysm 

(D) Femoropopliteal occlusive disease 

(E) Tibial occlusive disease 

45. A young woman develops a left femoral arte- 
riovenous fistula a few months after a stab 
wound to the groin. Which of the following 
physiological changes (Nicoladoni-Branham 
sign) is elicited on physical examination? 

(A) Appearance of CHF when the artery 
proximal to the fistula is compressed 

(B) Slowing of the pulse rate when the 
fistula is compressed 

(C) A rise in the pulse rate when the artery 
distal to the fistula is compressed 

(D) A bruit heard only after the fistula is 
occluded 

(E) Absent dorsalis pedis after leg is elevated 



46. A young patient sustains blunt trauma to his 
right knee that results in acute thrombosis of 
his popliteal artery. Which tissue is most sen- 
sitive to ischemia? 

(A) Muscle 

(B) Nerve 

(C) Skin 

(D) Fat 

(E) Bone 

47. Seven years after undergoing resection of an 
abdominal aortic aneurysm and repair with a 
Dacron graft, a 65-year-old man develops an 
aortoenteric fistula. What would be the safest 
method to treat this patient? 

(A) Administration of a prolonged course of 
antibiotics 

(B) Removal of the Dacron graft, closure of 
the enteric defect, and the insertion of a 
new aortic graft 

(C) Closure of the enteric fistula, removal of 
the Dacron graft, ligation of the infrarenal 
aorta, and insertion of an extra-anatomic 
axillobifemoral bypass graft 

(D) Division of the fistula, closure of the 
aortic and enteric defects, and 
interposition of omentum in between 

(E) Closure of the enteric fistula, removal of 
the Dacron graft, ligation of the infrarenal 
aorta, and insertion of an extra-anatomic 
bypass at a later date 

48. A 24-year-old male cyclist undergoes repair of 
both popliteal artery and vein following a gun- 
shot wound to the right knee. Thirty-six hours 
postoperatively there is increasing swelling of 
the leg and foot, and the patient complains of 
increasing foot pain and inability to move his 
toes. His pedal pulses are palpable. What is the 
most immediate next step that should be 
undertaken? 

(A) Arteriography 

(B) Leg and foot elevation 

(C) Fasciotomy 

(D) Venography 

(E) Immediate reexploration of the popliteal 
space 



Questions: 42-53 



225 



49. A homeless elderly man is brought to the emer- 
gency department after sustaining frostbite to 
both feet. What is the most appropriate imme- 
diate management? 

(A) Slow rewarming at room temperature 

(B) Amputation of the gangrenous toes 

(C) Rapid rewarming with warm water 

(D) Rapid rewarming with hot water or dry 
heat 

(E) Thorough debridement of blisters and 
devitalized tissue 

50. A 55-year-old woman who comes from a high- 
altitude location is diagnosed as having a 
carotid body tumor (Fig. 10-3). What is true of 
these tumors? 




Figure 10-3. 

Carotid body tumor. (Reproduced, with permission, from 
Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 819. McGraw-Hill, 2006.) 



(A) They most frequently present as a 
painless neck mass. 

(B) They arise from endothelial cells. 

(C) They are usually hypovascular. 

(D) They frequently manifest with a stroke. 

(E) They are usually treated by embolization. 

51. A middle-aged man complains of short- 
distance claudication in the right thigh. The 
angiogram shows a right common iliac artery 
stenosis of 90% over a short segment. What is 
the treatment of choice? 

(A) Aortofemoral bypass 

(B) Left -to-right fermorofemoral bypass 

(C) Iliofemoral bypass 

(D) PTA and stent placement 

(E) Axillofemoral bypass 

52. A 65-year-old man with hypertension and a 
blood pressure of 190/105 mm Hg has unilat- 
eral renal artery stenosis. What is the best diag- 
nostic test to determine the physiologic 
significance of the lesion? 

(A) Aortography 

(B) Renal scan 

(C) Renal ultrasound 

(D) Renal vein renin assay 

(E) Rapid-sequence intravenous pyelogram 

53. A young college student injures his left knee 
while playing football and is unable to bear 
weight. The provisional x-ray report indicates 
that there are no fractures seen. He is dis- 
charged home but presents the next morning to 
the emergency department with a severely 
swollen, painful left knee and severe pain in the 
foot. On examination, the foot is pale, cold, and 
pulseless. What is the most likely diagnosis? 

(A) Traumatic deep vein thrombosis 

(B) Gastrocnemius muscle tear 

(C) Traumatic arteriovenous fistula 

(D) Posterior knee dislocation with 
thrombosed popliteal artery 

(E) Traumatic sciatic neuropathy 



226 



10: Vascular 



54. An elderly patient complains of recurrent 
episodes of amaurosis fugax. This is attributable 
to microembolization of which of the following? 

(A) Facial artery 

(B) Retinal artery 

(C) Occipital artery 

(D) Posterior auricular artery 

(E) Superficial temporal artery 

55. A 65-year-old woman television technician 
undergoes femoral embolectomy and leg fas- 58. 
ciotomy. Following surgery, she is noted to 

have oliguria, and her urine is red. What is the 
most probable diagnosis? 

(A) Hematuria secondary to heparin 

(B) Embolus of the renal artery 

(C) Myoglobinuria 

(D) Retroperitoneal hematoma 

(E) Hemoglobinuria 

56. A 24-year-old woman on oral contraceptive 
pills develops an episode of deep vein throm- 
bosis that is adequately treated with anticoag- 
ulation. She is at increased risk of developing 59. 
which of the following? 

(A) Recurrent foot infections 

(B) Claudication 

(C) Pulmonary embolism 

(D) Postphlebetic syndrome 

(E) Superficial varicose veins 

57. A 72-year-old businessman undergoes a femoral- 
to-posterior tibial in situ bypass graft for a 



nonhealing foot ulcer. During routine follow-up 
examination 4 years later, the graft is found to be 
occluded. The cause of his graft failure is most 
probably secondary to which of the following? 

(A) Progression of atherosclerosis 

(B) Technical error 

(C) Retained valve in the conduit 

(D) Venous aneurysm 

(E) Intimal hyperplasia 

A 60-year-old woman has an asymptomatic right 
carotid bruit. A carotid duplex scan shows no 
evidence of significant carotid bifurcation dis- 
ease but reveals reversal of flow in the right ver- 
tebral artery. What is the most likely diagnosis? 

(A) Stenosis of the origin of the common 
carotid artery 

(B) Stenosis of the vertebral artery 

(C) Stenosis of the subclavian artery 

(D) Stenosis of the external carotid artery 

(E) Stenosis of the intracranial portion of 
the internal carotid artery 

A newborn girl with family history of lym- 
phedema is noted to have bilateral lower 
extremity swelling. What is the diagnosis? 

(A) Secondary lymphedema 

(B) Lymphedema praecox 

(C) Milroy disease 

(D) Lymphedema tarda 

(E) Meigs's syndrome 



Answers and Explanations 



1. (D) The treatment goal in these patients is to 
reestablish blood flow to the lower extremity. 
The treatment is based on the findings at 
angiogram. All the treatment options are valid 
and are used in treatment of the aortoocclusive 
disease. Patients with short-segment (TASCA) 
stenosis in common iliac artery are treated with 
angioplasty and /or stent placement and the 
patency results are expected to be comparable to 
surgery. In patients with long-segment stenosis 
and good risk patient treatment options would 
include aortobifemoral bypass. These procedures 
are long lasting. The long-term patency rates are 
reported to be 65-90%. Axillobifemoral bypass is 
utilized in patients with high risk and poor gen- 
eral condition. The patency rates for this group 
vary between 50-85% in 5 years. The patient 
described would be an ideal candidate for axil- 
lobifemoral bypass. 

2. (C) The current indication for repair of abdom- 
inal aortic aneurysm in female includes 
aneurysm size 5 cm in acceptable risk patient. A 
United Kingdom small aneurysm study has 
increased the size that could be observed to 
5.5 cm in male while in female it is acceptable 
to treat aneurysm at 5 cm size for acceptable 
risk. Any aneurysm with associated complica- 
tion should be treated; just the presence of 
intramural thrombus does not justify repair. 
Asymptomatic 5.5-cm aneurysm should be 
treated in all patients, male or female, at accept- 
able cardiac risk. Patients with 2-cm aneurysm 
of iliac artery without any symptoms and com- 
plications should be observed; as the risk of sur- 
gery is higher than risk of observation till they 
reach to 4 cm. In patients, not in child-bearing 
age, 1.5-cm splenic aneurysm could be observed. 



3. (B) An 8-cm aneurysm carries significant 
mortality which exceeds 50% in 1 year from 
aneurysm related death if observation or med- 
ical management is chosen as treatment option. 
It would be appropriate, if the neck size is 
greater than 1.5 cm and diameter is less than 
26 mm, without any significant thrombus or 
calcification in the neck. This patient does well 
at least on mid term follow-up. They have 
lower perioperative morbidity compared to tra- 
ditional open repair. Open repair with given 
cardiac history would carry high morbidity 
and morotality /3-blocker therapy would be 
indicated for his cardiac condition but is not a 
standard therapy for aneurysm. 

4. (D) Mortality associated with aortic aneurysm 
is usually around 0-3%. A ruptured AAA car- 
ries mortality in range of 60-80% depending on 
presentation. Risk of large-bowel ischemia with 
ruptured AAA is about 10%. The first investi- 
gation with patients where colonic ischemia is 
suspected is to perform sigmoidoscopy. All 
other investigations may be done but none of 
them would be the primary investigation for 
the suspected pathology. 

5. (E) Ruptured AAA carries a mortality of 
40-50%. It is true that only 50% of all ruptured 
AAA reaches the hospital. Free peritoneal rup- 
ture carries a very high mortality. Thoracotomy 
is not the standard approach for proximal aortic 
control. Ruptured AAA can be treated with 
endovascular grafts. Preoperative hypotension 
is a good predictor of poor outcome but car- 
diac arrest is associated with 100% mortality in 
most of the studies. 



227 



228 



10: Vascular 



6. (A) Neurological events are associated with 
extracranial carotid artery in about 60%. Fourty 
percent may have extracranial/intracranial 
cause for neurological events, which includes 
cardiac emboli, arch of aorta as source of emboli; 
intracranial bleed may be more than just a TIA. 
It is not always that platelet emboli are the cause 
of TIA, it could be due to atheroma. It is not 
always attributed to thrombus. 

7. (D) Asymptomatic carotid artery stenosis is only 
treated surgically if it is greater than 70% steno- 
sis. The risk reduction with surgical treatment is 
favorable with 70% stenosis when compared 
to nonoperative treatment. Any symptomatic 
stenosis is an indication for surgical intervention 
including ulcerated plaque. Any amount of 
stenosis with unstable angina would need appro- 
priate workup for cardiac risk prior to carotid 
intervention. Carotid endarterectomy and CABG 
are viable options if they are left main disease 
and have undergone coronary angiogram. In this 
patient the most appropriate treatment is option 
to perform coronary angiogram and possible 
carotid stenting if feasible. Role of anticoagula- 
tion to prevent recurrent TIA is not well estab- 
lished. Aspirin and clopidogrel bisulfate are 
appropriate options for TIA. 

8. (D) Recurrent stenosis is secondary to intimal 
hyperplasia but it occurs in first two years. If 
more than two years, it is progression of dis- 
ease and it does not carry high risk for 
embolization, so it is reasonable to observe it. It 
is also a surgery which carries higher stroke 
rate and morbidity with nerve injury which 
is in range of 7%. Patient is treated with 
antiplatelet therapy which includes aspirin and 
clopidogrel bisulfate. Anticoagulation with 
warfarin is not a standard therapy. It is appro- 
priate to treat the opposite side with 80% 
carotid stenosis. Angiogram and angioplasty 
is an option but if the stenosis is significant 
and symptomatic. Priority in this case would be 
to treat the opposite side. 

9. (B) The treatment for symptomatic carotid 
artery stenosis greater than 70% is carotid 
endarterectomy. Since patient has left cerebral 
symptoms, it would be appropriate to treat that 



side first. Patient would need bilateral carotid 
endarterectomy but symptomatic side would 
be the first one to be operated. Heparin has no 
significant role in preventing stroke. Aspirin is 
a part of therapy but would not constitute a pri- 
mary modality for treatment. 

10. (E) In recovery room, the immediate approach 
would be to explore the patient. The cause for 
immediate stroke is usually technical and is 
most likely reversible if treated early on. All 
investigations are valid options once the tech- 
nical cause is addressed and it would not be a 
primary option. 

11. (B) All the listed conditions may result in 
isolated digital ischemia. In this age group, 
atheroembolism is the most likely diagnosis in a 
man. The atheroma is derived from an occult 
aortic aneurysm or a proximal ulcerative ather- 
osclerotic lesion. This plaque or ulcer can be any 
part of the vascular tree proximal to the ischemic 
toe. Cardiac emboli also are common in this 
age group but are a less likely cause in the 
absence of previous MI, arrhythmia, or valvu- 
lar disease. 

12. (E) This patient suffers from thromboangiitis 
obliterans (Buerger's disease), a disease found 
most frequently in white men between 20 and 
40 years of age. It is a form of panvasculitis 
involving the artery, vein, and nerve. Heavy 
tobacco smoking is strongly associated with 
this disease. Early in the course of the disease, 
there is involvement of the superficial veins, 
producing recurrent migratory superficial 
phlebitis. The distribution of arterial involve- 
ment is usually segmental, involving the 
peripheral arteries. In the lower extremities, 
the disease occurs generally beyond the 
popliteal arteries and distal to the forearm in 
the upper extremities. As long as ulceration or 
gangrene is confined to a digit, amputation 
should be postponed as long as possible unless 
rest pain or infection cannot be otherwise con- 
trolled. Bypass surgery is rarely indicated, and 
long-term anticoagulation has not been of 
much benefit. The most important aspect of 
treatment is cessation of smoking, which can 
halt progression of the disease. 



/Answers: 6-18 



229 



13. (B) Although aortography, CT, and MRI can 
all establish the diagnosis of abdominal aortic 
aneurysm, ultrasound remains the best screen- 
ing test. It is the preferred method for making 
the initial diagnosis, because it is reliable, inex- 
pensive, and noninvasive. Aortography is used 
infrequently because of the small but definite 
risk it entails and because diagnosis can be 
made by other means. Once the aneurysm 
meets the criteria for repair, then a CT scan is 
done preoperatively to establish the true size 
and to delineate the aneurysm more accurately. 
Plain films of the abdomen are inaccurate in 
establishing the diagnosis. 

14. (A) Operative treatment is indicated if the diam- 
eter of the stenosis is greater than 60%, even if 
the patient is asymptomatic. The value of pro- 
phylactic carotid endarterectomy, for hemody- 
namically significant carotid stenosis, decreases 
the incidence of subsequent cerebral ischemic 
events if performed with morbidity and mor- 
tality rates under 4%. Several studies including 
asymptomatic carotid artery surgery (ACAS) 
have shown that surgical treatment is superior 
to medical management if the stenosis is 60% or 
greater. The ACAS trial has shown the benefits 
of surgical treatment over medical management 
if the stenosis is greater than 60%. However, 
there are no data to support the use of carotid 
endarterectomy in asymptomatic patients with 
stenosis of less than 60%. If ischemic events 
eventually develop, stroke can be the presenting 
symptom. 

15. (C) This patient is experiencing recurrent left 
hemispheric TIA with a hemodynamically sig- 
nificant stenosis of the left carotid artery. This 
is clearly an indication for surgery because 
operative management is superior to aspirin 
in symptomatic carotid bifurcation disease with 
stenosis greater than 70%. Oral anticoagulants 
may decrease the incidence of TIAs but not of 
completed strokes, and they are associated with 
a considerable risk of hemorrhage. Carotid 
endarterectomy, and not carotid artery bypass, 
is the surgical procedure of choice. Surgical 
treatment must be performed before and not 
after major neurologic deficits are produced 
from cerebral infarction. 



16. (D) Popliteal artery entrapment syndrome con- 
sists of intermittent claudication caused by an 
abnormal relation of that artery to the muscles, 
usually the medial head of the gastrocnemius 
muscle. As a consequence of developmental 
abnormalities, the popliteal artery may be com- 
pressed by the medial head of the gastrocne- 
mius muscle, resulting in ischemia of the leg at 
an unusually early age. On examination, the 
pulses may be diminished or absent, but they 
may also be normal and be made to disappear 
on dorsiflexion of the foot. Angiography is 
essential to establish the diagnosis. 

17. (C) Phlegmasia cerulae (blue) dolens, indicates 
that major venous obstruction has occurred. 
The standard treatment for postoperative 
thrombosis includes bed rest and anticoagula- 
tion. Venous thrombectomy may be indicated 
when impending gangrene is noted. Vena caval 
filters are inserted in patients with estab- 
lished pulmonary emboli, but they may be 
considered as a prophylactic measure when 
iliofemoral thrombosis is massive. They are 
also inserted as an adjunct to venous thrombec- 
tomy along with creation of an arteriovenous 
fistula to prevent the venous system from 
rethrombosing. Thrombolysis of major venous 
thrombi requires placement of a multihole 
pigtail catheter inside the thrombus and 
administration of tPA, including systemic 
heparinization and is therefore contraindicated 
postoperatively. 

18. (D) A through clinical evaluation followed by 
a venous duplex examination are the two most 
important steps in managing varicose vein of 
the lower extremity. An asymptomatic patient 
without complications of phlebitis, ulceration, 
or hemorrhage should be treated with com- 
pression stocking. Duplex evaluation will help 
map the valvular incompetence of the superfi- 
cial and deep system including the perforators 
that guide the extent of the initial surgical inter- 
vention, and also investigate if these are pri- 
mary or secondary varicosities. Sclerotherapy is 
an alternative to surgery but in the presence of 
saphenofemoral, saphenopopliteal, or perfora- 
tor reflux is associated with a high incidence of 
recurrence and complications. 



230 



10: Vascular 



19. (C) A traumatic AV fistula results from a pen- 
etrating injury to adjacent artery and vein, per- 
mitting blood flow from the injured artery 
into the vein. The iatrogenic injury in this 
case occurred during cardiac catheterization. 
Femoral artery thrombosis results in signs of 
limb ischemia. A bruit is usually not heard 
with venous insufficiency. Traumatic pseudoa- 
neurysm presents as an enlarging pulsating 
mass. Once the diagnosis of AV fistula is made, 
an angiogram is performed, and surgical repair 
(division of the fistula and reconstruction of 
the artery and preferably of the injured vein as 
well) is carried out. 

20. (C) Effort thrombosis, also called Paget-von 
Schroetter syndrome, is the development of 
thrombosis of the axillary-subclavian vein as a 
result of injury or compression. It occurs pri- 
marily in young athletes and is disabling. 
When these patients are seen early, throm- 
bolytic therapy is the first step in management 
and is followed by a venogram to detect cor- 
rectable lesions. If effort thrombosis is associ- 
ated with thoracic outlet syndrome, then 
thrombolytic therapy should be followed by 
cervical rib resection. If the condition is chronic, 
thrombolytic therapy might not be successful; 
these patients usually respond to limb eleva- 
tion and anticoagulation. 

21. (B) Stump prognosis can be judged by tran- 
scutaneous oxygen monitoring. Doppler is not 
fully reliable to select the level of transection, 
because it cannot calculate the quantity of vas- 
cular flow. Transcutaneous oxygen (P0 2 >40 
mm Hg) offers a fairly accurate prediction of a 
favorable result; although, Doppler fails to con- 
firm a patient pulse at the level of transection. 
On the other hand, a duplex evaluation with 
blood flow of more than 50 cm/s is also a fairly 
accurate predictor for stump prognosis. The 
level of transection is 13-15 cm below the level 
of the medial condyle of the tibia. 

22. (A) If claudication is the only symptom, elec- 
tive vascular reconstruction is considered only if 
claudication is disabling and interferes with day- 
to-day activity. Because the risk of gangrene, 
occurring in a patient who has only claudication, 



is small, this alone does not constitute a clear-cut 
indication for operation. Vigorous exercise pro- 
grams have resulted in marked improvement 
in claudicants. Revascularization surgery is usu- 
ally reserved for rest pain or tissue loss (non- 
healing ulcer, gangrene). Addition of a 
phosphodiastraze inhibitor, cilostazol (pletal), 
or pentoxiphyline (trental) can help increase the 
claudication distance. It should also be kept in 
mind that an angiogram is not indicated for 
claudication. An initial evaluation with nonin- 
vasive vascular studies is the investigation of 
choice. Angiogram is only requested if the deci- 
sion is made to intervene surgically. 

23. (D) Splenic artery aneurysms are rare and are 
most frequently caused by medial necrosis. 
Small asymptomatic aneurysms caused by ath- 
erosclerosis are more commonly incidental 
findings at autopsy. Larger (>3 cm) aneurysms 
predominate in women and characteristically 
may rupture during late pregnancy. Rupture 
may be preceded by an initial warning bleed 
into the retroperitoneum, with massive bleed- 
ing following after 1 or 2 days. 

24. (E) Patients with a diabetic foot may have local- 
ized arterial occlusion involving the popliteal 
artery and its branches, usually sparing the 
femoral artery. Although patients have gangrene 
of the toes, there may be a palpable pulse in the 
foot. In the presence of localized disease, trophic 
ulcers and even gangrene of the toes may 
respond to local foot care, and major vascular 
reconstruction or amputations are not required. 
The trophic ulcers have punched sides. Patients 
may not realize the gravity of localized gan- 
grene with spreading cellulitis, which develops 
because of the neurotropic nature of the lesions 
with the absence of pain sensation. 

25. (C) Lymphangiosarcoma is a rare complication of 
long-standing lymphedema, most frequently 
described in a patient who has previously under- 
gone radical mastectomy (Stewart-Treves syn- 
drome). It usually presents as blue, red, or purple 
nodules with satellite lesions. Early metastasis, 
mainly to the lung, may develop if it is not rec- 
ognized early and widely excised. Lymphedema 
is a complication of radical mastectomy and 



/Answers: 19-29 



231 



presents as diffuse swelling and nonpitting 
edema of the limb. Lymphangitis and hyperker- 
atosis are complications of lymphedema. 

26. (B) The most accurate method of confirming the 
diagnosis of venous thrombosis is the injection 
of contrast material to visualize the venous 
system (venography). However, this method is 
invasive and time-consuming and must be done 
in the radiology suite. Venous duplex ultra- 
sound is noninvasive, can be done bedside, and 
has a sensitivity and specificity of 96 and 100%, 
respectively. The other methods listed are used 
less often in certain selected patients. 

27. (B) The mainstay of treatment of chronic venous 
insufficiency and its complication, venous stasis 
ulceration, is conservative management. Elastic 
stocking support, frequent elevation of the legs, 
and avoidance of prolonged sitting and stand- 
ing is used for venous insufficiency in the 
absence of ulceration. If venous stasis ulcers 
develop, then paste boots (e.g., Unna's boots) 
are used along with appropriate bed rest and 
foot elevation until the ulcer heals. Patients 
whose ulcers fail to heal after such conservative 
management may need perforator vein liga- 
tion. Skin grafting should be considered for 
chronic stasis ulcers that are large, and perfora- 
tor incompetance has been treated. Venous 
reconstruction procedures, including valvulo- 
plasty, can be useful for a selected group of 
patients, especially those with venous claudi- 
cation to less than half a block, that have been 
treated with all the procedures above, including 
stripping and ligation. Unlike previous opin- 
ions, superficial venous stripping and ligation 
is not always contraindicated in the presence of 
chronic venous insufficiency and even previ- 
ous history of deep vein thrombosis. 

28. (E) The Trendelenburg's test is a two-part test 
used to access the competency of the superficial 
and perforating veins. The legs are elevated to 
evacuate the veins, and pressure is applied to 
the saphenofemoral junction either by hand or 
tourniquet. The four possible results are: (a) neg- 
ative/negative response if there is gradual filling 
of veins from below and continued slow filling 
after release of pressure, indicating absence of 



29. 



incompetent superficial and perforating veins; 
(b) negative /positive response if there is gradual 
filling of veins from below while there is rapid 
retrograde filling after release of pressure, indi- 
cating incompetent superficial veins only; (c) 
positive/negative response if there is rapid ini- 
tial filling of the veins from below while only 
continued slow filling after the release of pres- 
sure, indicating incompetent perforators only; 
and (d) positive /positive response if there is 
rapid filling of the saphenous vein before and 
after release of pressure, indicating incompetent 
superficial and perforating veins. 

(D) The main treatment of DVT is adequate anti- 
coagulation. However, if pulmonary embolism 
develops during anticoagulant therapy or if there 
is contraindication to anticoagulation, the inser- 
tion of an IVC filter is indicated either to prevent 
occurrence of or to offer prophylaxis against 
recurrence of pulmonary embolism (Fig. 10^1). 
Observation alone leaves the patient unprotected 
against pulmonary embolism, and operative 
thrombectomy is reserved for limb salvage in 
the presence of impending venous gangrene. 
Obviously, if anticoagulation is contraindicated 
(as in the patient presented), thrombolytic ther- 
apy cannot be used. 




Greenfield 

tiller 



Figure 10-4. 

Surgical prevention of pul- 
monary embolism. Large 
emboli can be trapped by 
partial interruption of the 
IVC (Greenfield filter). 
(Reproduced, with permis- 
sion, from Way LW: Current 
Surgery Diagnosis & Treat- 
ment, 10th ed. Appleton & 
Lange, 1994.) 



232 



10: Vascular 



30. (A) The relatively benign course of intermit- 
tent claudication has been well established. The 
risk of gangrene developing within 5 years in 
an extremity with claudication as the only 
symptom is only about 5%. The patient must be 
encouraged to stop smoking, to exercise, and be 
placed on a diet that lowers cholesterol. 

31. (D) The occurrence of bowel movements 
during the first 24-72 hours after repair of an 
abdominal aortic aneurysm (especially if the 
hemoccult test is positive), should raise suspi- 
cion for ischemic colitis. It may develop as a 
result of interruption of flow to the inferior 
mesenteric artery with inadequate collateral 
circulation from either the superior mesenteric 
artery or the iliac arteries. Aortoduodenal fis- 
tula is a late complication of aneurysm repair. 
Pseudomembranous enterocolitis occurs late 
in the postoperative course. 

32. (D) Popliteal aneurysms are usually arte- 
riosclerotic and are bilateral in at least 50% of 
cases. Any popliteal aneurysm twice the size of 
the normal artery is an indication for surgical 
repair. Although often asymptomatic and 
small, they should be treated surgically because 
of their propensity to produce limb-threatening 
ischemia related to thrombosis or embolism. 
Spontaneous rupture and/or nerve compres- 
sion are rare complications of a popliteal 
aneurysm. The ideal repair consists of ligation 
of the aneurysm, including its branches and a 
bypass to the open distal vessels. 

33. (B) The presence of acute vascular collapse with 
history of abdominal or flank pain and associ- 
ated pulsating abdominal mass is characteristic 
of a ruptured abdominal aneurysm. Operation 
should be performed as quickly as possible, 
because the first priority is to control the hem- 
orrhage. No time should be lost in obtaining 
diagnostic studies, because these patients often 
crash in the radiology suite. These patients 
should not be resuscitated aggressively, because 
an increase in systolic pressure will only cause 
more intra-abdominal hemorrhage. 

34. (E) The clinical picture presented is that of a sub- 
clavian artery stenosis resulting in subclavian 



steal syndrome, represented by vertebrobasilar 
symptoms and extremity ischemia. The symp- 
toms are due to a decrease of posterior circulation 
(vertebral artery) blood flow. Claudication occurs 
more commonly than ischemic findings. Most 
patients have no triggering events, and the 
symptoms are not readily reproducible. Carotid 
subclavian bypass restores the circulation 
beyond the stenotic area and corrects the steal 
syndrome. Ligation of the vertebral artery will 
correct the steal syndrome but will not improve 
the circulation of the arm. Anticoagulation has no 
role in the treatment of this entity. Other treat- 
ment options include subclavian artery transpo- 
sition, axilloaxillary bypass, and subclavian 
artery angioplasty. Coarctation of the aorta 
results in pulse and pressure difference between 
the upper and lower extremities. 

35. (D) Spontaneous thrombophlebitis in this age 
group is unlikely. Plantaris or gastrocnemius 
tear may occur during physical exertion involv- 
ing running or walking, causing a sharp pain in 
this region. After resolution of a hematoma in 
this region, it may be difficult to exclude cel- 
lulitis if there is any question that the integrity 
of the skin has been damaged. In superficial 
thrombophlebitis, there is tenderness along the 
distribution of the long or short saphenous 
veins. A tear of the medial lemniscus of the knee 
joint is detected by tenderness over the medical 
aspect of the knee joint during flexion and inter- 
nal rotation of the knee joint (McMurray sign). 

36. (A) Patients with atrial fibrillation are more 
likely to develop emboli to different sites 
throughout the body. Nonocclusive ischemic 
disease is characterized by spasm of the major 
mesenteric arterial vessels, with a characteris- 
tic beading effect. Early recognition may result 
in improvement with direct intra-arterial infu- 
sion of papaverine (which causes vasodilation), 
thus avoiding operative intervention. 

37. (E) Clinical findings of peritoneal irritation and 
leukocytosis in patients with suspected visceral 
ischemia indicate necrosis of ischemic bowel. 
Immediate arteriography is required to establish 
the diagnosis and initiate treatment to restore 
circulation before massive bowel infarction, 



/Answers: 30-47 



233 



acidosis, and possible perforation occur. The 
most likely diagnosis is a mesenteric embolus 
arising from the heart, especially in the pres- 
ence of atrial fibrillation. The catheter should be 
left in place to allow papaverine infusion to an 
area of borderline ischemic bowel. 

38. (C) Among all causes of renovascular hyper- 
tension, FMD responds best to angioplasty. 
Intermediate results of PTA for FMD are similar 
to those of bypass. PTA has lower morbidity, 
causes less discomfort, and is less expensive. 
Recurrence can be treated by repeated PTA. 

39. (C) The heart is the origin of about 90% of 
lower extremity emboli. The causes are usu- 
ally mitral stenosis, atrial fibrillation, or MI. A 
rare source of left atrial emboli is a left atrial 
myxoma. The remaining 10% arise from ulcer- 
ated plaques in the aorta or peripheral arteries. 
Paradoxical emboli arising from the venous 
system may reach the arterial circulation through 
a patent foramen ovale. 

40. (D) Arterial emboli usually lodge proximal to 
bifurcations, the most common site being the 
common femoral artery. 

41. (A) Once the diagnosis is made clinically, 
heparin is administered intravenously to pre- 
vent the development of thrombi distal to 
the embolus. Then embolectomy can be done 
in most instances under local anesthesia. 
Arteriography to confirm what is already clin- 
ically apparent only delays the needed surgical 
procedure. If there is a doubt, duplex evalua- 
tion will help confirm the diagnosis. Lumbar 
sympathectomy locks are of dubious value. In 
patients who have known occlusive disease, 
absent pulses in the contralateral extremity, 
absence of clinical features of hyperacute 
ischemia would be best managed by an angio- 
gram and thrombolytic infusion. 

42. (A) Patients with combined segmental occlu- 
sive disease require correction of proximal 
hemodynamic ally significant disease before 
distal (infrainguinal) bypass. Only about 20% 
of patients undergoing aortofemoral recon- 
struction in the presence of superficial femoral 



artery occlusion will subsequently require 
femoropopliteal bypass. Combined procedures 
should be reserved for patients with severe life- 
threatening ischemia. Lumbar sympathectomy 
and vasodilator therapy are ineffective in treat- 
ing severe arterial occlusive disease. 

43. (C) Most patients are unaware of their abdominal 
aneurysm until it is incidentally discovered by 
their physician. The importance of careful deep 
palpation of the abdomen cannot be overem- 
phasized. On occasion, these aneurysms may 
expand, causing abdominal or back pain, and 
may even leak or rupture, mimicking other acute 
intra-abdominal conditions. Signs and symptoms 
of acute ischemia in the lower extremities are rare 
and usually follow thrombosis or embolization 
from an abdominal aneurysm. 

44. (B) Leriche syndrome consists of the manifesta- 
tions of aortoiliac occlusive disease and includes 
thigh and buttock claudication, atrophy of the 
leg muscles, diminished femoral pulses, and 
impotence in men. 

45. (B) The Nicoladoni-Branham sign can be elicited 
in some patients with an AV fistula. Occlusion of 
the fistula or the artery proximal to the fistula 
may result in slowing of the heart rate. By 
this compression, the peripheral resistance is 
increased, venous return is decreased, and the 
pulse rate falls. 

46. (B) Peripheral nerve endings are the tissues most 
sensitive to anoxia in the extremity. Therefore, 
paralysis and paresthesia are most important 
when evaluating an extremity with acute arterial 
occlusion. The second most sensitive tissue is 
the muscle. This is why an extremity with paral- 
ysis and paresthesia will develop gangrene if 
circulation is not restored. Gangrene is less likely 
to occur if signs of ischemia are present, but 
motor and sensory functions are intact. 

47. (E) The use of an extra-anatomic bypass (axil- 
lobifemoral) is indicated in the presence of 
"hostile" abdomen (infection, dense and severe 
adhesions, tumors) or if the patient is too sick to 
undergo an abdominal operation. If a previ- 
ously placed graft is contaminated (infection, 



234 



10: Vascular 



aortoenteric fistula), the graft must be removed, 
and the enteric defect must be closed. Although 
some surgeons advocate removing the infected 
graft and replacing it in situ with a new graft, the 
safest approach remains the extra-anatomic 
route to restore circulation to the lower extrem- 
ities (axillobifemoral bypass). 

48. (C) Compartment syndrome can occur follow- 
ing repair of vascular injuries, especially if 
ischemia time is more than 6 hours or if there 
have been substantial periods of shock. Other 
instances include the combination of arterial 
and venous injury and the presence of con- 
comitant soft-tissue crush injury or bone frac- 
ture. Compartment swelling and tenderness, 
pain disproportionate to the physical findings, 
paresthesia, and weakness are all clinical signs 
of compartment syndrome and require urgent 
surgical decompression. A palpable pulse does 
not rule out the presence of a compartment 
syndrome, because compartment pressures are 
high, even before loss of a palpable pulse. 

49. (C) Rapid warming of the injured tissue is the 
most important aspect of treatment. The frozen 
tissue should be placed in warm water, with a 
temperature in the range of 408-448°C. Dry 
heat or hot water carries the risk of thermal 
injury because of decreased sensation in the 
injured part. Opening of blisters and debride- 
ment of devitalized tissue are contraindicated. 
Demarcation of gangrenous areas should be 
carefully observed, often for several weeks, 
before amputation is performed. The extremity 
should be elevated, tetanus prophylaxis should 
be administered as indicated, and antibiotics 
should be given in the presence of open wounds. 

50. (A) Carotid body tumors are usually 3^1 mm in 
size and are located at the carotid bifurcation. 
They arise from nests of chemoreceptor cells 
of neuroectodermal origin (carotid body). In 
normal individuals, the carotid body responds 
to a fall in P0 2 and pH and to a rise in PC0 2 and 
temperature to cause an increase in cardiac con- 
traction, heart rate, and respiratory rate. Carotid 
body tumors are uncommon, slow growing, and 
highly vascular. Although large tumors may 
cause compression of the vagus or hypoglossal 



nerves, most tumors present as a palpable pain- 
less mass at the carotid bifurcation. The treat- 
ment is definitely excision whenever possible. 

51. (D) PTA is technically successful in approxi- 
mately 90% of iliac lesions with good patency 
rates. It is more successful for single short 
stenoses rather than multiple long stenosis or 
occlusions. The advantages of PTA is that it is 
less invasive than surgery, has a lower initial 
cost, has a shorter hospital stay, and lower mor- 
bidity, enables an earlier return to full activity, 
and the procedure can be repeated without an 
increase in morbidity or a decrease in clinical 
result. It is particularly useful for patients who 
are at high operative risks. The ideal procedure 
would be and angioplasty and stent placement. 

52. (D) Aortography and renal ultrasound can detect 
the presence of renal artery stenosis, but they do 
not determine the functional significance of the 
lesion. IVP is not a sensitive enough test to detect 
the presence of renal artery stenosis. A renal scan 
can show decreased flow (uptake) or decreased 
function of the affected kidney, but it, too, lacks 
sensitivity. The assessment of renal vein renin 
levels is a good diagnostic test to determine the 
physiologic significance of renal artery stenosis. 
It indicates whether the stenosis is significant 
enough to decrease the glomerular filtration rate 
and cause the release of renin. In addition, the 
opposite kidney should have suppression of 
renin secretion. 

53. (D) Normal radiographic findings in the pres- 
ence of severe knee trauma should raise suspi- 
cion for posterior dislocation of the knee, which 
is often associated with popliteal artery throm- 
bosis. A careful vascular examination should, 
therefore, be made in such a situation. The pres- 
ence of pain, pallor, and pulselessness (three of 
the five p's) is indicative of severe ischemia. This 
patient should undergo urgent exploration for 
vascular repair. The other options are unlikely to 
cause the signs and symptoms presented. 

54. (B) Amaurosis fugax, one type of TIA, is a man- 
ifestation of carotid bifurcation atherosclerotic 
disease. It is manifested by unilateral blindness, 
being described by the patient as a window 



/Answers: 48-59 



235 



shade across the eye, lasting for minutes or 
hours. It is caused by microemboli from a carotid 
lesion lodging in the retinal artery the first intrac- 
erebral branch of the internal carotid artery. 

55. (C) Patients with sudden severe ischemia are 
prone to "ischemia-reperfusion" syndrome. With 
revascularization, there is sudden release of the 
accumulated products of ischemia into the cir- 
culation; namely, potassium, lactic acid, myo- 
globin, and cellular enzymes. Hyperkalemia, 
metabolic acidosis, and myoglobinuria (red 
urine, clear plasma) are the key features of 
the syndrome. Renal tubular acidosis results 
in myoglobin deposition in the renal tubules. 
Anticipation and early recognition require the 
induction of diuresis with mannitol, alkaliniza- 
tion of the urine to avoid precipitation of myo- 
globin in the renal tubules, and correction of 
hyperkalemia. 

56. (D) Despite receiving optimal treatment for 
DVT, approximately 50% of the patients will 
develop the post-thrombotic syndrome. The 
recanalization of the deep veins will result in 
deformity and subsequently incompetence of 
the affected venous valves. Although patients 
with DVT can develop infections secondary to 
edema, these are usually located about the 
ankle and resolve with adequate treatment. 
Patients adequately treated for DVT are not at 
increased risk of developing pulmonary embo- 
lus. Neither the arterial circulation nor the 
superficial venous system are affected by the 
development of DVT. Young patients with 
iliofemoral thrombosis are best managed by 
thrombolytic infusion, which has been shown 
to preserve valvular function and decrease the 
incidence of postphlebitic syndrome. 

57. (A) The causes of graft failure can be divided 
into early and late. Although early failure of 



vein grafts is usually attributed to either tech- 
nical error or inadequate outflow tract, late fail- 
ure is usually related to progressive proximal 
or distal atherosclerotic disease. Other less 
common causes of late graft failures include — 
local stenotic areas from trauma or endothelial 
damage, valve stenosis from fibrosis, and venous 
aneurysms and subsequent thrombosis. Intimal 
hyperplasia is a rare cause of late failure. 

58. (C) Occlusion or stenosis of the subclavian 
artery proximal to the origin of the vertebral 
artery results in the "subclavian steal" syn- 
drome. In response to decreased pressure in the 
distal subclavian artery, especially in instances 
in which increased perfusion is needed, there is 
reversal of flow in the vertebral artery. The clin- 
ical picture is that of vertebrobasilar symptoms 
in association with upper extremity exercise. 
Although this phenomenon is sometimes seen 
on duplex scanning or angiography evolution 
into a clinical syndrome is relatively rare. The 
other mentioned options do not result in retro- 
grade flow in the vertebral artery. 

59. (C) Lymphedema is classified by etiology — pri- 
mary versus secondary. Primary lymphedema 
is divided into congenital, praecox, and tarda, 
depending on the age of onset. The diagnosis of 
Milroy disease is reserved for patients with 
familial lymphedema in which clinical factors 
are present at birth or noticed soon thereafter. 
Lymphedema is classified as praecox if the age 
of onset is between 1 and 35 years. Meigs' 
disease is the familial form of primary lym- 
phedema praecox. If the onset of primary lym- 
phedema is after 35 years of age, it is called 
lymphedema tarda. Secondary lymphedema 
usually results from a disease process that 
causes obstruction of the lymphatic system. 



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CHAPTER 11 



Neurosurgery 

Kamran Tabaddor, MD 



Questions 



DIRECTIONS (Questions 1 through 58): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 



A 43-year-old man experiences lower back pain 
after lifting a heavy object off the ground. The 
following morning, he notices that the pain has 
begun to radiate down the posterolateral aspect 
of the right leg and across the top of the foot to 
the big toe. The pain is severe, electric in qual- 
ity, associated with paresthesia over the same 
distribution, and made worse by coughing. On 
examination, it is found that he has an area of 
diminished sensation to pinprick over the 
dorsum of the right foot and mild weakness in 
his right extensor hallucis longus muscle. The 
deep tendon reflexes are all intact. What is the 
most likely diagnosis? 

(A) Lumbar spinal fracture with compression 
of the cauda equina 

(B) Herniated lumbar disk on the right at 
the level of L4-L5 

(C) Herniated lumbar disk on the left at the 
level of L4-L5 

(D) Herniated lumbar disk on the right at 
the level of S1-S2 

(E) Intermittent claudication 



(A) 
(B) 



(C) 
(D) 

(E) 



A lesion at the right L4-L5 interspace 

Pathology where the nerve exits the 

spinal canal immediately above the 

pedicle of S3 vertebra 

A herniated nucleus pulposus 

Compression by the L5 lamina 

A lesion outside the vertebral column 



3. A 35-year-old secretary complains of severe 
pain in the neck that radiates down the right 
arm. The pain is electric in quality and affects 
specifically the radial aspect of the right forearm 
and the thumb. She also describes numbness 
and paresthesia over the same distribution. On 
physical examination, she is found to have an 
area of diminished sensation to pinprick over 
the right wrist and thumb. The right biceps 
tendon reflex is diminished, but there is no loss 
of muscle strength. She has right C5-C6 disk 
compression and radiculopathy affecting which 
of the following? 

(A) The right C4 root 

(B) The right C4 mixed spinal nerve 

(C) The right C4 anterior primary rami 

(D) The right C6 root 

(E) The right C6 spinal ganglion 



A 48-year-old woman has a lower back pain 
and hypoesthesia in the left SI dermatomal dis- 
tribution (left calf and lateral left foot). What is 
the most likely cause? 



237 



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238 



11: Neurosurgery 



Questions 4 and 5 

A 47-year-old man presents to the emergency depart- 
ment after falling from his bicycle. He claims that 
his neck was suddenly and violently hyperflexed. 
Although he is currently complaining of neck pain, 
his chief complaint is weakness of the arms. On 
examination, he is found to have profound sym- 
metric weakness of both hands and wrists. His 
biceps and triceps are moderately weak. The lower 
extremities are only minimally weak, and he is able 
to ambulate, albeit with some difficulty. His sensa- 
tion to all modalities is within normal limits. Plain 
radiographs of his neck reveal no fracture or dislo- 
cation, but there is evidence of severe spondylosis 
with osteophytes narrowing the neural canal at 
C3-C4, C4-C5, and C5-C6. 

4. What is the most likely mechanism of injury? 

(A) Brachial plexus injury 

(B) Epidural hematoma 

(C) Contusion of the spinal cord 

(D) External carotid artery occlusion 

(E) Internal jugular vein occlusion 

5. What is this pattern of motor findings that 
results from this injury termed? 

(A) Central cord syndrome 

(B) Cervical radiculopathy 

(C) Cauda equina syndrome 

(D) Lhermitte sign 

(E) Posterior cord syndrome 

Questions 6 and 7 

A 57-year-old woman is referred to you for evalua- 
tion of difficulty with ambulation. Her chief com- 
plaint is weakness of her left leg that has been slowly 
progressive over the last 6 months. On neurologic 
examination, her mental status and cranial nerve 
findings are within normal limits. She has marked 
(grade 4-5) weakness of both her left leg and arm. 
On her left side, she has diminished sensation to 
light touch and vibration below the C5 dermatome. 
Sensation to pinprick and temperature are severely 
diminished on the right side below approximately 
the C8 dermatome. Her deep tendon reflexes and 
muscle tone are increased on the left. 



6. This pattern of neurologic deficits is which of 
the following? 

(A) Spondylolisthesis 

(B) Brown-Sequard syndrome 

(C) Central cord syndrome 

(D) Guillain-Barre syndrome 

(E) Poliomyelitis 

7. This pattern of neurologic deficits is explained 
by injury to the spinal cord with damage to 
which of the following? 

(A) Anterior horn cells 

(B) Peripheral neuropathy 

(C) Central cord 

(D) Right half (right hemicord) 

(E) Left half (left hemicord) 

8. A 73-year-old man presents for evaluation of 
weakness in his lower extremities and recurrent 
falls. On further questioning, the patient admits 
to having frequent spasms affecting both of his 
lower extremities. He also claims that his legs 
occasionally feel as if ants were crawling all over 
them. On neurological examination, he is found 
to have a slightly unstable gait and with mini- 
mal flexion of the knees. His strength is slightly 
but symmetrically diminished in both lower 
extremities and both triceps muscles. There is 
decreased sensation to vibration and light touch 
below approximately the level of the nipples 
bilaterally. In both lower extremities, muscle 
tone is markedly increased, and deep tendon 
reflexes are hyperactive. Babinski's reflex is pres- 
ent bilaterally. What is the most likely diagnosis? 

(A) A thoracic spinal cord compression 

(B) A thoracic radiculopathy 

(C) A cervical myelopathy 

(D) Cerebellar tumor 

(E) Intracranial aneurysm 

9. An 87-year-old woman is referred to you for 
evaluation of lower back pain. It is exacerbated 
by walking or prolonged standing and occa- 
sionally made better by bending over. Physical 
examination reveals a thin, elderly woman 
who walks with a cane with her lower back 
moderately flexed. Motor power in her lower 



Questions: 4-12 



239 



extremities is normal, but she has impaired 
sensation to light touch and vibration below 
the L4 dermatome bilaterally. Deep tendon 
reflexes are normal in her upper extremities 
but absent in both lower extremities. You refer 
her for magnetic resonance imaging (MRI) of 
the lumbosacral spine. What will be the most 
likely finding on this study? 

(A) Lumbar spinal stenosis 

(B) A fracture of the odontoid process 

(C) A herniated L3-L4 disk causing unilateral 
compression of the L4 root 

(D) Spinal cord compression at the level of 
LI vertebra level 

(E) Spinal cord compression at the Tl 
vertebra level 

10. A 33-year-old man is brought to the emergency 
department after being involved in a major 
motor vehicle accident. He is unable to move his 
legs and complains of severe pain in his mid 
to lower back. On physical examination, he is 
found to have exquisite tenderness over some of 
the bony prominence of his lower back, but no 
gross physical deformity can be appreciated. On 
neurologic examination, flaccid paralysis of both 
lower extremities and complete anesthesia to all 
sensory modalities below approximately the L3 
dermatome are noted. Catheterization of his 
bladder yields approximately 700 mL of urine. 
Plain radiographs of the spine reveal compres- 
sion fracture in the body of L3 with greater than 
50% of loss in its height. A computed tomogra- 
phy (CT) scan through this area reveals a burst 
fracture of the body of L3. There are large frag- 
ments of bone driven dorsally with an 80% canal 
compromise. What is the cause of weakness? 

(A) Compression of the conus medullaris 

(B) Compression of the spinal cord at the 
level of L3 

(C) Compression of the cauda equina 

(D) Rupture of the anterior spinal ligament 

(E) Associated epidural hemorrhage 



Questions 11 and 12 

A 17-year-old boy suffers a hyperextension injury of his 
neck when he jumps headfirst into a shallow pool. He 
does not lose consciousness. He arrives at the emer- 
gency department holding his neck stiffly and com- 
plaining of severe neck pain. He says the pain is 
particularly severe whenever he tries to move his head. 
He says he has no neurologic symptoms such as weak- 
ness, numbness, or paresthesia. On physical examina- 
tion, he is found to have no areas of ecchymosis or 
deformity on the cervical spine. He has exquisite pain 
on deep palpation of the bony prominence of the mid- 
cervical spine. There are no neurological signs. Routine 
plain radiographs (anteroposterior [AP], lateral, open- 
mouth view) of the cervical spine in the neutral posi- 
tion show no fracture or subluxation of the bony 
elements. There is, however, thickening of the pretra- 
cheal space ventral to the body of C6, suggesting soft- 
tissue swelling. 

11. What would the next step in management 
involve? 

(A) Analgesics alone 

(B) A hard cervical collar 

(C) Internal fixation of the cervical vertebra 

(D) Burr holes and traction 

(E) Plaster cast to face, neck, and thorax 

12. What would be the most appropriate radio- 
logic examination? 

(A) Plain lateral radiographs in flexion and 
extension to rule out occult ligamentous 
tear and instability of the cervical spine 

(B) A CT scan of the cervical spine to rule 
out the possibility of a bony fracture not 
seen on plain radiographs 

(C) Lateral tomogram of the cervical spine 
to rule out the possibility of an occult 
fracture 

(D) Angiography 

(E) Ultrasound of the neck 



240 



11: Neurosurgery 



Questions 13 and 14 

A 63-year-old woman with a history of local inopera- 
ble breast cancer is referred to you for the evaluation of 
new-onset diplopia. Upon questioning, she admits that 
diplopia occurs mostly when she attempts to look at 
objects in the distance and when she attempts to look 
toward the left side. In addition, she reports having 
severe headaches and an electric-type discomfort 
affecting her right deltoid region for approximately 
3 weeks. On neurologic examination, she is found to 
have left abducens (sixth) nerve palsy; the rest of her 
cranial nerves are intact. She also has mild weakness of 
the right deltoid and a diminished biceps tendon jerk 
on the same side. Findings on an MRI of the brain with 
intravenous contrast are unremarkable. 

13. In this patient, what would be the most likely 
site where metastasis occurs? 

(A) Brain 

(B) Orbital cavity 

(C) Meninges 

(D) Cerebellum 

(E) Optic chiasm 

14. What would the next step in management 
involve? 

(A) An MRI of the cervical spine to rule out 
metastatic deposits within the cervical 
roots 

(B) A CT scan of the brain with intravenous 
contrast 

(C) A lumbar puncture to measure opening 
pressure and obtain cerebrospinal fluid 
(CSF) for cytologic analysis 

(D) Repeated breast biopsy 

(E) No further tests until further symptoms 
develop 

15. A 57-year-old woman presents to the emergency 
department with new-onset seizures. She was 
witnessed by her husband to have a general- 
ized seizure lasting approximately 1 minute. She 
has smoked 1 pack of cigarettes a day for over 
40 years. In the past 3 months, she has lost 25 lb 
in weight. On examination, she appears thin 
and nervous but findings on her neurologic 
examination are otherwise essentially within 



normal limits. Plain radiographs of the chest 
obtained in the emergency department show a 
4-cm nodule in the upper lobe of her right lung. 
To exclude cerebral metastasis as a cause of her 
seizure, what should the next test requested be? 

(A) An electroencephalogram (EEG) 

(B) A CT scan of the brain with intravenous 
contrast 

(C) A spinal tap to measure opening pressure 
and obtain CSF for cytology 

(D) An MRI of the brain with intravenous 
contrast 

(E) Doppler ultrasound 

Questions 16 and 17 

A 58-year-old woman is admitted from the emergency 
department with a history of approximately 2 weeks 
of headache. She has a history of breast cancer. Her 
headache is severe, particularly in the mornings when 
she wakes up. It is accompanied by occasional vom- 
iting. She says she experiences no focal weakness, 
numbness, or paresthesia. On physical examination, 
she is found to have a mild weakness of her left arm. 
An MRI of the brain with intravenous contrast reveals 
the presence of a neoplasm in the right motor cortex 
that is considered responsible for her weakness. 

16. If the MRI shows multiple brain metastasis, 
what should be the treatment required in addi- 
tion to corticosteroids? 

(A) Whole-brain radiotherapy 

(B) Craniotomy to resect the lesion 
responsible for her left arm weakness 

(C) Chemotherapy 

(D) Placement of an Ommaya reservoir for 
use in treatment by intrathecal 
chemotherapy 

(E) No further treatment 

17. If the MRI shows a single brain metastasis, 
what should be the next step in management? 

(A) Whole-brain radiotherapy 

(B) Craniotomy to resect the lesion 
responsible for her left arm weakness 

(C) Chemotherapy 



Questions: 13-21 



241 



(D) Placement of an Ommaya reservoir for 
use in treatment by intrathecal 
chemotherapy 

(E) No further treatment 

18. A 63-year-old woman presents with a several- 
week history of headaches and difficulties with 
speech. A sister who lives with her claims that 
her language "has recently not been making 
much sense" and that she is a bit confused. Her 
condition seems to be deteriorating. On neu- 
rologic examination, she has a moderately 
severe aphasia, with difficulty understanding 
language and following commands, and she 
makes frequent paraphasic errors when she 
speaks. There are no other motor or sensory 
deficits. An MRI with intravenous contrast 
reveals the presence of a ring-enhancing mass 
lesion within the substance of the left temporal 
lobe. The lesion is approximately 3 cm in great- 
est diameter, poorly demarcated from the sur- 
rounding brain, and surrounded by a moderate 
amount of cerebral edema. Findings on rou- 
tine admission tests, including a chest x-ray 
and serum chemistry, are unremarkable. What 
is the most likely diagnosis? 

(A) Low-grade cerebral astrocytoma 

(B) Glioblastoma multiforme 

(C) Metastasis to the brain from an occult 
primary cancer 

(D) Meningioma 

(E) Glomus tumor 

19. A 64-year-old man presents with headache and 
left-sided upper extremity weakness. The MRI 
findings suggest that this is a glioblastoma 
multiforme. This is because the tumor exhibits 
which of the following? 

(A) It is regular in shape. 

(B) It is well demarcated from surrounding 
brain tissue. 

(C) It shows a ring pattern of enhancement 
with intravenous contrast and has a 
nonenhancing necrotic center. 

(D) It shows an absence of surrounding 
white-matter edema. 

(E) It arises from the carotid body. 



20. A 63-year-old woman presents for workup to 
determine the reason for a gradual hearing loss 
over approximately 5 years and intermittent 
tinnitus over the last several months. Findings 
on physical and neurologic examination are 
entirely within normal limits, except for the 
presence of sensorineural hearing loss in the 
left ear. She has no cranial nerve deficits. An 
MRI of the brain with gadolinium reveals the 
presence of an extra-axial tumor in the region 
of the left cerebella-pontine angle. What is the 
most likely diagnosis? 

(A) Epidermoid tumor (cholesteatoma) 

(B) Glioblastoma multiforme 

(C) Meningioma 

(D) Acoustic neuroma 

(E) Glomus tumor 

Questions 21 and 22 

A 4-year-old boy is brought to the emergency depart- 
ment with the complaint of approximately 2 weeks of 
headache and vomiting. He was seen in the emer- 
gency department 1 week earlier with the same com- 
plaints. At that time, his parents were told that the 
probable cause was a gastrointestinal virus, and 
the boy was sent home. His symptoms have not 
improved. On general examination, the child appears 
somewhat dehydrated and has a dry mouth and 
sunken eyes. His examination findings are also 
remarkable for the presence of bilateral papilledema 
and marked nystagmus. An MRI with intravenous 
contrast is obtained that reveals the presence of a 
2-cm mass in the posterior fossa. The mass is entirely 
within the fourth ventricle and appears to be arising 
from the vermis of the cerebellum. It enhances uni- 
formly with contrast. The lateral and third ventricles 
are moderately dilated with hydrocephalus. 

21. What is the most likely diagnosis? 

(A) Acoustic neuroma 

(B) Craniopharyngioma 

(C) Medulloblastoma 

(D) Brain metastasis 

(E) Polycystic cerebellar astrocytoma 



242 



11: Neurosurgery 



22. If at craniotomy the tumor found is not that 
listed in question 21 and the pathologist reports 
that it is a benign lesion, what is that lesion? 

(A) Ependymoma 

(B) Choroid plexus papilloma 

(C) Polycystic (cystic) cerebellar astrocytoma 

(D) Teratoma 

(E) Dermoid cyst 

Questions 23 and 24 

A 5-year-old girl undergoes debulking of medul- 
loblastoma. She undergoes a repeat MRI of the brain 
with intravenous contrast, which shows a small 
amount of enhancement consistent with limited resid- 
ual tumor. She is given a full course of radiotherapy 
to the posterior fossa and does very well for 6 weeks, 
until she experiences difficulty in walking. Physical 
examination at this time indicates moderate weak- 
ness of both lower extremities (particularly on the 
right side) but strength in her upper extremities and 
cranial nerves are normal. Her sensation to light touch 
and vibration are intact, but she has diminished sen- 
sation to pinprick throughout her left leg. 

23. What should be the next step in management? 

(A) Repeat the MRI of the brain to rule out 
an early recurrence 

(B) Obtain a single-photon-emission CT 
(SPECT) scan of the brain to rule out the 
possibility of radiation-induced toxicity 

(C) Begin treatment with chemotherapy for 
the residual tumor within the brain 

(D) Obtain an MRI or myelogram of the 
entire spinal axis to rule out the 
possibility of "drop metastasis" from the 
medulloblastoma 

(E) Obtain an ultrasound of the lumbar spine 

24. What should treatment of this girl involve? 

(A) Removal of recurrent medulloblastoma 
and neck dissection 

(B) Ventriculoperitoneal shunt 

(C) Repeat irradiation to the posterior cranial 
fossa 



(D) Complete craniospinal irradiation with 
local boosts to the areas where tumor 
nodules are detected 

(E) Cortisone alone 

25. A 35-year-old man is brought to the hospital 
unconscious after being resuscitated in an ambu- 
lance from the site of a motor vehicle accident. 
No other history or information is available. 
On general inspection, he is found to have mul- 
tiple bruises over his body and has a massively 
swollen left thigh. His vital signs are stable with 
a heart rate of 100 beats per minute (bpm) and 
a blood pressure of 150/75 mm Hg. He is 
obtunded and does not follow commands or 
open his eyes. He withdraws his left arm and 
leg from painful stimuli, but not his right. His 
left pupil is 3 mm in diameter, and it is slug- 
gishly reactive to light, while his right is 5 mm 
in diameter and fixed. Corneal reflexes are pres- 
ent bilaterally. His pulse rate is 120 bpm and res- 
piration rate is 40 breaths per minute. To avoid 
injury to his spinal cord by an unstable cervical 
spine, an order is issued to not perform testing 
of his doll's eye reflex. Intracranial hemorrhage 
causing increased intracranial pressure (ICP) is 
suspected, along with a right uncal herniation. 
What is the next step in management? 

(A) Intubation of his airway for 
hyperventilation and administration of 
intravenous mannitol 

(B) Immediate CT scanning of the brain to 
confirm the presence of the suspected 
intracranial hemorrhage 

(C) Intubation of his airway for 
hyperventilation and intravenous 
administration of corticosteroids 

(D) Immediately evacuation of the suspected 
intracranial hematoma 

(E) Controlled hypoventilation 

26. In the management of a 64-year-old woman 
struck by a car, mannitol is given to do which 
of the following? 

(A) Increase CSF formation 

(B) Increase the respiratory rate 



Questions: 22-29 



243 



(C) Increase the pulse rate 

(D) Replace extensive fluid loss 

(E) Lower raised ICP 

27. A 17-year-old boy is brought to the emergency 
department after he was assaulted. Witnesses 
claim that he was hit on the head with a lead 
pipe, after which he was unconscious for sev- 
eral minutes. No seizure activity was wit- 
nessed. On arrival, he complains of a headache, 
particularly severe at the point where he was 
hit in the right frontoparietal region. On exam- 
ination, he is found to have swelling and ecchy- 
mosis over this region. He is awake, alert, and 
fully oriented. A complete neurologic exami- 
nation reveals no deficit. Plain radiographs of 
the skull show a linear, nondepressed skull 
fracture in the frontoparietal skull that crosses 
the groove of the medial meningeal artery. 
During the following hour, he becomes sleepier 
and begins to vomit. A repeat neurologic exam- 
ination at that time reveals him to be lethargic 
but without weakness, numbness, paresthesia, 
or other focal deficit. What is the most likely 
cause of the neurologic deterioration? 

(A) Diffuse axonal injury (DAI) 

(B) Todd's phenomenon 

(C) Subdural hematoma 

(D) Epidural hematoma 

(E) Trigeminal ganglion hematoma 

28. Following a sudden impact in an accident, the 
34-year-old race car driver becomes uncon- 
scious and is admitted to the hospital. A CT 
scan is performed, and a right space-occupying 
lesion is noted (Fig. 11-1). What is the most 
likely diagnosis? 

(A) Corpus callosum injury 

(B) Pituitary apoplexia 

(C) Acute subdural hematoma 

(D) Acute epidural hematoma 

(E) Chronic subdural hematoma 

29. A 44-year-old woman was brought to the emer- 
gency department after she was involved in a 




Figure 11-1. 

(Reproduced, with permission, from Doherty GM: Current 
Surgical Diagnosis and Treatment, 12th ed. 876. McGraw- 
Hill, 2006.) 



high-speed motor vehicle accident. She was 
extracted from the wreckage by paramedics. 
She was intubated at the site and rushed to the 
emergency department. On arrival, her blood 
pressure was 160/80 mm Hg and heart rate 
was 100 bpm, and exam showed evidence of 
decerebrate rigidity. A CT scan of the head 
revealed small punctate hemorrhages in the 
corpus callosum and the midbrain tegmentum, 
but there was no mass effect on adjacent struc- 
tures. The size of the ventricles was normal. 
This grave clinical presentation and these CT 
findings are most consistent with the diagnosis 
of which of the following? 

(A) DAI 

(B) Cerebral contusion 

(C) Cerebral concussion 

(D) Traumatic subarachnoid hemorrhage 
(SAH) 

(E) Petrous temporal lobe fracture 



244 



11: Neurosurgery 



30. A 43-year-old man presents to the emergency 
department after falling down a flight of stairs 
and landing on his head. He did not lose con- 
sciousness. He complains of severe headache, 
marked decreased acuity in hearing in the left 
ear, and a "runny nose" since the fall. On phys- 
ical examination, he is found to have a left- 
sided Battle's sign (an ecchymosis in the area of 
the left mastoid process) and hemotympanum. 
He has a constant dripping of a clear, watery 
fluid through his nose. Findings on his neuro- 
logic examination, other than the hearing loss, 
are completely normal. X-ray studies will 
reveal which of the following? 

(A) A fracture of the cribriform plate with a 
CSF leak into the paranasal sinuses 

(B) A skull-base fracture with a mucocele 

(C) A temporal bone fracture with 
paradoxical rhinorrhea 

(D) Occipital bone fracture 

(E) Fracture of the maxillary antrum and 
greater wing of the sphenoid 

31. A 52-year-old painter injured his lower back 3 
weeks ago when he fell off a ladder. He pres- 
ents for evaluation of abnormal findings on 
plain radiographs of his lumbar spine. His pain 
has subsided, and he is now asymptomatic. 
Physical examination reveals a dense tuft of 
hair in his lumbosacral region that has been 
present for as long as he can remember. There 
is no tenderness or palpable abnormality in his 
spine. Findings on his neurologic examination 
are unremarkable. The radiographs mentioned 
show absence of the spinous processes and 
laminae at the levels of L5 and SI, with their 
corresponding pedicle displaced and angled 
laterally. What is the diagnosis? 

(A) An L5-S1 spondylolisthesis 

(B) A burst fracture of L5 and SI 

(C) Spina bifida 

(D) Spinal stenosis 

(E) Fracture of the vertebral bodies and 
nucleus pulposus 

32. In the investigation of chronic back pain, a 
72-year-old man is found on radiologic exam- 
ination to have congenital spondylolisthesis. 



The pathology is based upon disruption 
between two adjacent vertebra at which site? 

(A) Bodies and disks 

(B) Spinous process 

(C) Transverse process 

(D) Articular process(pars interarticularis) 

(E) Pedicle 

33. A baby is born with a 2.5- x 2.0-cm myelom- 
eningocele in the mid to lower lumbar region. 
Just hours after birth, he is rushed to the oper- 
ating room (OR) for repair of this defect. 
Approximately 48 hours later, the baby is doing 
well, but it is noted that his head circumference 
has increased by 2 cm. On examination, the 
fontanelle is found to be slightly bulging and 
tense. On neurologic examination, the baby is 
awake but is found to have no spontaneous sen- 
sory or motor function below approximately the 
L3 dermatome. An ultrasound of the brain is 
obtained through the open fontanelle. This study 
shows an enlarged ventricular system, consis- 
tent with the presence of hydrocephalus. What is 
the related abnormality responsible for the 
hydrocephalus? 

(A) A fourth-ventricle ependymoma 

(B) Stenosis of the aqueduct of Sylvius 

(C) Amelia (failure of limbs to develop) 

(D) Arnold-Chiari malformation 

(E) Nasopharyngeal hamartoma 

34. A 4-month-old infant has undergone surgical 
treatment for meningomyeloencephalocele. A 
CT tomogram of head was made immediately 
after birth (see Fig. 11-2). At birth, an operation 
was carried out in the posterior cranial fossa to 
partially replace brain cerebellar contents to 
an intracranial position. In investigations for 
progressive hydrocephalus, it is noted that 
there is herniation of the cerebellar tonsils 
through the foramen magnum, and a diagno- 
sis of Arnold-Chiari syndrome is established. 
This syndrome may also include which of the 
following? 

(A) Fusion of the frontal lobes 

(B) Fusion of the temporal, parietal, and 
occipital lobes 



Questions: 30-36 



245 




Figure 11-2. 

Tomogram from CT head taken 4 months previously (immediately after birth). Opening in the posterior cranial fossa showing brain and 
meninges protruding into sac (axial view). 



(C) Abnormal elongation of the medulla 
and lower cranial nerves 

(D) Partial or complete absence of the 
pituitary gland 

(E) Hypertrophy of cerebral lobes 

35. During a regular visit to the pediatrician 1 week 
after birth, an infant's size and head circumfer- 
ence are recorded as being in the seventy-fifth 
percentile. Repeat measurement 1 month later 
still shows the size of the baby at the seventy-fifth 
percentile, but the baby's head circumference is 
now at the ninty-fifth percentile. The pediatrician 
notices that the baby's anterior fontanelle is tense 
and that the skull sutures are open. He obtains an 
MRI of the brain with intravenous contrast. This 
study shows the presence of greatly dilated lat- 
eral and third ventricles. The aqueduct of Sylvius 
cannot be easily visualized. The fourth ventricle 
is small. There are no lesions within the sub- 
arachnoid space or cerebral parenchyma. The 
appearance of the MRI is consistent with which 
of the following? 



(A) 
(B) 
(C) 
(D) 



(E) 



Noncommunicating hydrocephalus 
Communicating hydrocephalus 
Normal-pressure hydrocephalus 
Arnold-Chiari malformation with 
herniation of the cerebellum into the 
foramen magnum 
Anencephalus 



36. A 64-year-old woman complains of gait imbal- 
ance, headache and deterioration of mental 
status over the past several months. Her vision 
is normal. A CT scan reveals hydrocephalus, 
but the lumbar puncture pressure is unexpect- 
edly low. What does she have? 

(A) Meningitis 

(B) Normal-pressure hydrocephalus 

(C) Sigmoid sinus thrombosis 

(D) Echinococcus 

(E) Glioblastoma multiforme 



246 



11: Neurosurgery 



37. A 23-year-old woman complains of progressive 
loss of vision and papilledema. Investigations 
show normal findings on CT scan. A lumbar 
puncture shows marked elevation of pressure. 
What is the most likely diagnosis? 

(A) Pseudotumor cerebri 

(B) Corpus cavernous thrombosis 

(C) Cavernous sinus thrombosis 

(D) Retinoblastoma 

(E) Chordoma 

38. During her eighth month of pregnancy, a 
29-year-old woman is noted to have hydram- 
nios. Further testing shows anencephalus. In 
this case hydramnios is caused by which of the 
following? 

(A) Impairment of the fetus's swallowing 
mechanism 

(B) Tumor of the fetus's brain 

(C) A secretory peptide from the placenta 

(D) Excess antidiuretic hormone (ADH) 
from the fetus 

(E) Renal agenesis 

39. A 28-year-old man presents with a history of 
chronic headache. The headache is intermit- 
tent, severe, poorly localized, and most often 
present when he arises in the morning. He suf- 
fered a severe blow to the head and sustained 
a skull fracture at the age of 15. Findings on his 
physical and neurologic examinations are 
within normal limits. An MRI of the brain with 
gadolinium reveals the presence of a large, 
nonenhancing extra-axial cyst in the region of 
the right temporal tip. This most likely repre- 
sents which of the following? 

(A) An arachnoid cyst 

(B) A cystic astrocytoma 

(C) Rathke's cleft cyst 

(D) A Dandy-Walker cyst (failure of proper 
formation of the foramina of Lushka 
and Magendie) 

(E) Polycystic disease 

40. A 15-year-old boy complains of right-sided 
weakness and gait impairment. A CT scan shows 
a large, nonenhancing cyst in the posterior 



cranial fossa, with an enhancing tumor nodule in 
the left cerebellum. What is the most likely 
diagnosis? 

(A) An arachnoid cyst 

(B) A cystic astrocytoma 

(C) Rathke's cleft cyst 

(D) Glioblastoma multiforme 

(E) A large sebaceous cyst 

41. A 56-year-old woman presents with a history of 
several months of pain involving both hands. 
She describes the pain as electric and severe. It 
is localized to the palmar aspect of the first three 
digits of each hand and associated with numb- 
ness. The pain is particularly severe in the 
morning when she wakes up. She reports no 
weakness of the hands, but she says that some- 
times objects fall off her hand because she 
cannot feel them. Physical examination reveals 
atrophy and weakness in the muscles of the 
thenar eminence bilaterally. She also has numb- 
ness in the distribution of the median nerve 
within the hands. Phalen test is positive. Which 
is the best test to confirm the clinical diagnosis? 

(A) An MRI of the hand to visualize an 
enlarged carpal ligament 

(B) An EMG and nerve-conduction study 

(C) MRI of the cervical spine to rule out 
radiculopathy 

(D) An x-ray of the hand 

(E) Physical examination 

Questions 42^4 

A 28-year-old police officer is brought to the emer- 
gency room (ER) by ambulance following a gunshot to 
the head. Emergency medical services (EMS) reports 
that he was found unresponsive at the site of the shoot- 
ing and was immersed in a pool of blood. There were 
no witnesses. On arrival to the emergency depart- 
ment, he is noted to have a bullet entry wound on the 
right frontal region without any exit wound. His blood 
pressure is 80/35 mm Hg, pulse rate 150 bpm, and on 
examination, he does not open his eyes or follow com- 
mands. He is unresponsive to deep painful stimuli 
such as testing by sternal rub. His pupils are dilated 
approximately 4 mm bilaterally, but sluggishly reac- 
tive. He is aggressively resuscitated with colloid and 



Questions: 37-45 



247 



blood products. The blood pressure is now 140/75 
mm Hg. There is improvement in his neurologic exam- 
ination — 1 hour after admission, he withdraws his 
limbs from painful stimuli. A CT scan shows a small- 
skull defect in the right frontal region, representing the 
bullet entry site. The bullet is lodged within the cere- 
bral parenchyma, approximately 2 cm from the surface 
of the brain, and there is a trail of bone fragments 
along the bullet path. The bullet has not crossed the 
midline. There is a 2 x 2 x 2.5-cm hematoma within the 
substance of the right frontal lobe with surrounding 
edema and subfalcian herniation. 

42. Which item is least likely to be useful as a prog- 
nostic marker for subsequent recovery? 

(A) Neurologic examination upon 
presentation and early response 

(B) The fact that the bullet did not cross the 
midline 

(C) The presence of an intracerebral 
hematoma 

(D) The presence of edema with subfalcian 
herniation 

(E) Bullet crosses the midcoronal plane 

43. What is the next step in management? 

(A) Administration of mannitol (1 g/kg) 
through a rapid IV infusion followed by 
the placement of an intracranial pressure 
monitor 

(B) Administration of mannitol (1 g/kg) 
through a rapid IV infusion followed by 
urgent craniotomy 

(C) Administration of mannitol (1 g/kg) 
through a rapid IV infusion followed by 
the placement of burr holes for emergent 
decompression of raised intracranial 
pressure 

(D) No treatment should be administered, 
because the patient's prognosis is poor, 
and he is unlikely to survive 

(E) Steroids and antibiotics alone 



44. Intraoperative management of this patient 
should be avoidance of which of the following? 

(A) Placement of an intracranial pressure 
monitor 

(B) Performance of a wide craniotomy for 
evacuation of the intraparenchymal 
hematoma 

(C) Extensive debridement of all bullet and 
bone fragments 

(D) Reconstruction of the cranial defect 
caused by the bullet 

(E) Removal of necrotic brain material 

Questions 45 and 46 

A 54-year-old-man comes to the emergency depart- 
ment complaining of a severe headache for several 
hours. He describes this headache as the worst of his 
life. It started suddenly "like a firecracker had gone 
off" inside his head. He has had no loss of con- 
sciousness but has had several episodes of vomiting. 
General physical examination reveals a patient who 
is in severe distress due to the headache. His blood 
pressure is 180/70 mm Hg, and his pulse racing at 
120 bpm. He is afebrile. He has photophobia and 
gross neck rigidity. Neurologically, he is fully alert 
and oriented. He has a normal motor and sensory 
examination. His left pupil is 2 mm and briskly reac- 
tive to light; his right is 4.5 mm and fixed to both 
light and accommodation. 

45. What is the most likely diagnosis? 

(A) Acute bacterial meningitis 

(B) Incipient uncal herniation due to an 
expanding lesion in the right temporal 
lobe 

(C) Acute SAH from an anterior 
communicating artery aneurysm 

(D) Acute SAH from a right posterior 
communicating aneurysm 

(E) Cavernous sinus thrombosis 



248 



11: Neurosurgery 



46. What is the most appropriate test to establish 
the diagnosis? 

(A) MRI of the brain with and without 
gadolinium 

(B) CT scan of the brain without contrast 

(C) A lumbar puncture 

(D) An electroencephalogram 

(E) Optometry 



47. 



A 43-year-old man is treated with pyridostig- 
mine for facial, ocular, and pharyngeal weak- 
ness due to myasthenia gravis. Which statement 
is true of pyridostigmine? 

(A) It is unrelated to neostigmine. 

(B) It has far more side effects than 
neostigmine. 

(C) Pyridostigmine and neostigmine reverse 
depolarizing neuromuscular blockade. 

(D) It causes greater muscarinic effect than 
neostigmine. 

(E) It is an anticholinesterase agent. 



48. During anesthesia using a narcotic, thiopental, 
and N 2 0, the respiratory response to a rising 
end-respiratory CO, tension is which of the fol- 
lowing? 

(A) Depressed only by the narcotic 

(B) Depressed only by thiopental 

(C) Depressed progressively by the addition 
of each agent 

(D) Depressed by the narcotic and thiopental, 
then elevated by N 2 

(E) Unchanged from control response 



49. 



A plastic surgeon is performing a minor pro- 
cedure on the face of an 18-year-old woman. 
She has a seizure that is attributed to the local 
anesthetic agent. Convulsion following an 
overdose of local anesthesia is best treated by 
which of the following? 

(A) Droperidol 

(B) Hydroxyzine (Vistaril) 

(C) Diazepam (Valium) 

(D) Fentanyl ketamine 



Questions 50 and 51 

50. A 17-year-old male presents with 3-month 
history of headache, weight gain, decreased 
concentration, polyuria, and polydypsia. His 
headaches are mostly in morning and involves 
the frontal region. On examination he was found 
to have bitemporal visual field defect and no 
facial hair. MRI scan revealed a suprasellar par- 
tially calcified cystic lesion with displacement of 
optic chiasm. The most likely pathology is: 

(A) Giant aneurysm of carotid artery 

(B) Pituitary macroadenoma 

(C) Glioblastoma multiforme 

(D) Craniopharyngioma 

(E) Testicular metastasis 

51. He underwent a craniotomy for resection of 
his lesion. Twelve hours postoperatively, he 
developed diuresis of over 500 mL/h. The 
diagnosis of (DI) was entertained. What labo- 
ratory findings are most consistent with the 
clinical impression? 

(A) Urine specific gravity of over 1010 

(B) Serum sodium of less than 135 

(C) Decreased both serum and urine 
osmololity 

(D) Increased serum osmololity and 
decreased urine osmololity 

(E) Increased both serum and urine 
osmololity 

Questions 52 and 53 

52. A 55-year-old female presents with 3-years his- 
tory of severe lancinating pain extending from 
left ear to her maxillary area. Pain is triggered 
by chewing and brushing teeth. She was 
treated by otolaryngologist for sinus infection 
a year ago and undergone multiple dental 
work and teeth extraction with transient or no 
improvement. The most likely diagnosis is: 

(A) Maxillary sinusitis 

(B) Trigeminal neurolgia 

(C) Maxillary osteomyelitis 

(D) Gradenigo's syndrome 

(E) Otitis media 



Questions: 46-58 



249 



53. Which one of the following medications is not 
indicated in treatment of this condition? 

(A) Carbamezapin 

(B) Cefatin 

(C) Phenytoin 

(D) Gabapentin 

(E) Baclofen 

Questions 54 through 56 

54. A 45-year-old woman was brought to emergency 
department for sudden onset of severe headache 
associated with photophobia, nausea, and tran- 
sient loss of consciousness. On examination, she 
is awake and alert with normal cranial nerve 
function. She also exhibits normal muscle 
strength and sensation.Her past medical history 
is significant for sickle cell disease (SCD) and 
hypertension. CT scan confirms the diagnosis of 
SAH without any intraparenchymal abnormal- 
ity. What is the least likely cause of SAH? 

(A) Aneurysmal bleed 

(B) Sickle cell angiopathy 

(C) Arteriovenous malformation (AVM) 

(D) Hemorrhagic meningioma 

(E) Blood dyscrasia 

55. What is the most definitive diagnostic test in 
this condition? 

(A) CT angiography 

(B) Magnetic resonance angiography (MRA) 

(C) Cerebral angiogram 

(D) MR spectroscopy 

(E) Positron emission tomography (PET) 
scan 



56. What is the most likely complication of angiog- 
raphy in this patient? 

(A) Cerebral stroke 

(B) Aneurysmal rupture 

(C) Increased intracranial pressure 

(D) Vascular wall damage 

(E) Sickle cell crisis 

Questions 57 and 58 

57. A 69-year-old well-controlled, hypertensive man 
was seen in ER with 3-month history of mild 
headache and sudden onset of hemiparesis. On 
examination, he exhibit mild dysphasia and 
lethargy. His cognitive function testing indicates 
moderate diminution of his recent memory and 
executive function. His hemiparesis is more 
dense in arm and leg and is mild in his face.CT 
scan without contrast demonstrates a 3-cm irreg- 
ular hemorrhage surrounded by marked edema 
and mass effect in frontal-temporal region. The 
most likely cause of bleed is? 

(A) Amyloid angiopathy 

(B) Hypertensive hemorrhage 

(C) Hemorrhagic neoplasm 

(D) Arterial-venous malformation 

(E) Coagulopathy 

58. What is the next diagnostic test that should be 
ordered? 

(A) EEG 

(B) Cerebral angiography 

(C) MRI with contrast 

(D) Spinal tap to determine the ICP 

(E) Transcranial Doppler 



Answers and Explanations 



(B) The patient has a right-sided L5 radiculopa- 
thy, most likely resulting from a disk herniation 
at the right L4-L5 interspace. The key to this 
diagnosis is in understanding the dermatomal 
anatomy of the lower extremity. The L5 der- 
matomal distribution involves the lateral calf 
and the dorsomedial aspect of the foot. The der- 
matome also typically includes the big toe. 

(C) Thoracic, lumbar, and sacral nerves exit off 
the spinal canal immediately below the pedicle 
of the corresponding numbered vertebra. The 
left SI root, for example, passes immediately 
dorsal to the L5-S1 disk, where it can be sus- 
ceptible to compression by a herniated nucleus 
pulposus. The root then swings laterally to exit 
immediately caudal to the left L5 pedicle. For 
a correlation between level of disk herniation 
and the root affected, see the table below. 



Level c 


if Herniation 


Root Affected 


L1-L2 




L2 


L2-L3 




L3 


L3-L4 




L4 


L4-L5 




L5 


L5-S1 




SI 



(D) This patient has radiculopathy of her right 
C6 root. To make this diagnosis, it is essential 
to understand the dermatomal anatomy of the 
upper extremity. The C6 dermatome includes 
the radial aspect of the distal forearm and 
hand. The C4 dermatomes include the deltoid 
region. The biceps tendon jerk is mediated by 
the C5 and C6 roots. 

(C) The mechanism of injury was a contusion to 
the cervical spinal cord. This probably occurred 



when the violent hyperflexion of the neck 
caused the cervical cord to bump against the 
osteophytic ridges of the spine. The typical clin- 
ical picture of a spinal cord contusion is a cen- 
tral cord syndrome. 

5. (A) The central spinal cord syndrome describes 
the following pattern of weakness: (a) weakness 
in upper extremity is greater than weakness in 
lower extremity; (b) weakness in distal muscles 
is greater than weakness in proximal muscles 
and limb girdle. This results from the distribution 
of motor fibers within the corticospinal tracts of 
the cervical cord. Fibers supplying the upper 
extremity and more proximal muscles are more 
centrally located and, thus, more susceptible to 
dysfunction from a central injury. Within the 
spinal cord, sensory fibers are more peripher- 
ally located and, thus, less frequently affected. 
Sensory deficits, when present, are often vari- 
able and inconsistent. A Lhermitte's sign or syn- 
drome also results from stenosis of the cervical 
canal, causing compression of the spinal cord. 
The patient develops severe numbness and 
paresthesia of the upper extremities as the result 
of sustained hyperextension of the neck. 

6. (B) Brown-Sequard syndrome (Fig. 11-3) 
describe (a) weakness of muscle ipsilaterally 
below the spinal cord lesion, (b) impaired sen- 
sation to light touch and vibration ipsilaterally 
below the spinal cord lesion; and (c) impaired 
sensation to pain and temperature contralater- 
ally below the spinal cord lesion. 

7. (E) The motor deficit is on the left ipsilateral 
side. Brown-Sequard syndrome is caused by 
unilateral injury or dysfunction following 



250 



/Answers: 1-12 



251 



Impaired pain 
and temperature 
sensation 



Right side 




Loss of all 
sensation 



Impaired 
proprioception, 
vibration, 2-point 
discrimination, 

and joint and 
position sensation 

Left side 



Figure 11-3. 

Brown-Sequard syndrome. The lesion depicted here is at a lower 
spinal cord level than that described in the text. (Reproduced, with 
permission, from Lindner HH: Clinical Anatomy. Appleton & 
Lange, 1989.) 

hemisections of the spinal cord. In the human 
nervous system, motor and sensory functions 
on one side of the body are under the direct 
control of the opposite side of the brain. All 
major motor and sensory tracts decussate. The 
decussation of the various tracts occurs at dif- 
ferent levels of the neuraxis. 

8. (C) On subsequent MRI of the cervicothoracic 
spine, this patient is found to have severe 
spondylosis at multiple levels of the spine. 
There is spinal cord compression by a large 
osteophyte at the level of C6-C7. The patient 
has all the signs and symptoms of cervical 
spinal cord dysfunction. The weakness affect- 
ing the triceps muscles in addition to the lower 
extremities indicates that the lesion is above 
the level of the thoracic cord. Absence of simi- 
lar symptoms on the face as well as the absence 
of cranial nerve abnormalities indicate that 
the lesion is not intracranial. The diffuseness of 
the symptoms as well as the fact that they are 
associated with increased reflexes and tone 



indicate that the problem lies within the CNS 
(upper motor neuron) rather than the periph- 
eral nervous system (lower motor neuron). 

9. (A) The clinical presentation indicates a lower 
motor neuron lesion. The clinical diagnosis is 
neurologic claudication secondary to lumbar 
spinal stenosis, which is commonly seen in eld- 
erly persons in whom (as a consequence of 
wear and tear over the years) bony structures 
of the lumbar spine hypertrophy and develop 
osteophytes. These bony changes, in turn, lead 
to stenosis of the spinal canal and intervertebral 
foramina. Thus, the result is compression and 
dysfunction of multiple lumbosacral nerve 
roots bilaterally. Bending over opens the 
lumbar canal and relieves the stenosis. 

10. (C) This patient has suffered a traumatic frac- 
ture of L3 in which bony fragments were dis- 
placed dorsally to compress the cauda equina 
at that level. It is important to remember that 
the spinal cord does not extend along the entire 
length of the spine. The conus medullaris, the 
most caudal tip of the spinal cord, ends in 98% 
of people at or above L2 vertebrae. Thus, it is 
highly unlikely for an L3 fracture to cause com- 
pression of the spinal cord or conus medullaris. 

11. (B) The most appropriate step is to place him in 
a hard cervical collar to protect his neck and 
obtain plain lateral radiographs in flexion and 
extension. In this boy, the continuous neck pain 
and the prevertebral swelling on the plain radi- 
ographs are strongly suggestive of an injury to 
the ligamentous structures of the cervical spine. 
A severe ligamentous tear can lead to instabil- 
ity of the spine from excessive movement 
between adjacent vertebrae. Ligamentous 
injury must be ruled out by obtaining lateral 
radiographs in flexion and extension to demon- 
strate any excessive movement between adja- 
cent vertebrae. This excessive movement, if 
missed, can result in compression of the cervi- 
cal spinal cord and a serious neurologic deficit. 
These studies require supervision by appro- 
priate specialist consultants. 

12. (A) A CT scan of the cervical spine is more sen- 
sitive for fractures of the spine than are plain 



252 



11: Neurosurgery 



radiographs. Because CT images are in the axial 
plane, only one vertebral body can be seen at a 
time. This makes CT scanning entirely inade- 
quate to rule out all but large subluxation 
resulting from the most major ligamentous dis- 
ruptions. Sagittal MRI of the cervical spine in 
this case may show swelling or hematoma 
within the soft tissues of the spine. MRI, how- 
ever, is poor in demonstrating bony anatomy 
and detail. Furthermore, without flexion and 
extension of the neck, an MRI of the cervical 
spine is no better in showing bony instability 
than plain radiographs in the neutral position. 

13. (C) Meningeal carcinomatosis results when 
malignant cells gain access to the CSF and are 
able to disseminate within it. Cells most com- 
monly adhere to and affect the neural struc- 
tures traversing the CSF, such as cranial nerves 
and peripheral nerve roots. Cells cause dys- 
function at multiple sites of the CNS. This 
patient has a left abducens nerve palsy and a 
right C5 radiculopathy, making the diagnosis of 
meningeal carcinomatosis highly likely. 

14. (C) In the presence of meningeal carcinomato- 
sis (also called carcinomatous meningitis), the 
lumbar puncture CSF examination may reveal 
elevated protein and positive cytology. The sen- 
sitivity of MRI to detect small tumor deposits 
within the intracranial compartment is much 
greater than that of a CT scan. Thus, a CT scan 
is unlikely to be helpful in this clinical scenario. 

15. (D) An adult with new onset seizures is consid- 
ered to have a brain tumor until proved other- 
wise. The best test available to detect metastatic 
deposits in the brain is the MRI with intravenous 
contrast. MRI is exquisitely sensitive in diag- 
nosing brain metastasis, sometimes detecting 
them by the brain edema they induce even when 
the lesion itself is too small to be seen. The EEG 
may likely show the presence of seizure activity 
and even localize it to a particular region of the 
brain; it will not, however, answer the question 
of what pathologic process is responsible. Also, 
in this case, because a mass lesion is expected, 
performing a spinal tap is relatively contraindi- 
cated for the fear of inducing uncal herniation in 
a patient who may have increased ICP. 



16. (A) The optimal management of any intracranial 
neoplasm includes use of corticosteroids. These 
significantly diminish the amount of tumor- 
induced brain edema and are remarkably effec- 
tive in ameliorating symptoms caused by CNS 
neoplasms. The current recommendation for the 
treatment of multiple brain metastasis is treat- 
ment with a full course of fractionated radia- 
tion to the whole brain. This is geared to treat all 
visible lesions within the parenchyma as well as 
those that may still be too small to be detected. 
Intrathecal chemotherapy is effective in treat- 
ing meningeal carcinomatosis, where the pri- 
mary site of involvement is the meninges and 
the surface of the brain. The two available agents 
for this modality of treatment have very poor 
penetration into deeper regions of the brain 
when administered intrathecally 

17. (B) Surgical resection is recommended only for 
cases involving a single brain metastasis that is 
surgically accessible in patients with a reason- 
able life expectancy. It is also relatively indi- 
cated in patients with multiple brain lesions in 
whom one particular lesion is imminently life- 
threatening. Intravenous chemotherapy has, 
unfortunately, yielded poor results in the 
treatment of brain metastasis. This is particu- 
larly so in this patient, because her tumors are 
already likely to be resistant to the chemother- 
apeutic agents with which she has already been 
treated. 

18. (B) Glioblastoma multiforme is a highly malig- 
nant neoplasm, arising from glial cells or their 
precursors within the CNS. It is the most 
common of all primary malignancies of the CNS 
and its peak incidence is within the fifth to sev- 
enth decade of life. A low-grade astrocytoma is 
a tumor derived from glial cells of astrocytes. 
Fig. 11^, shows a large cystic giant astrocytoma 
on T2 weighted MRI where fluid is shown as a 
white area with midline shift (not glioblastoma 
multiforme presented in this question). 

19. (C) Glioblastoma multiforme grows rapidly, and 
the tumor often contains a necrotic core that 
occurs as its growth surpasses its blood supply. 
Additional features on MRI include irregular 
shape, poor demarcation from surrounding 



/Answers: 13-23 



253 




Figure 11-4. 

Large cystic giant astrocytoma on T2 weighted MRI where fluid is shown as a white area. Midline shift. 



brain tissue, and the presence of variable 
amount of surrounding white-matter edema. 

20. (D) This cerebella-pontine angle tumor is most 
likely an acoustic neuroma. This is the most 
commonly encountered neoplasm in this 
region. It arises from the Schwann cells that 
form the myelin sheath of the vestibular divi- 
sion of the eighth cranial nerve (hence a more 
accurate name is vestibular schwannoma). This 
tumor typically arises within the internal 
acoustic canal and growths in the direction of 
least resistance — through the meatus into the 
cerebellopontine angle cistern. 

21. (C) An astute neurologist once said that in neu- 
rologic diagnosis, as in real estate, location is 
everything. He alluded to the fact that in the 
diagnosis of neurologic ailments, one can often 
generate lists of possible diagnoses based solely 
on the location of the lesion in question. With 
unusual exceptions, each location within the 
CNS is likely to be associated with a certain type 
of neoplasm. The medulloblastoma (also called 
a primitive neuroectodermal tumor or PNET) is 
a highly aggressive and rapidly growing tumor 
that most often arises within the cerebellar 
vermis. It usually grows locally as a roughly 
spherical mass to bulge into and obliterate 
the adjacent fourth ventricle. Ependymoma or 



choroid plexus papilloma should also be con- 
sidered in the differential diagnosis. 

22. (B) Choroid plexus papillomas are benign 
tumors of the CNS that arise from the cells that 
form the choroid plexus. These tumors can be 
found wherever choroid plexus is present, 
including the lateral and fourth ventricles. 
They cause symptoms of increased ICP, most 
commonly by causing massive degrees of 
hydrocephalus. This can be from two mecha- 
nisms — obstruction of normal CSF pathways or 
production by the tumor of excessive volumes 
of CSF. (Remember that CSF is produced 
mainly by the choroid plexus.) Ependymomas 
are also highly malignant tumors usually 
found in the fourth ventricle of children. Its 
precursor cell is the ependymal cell that lines 
the ventricular system. As medulloblastomas, 
these tumors are highly aggressive and fast 
growing. Contrary to the former, however, 
ependymomas tend to arise from the floor of 
the fourth ventricle (the dorsal surface of the 
brainstem). 

23. (D) Obtain an MRI or myelogram of the entire 
spinal axis to rule out the possibility of "drop 
metastasis" from the medulloblastoma. The 
constellation of emerging new symptoms 
points toward spinal cord dysfunction; the 



254 



11: Neurosurgery 



most likely cause is the presence of drop metas- 
tasis from the medulloblastoma. Primary CNS 
neoplasms rarely metastasize outside of their 
site of origin. Exceptions to this statement 
include both medulloblastoma and ependy- 
moma. These tumors shed viable cells into the 
CSF, where they are transferred to such distant 
areas as the intracranial or, more commonly, 
the spinal subarachnoid space. There they can 
lodge and replicate to form tumor nodules that 
can compress adjacent neural structures. The 
test of choice for diagnosing the presence of 
these drop metastasis is a MRI of the spine with 
intravenous contrast or a myelogram. 

24. (D) Treatment of drop metastasis consists pri- 
marily of complete craniospinal irradiation with 
local boosts to the areas where tumor nodules 
are detected. Chemotherapy, particularly a com- 
bination of procarbazine, lomustine (CCNU), 
and vincristine (PCV), is usually given to treat 
disease that is locally recurrent after maximal 
irradiation. Radiation-induced toxicity or radio- 
necrosis is highly unlikely to be the cause of 
these newly developed symptoms. The first 
reason for this is that the child's new symptoms 
and findings appear to be exclusively spinal in 
origin. Second, radiation-induced necrosis, a 
feared complication of CNS irradiation, is never 
observed in such a short interval after complet- 
ing treatment. 

25. (A) Intubation will accomplish two purposes. 
First, it will protect the airway and prevent 
the possibility of aspiration. Second, it will 
allow controlled hyperventilation (PC0 2 of 
25-30 mm Hg), which causes cerebral vaso- 
constriction, which, in turn, transiently lowers 
ICP and reduces intracranial intravascular 
blood volume. Mannitol will reduce intracere- 
bral pressure and volume. The role of corti- 
costeroids in the management of cerebral 
trauma is controversial at best. Their advo- 
cates propose that corticosteroids work by 
reducing the amount of traumatically induced 
brain edema. Even these investigators concur 
that their effect is not immediate and that they 
take at least 4-6 hours to work. The subdural 
space is between the inner layer of dura and 
the arachnoid. 



26. (E) Mannitol is a complex sugar that remains in 
the intravascular space because of its high 
molecular weight. When it is given in large 
doses (1-2 g/kg of body weight), water is 
extracted from the cerebral interstitium by its 
osmotic effect, causing reduction in total brain 
volume. Both these measures are temporizing 
steps to allow enough time for definitive diag- 
nosis and treatment to take place. The effect of 
hyperventilation on ICP rapidly wears off after 
a few hours. Over time, mannitol will diffuse 
into the cerebral interstitium, losing its effec- 
tiveness and even exacerbating cerebral edema. 
A note of caution, however, mannitol is an 
osmotic diuretic and as such must be given 
with extreme caution in the setting of hypoten- 
sion due to excessive blood loss. 

27. (D) This is the classic presentation of an acute 
epidural hematoma (Fig. 11-5) transient trau- 
matic loss of consciousness, followed by a lucid 
interval and then by neurologic deterioration. 
Epidural hematomas are frequently associated 
with linear skull fractures, which cause injury 
to the middle meningeal artery located imme- 
diately deep to the overlying fracture. They are 
more common in younger individuals, because 
in younger people, the dura mater is less firmly 
adherent to the inner table of the skull. Todd's 
phenomenon is a transient focal weakness or 
paralysis that results after a seizure. The par- 
ticular pattern of weakness is often a clue to the 
site of the seizure focus within the brain. 

28. (C) Acute subdural hematomas (Fig. 11-1) 
occur most commonly when violent accelera- 
tions or deceleration injuries of the head cause 
tearing of the bridging veins within the sub- 
dural potential space. They generally imply a 
much more severe injury to the brain itself than 
in the case of their epidural counterpart. For 
this reason, they are associated with cerebral 
contusions in over 30% of cases. 

29. (A) This entity is caused by sharp accelerations 
or decelerations of the head and its contents as 
seen in high-speed motor vehicle accidents. 
FXiring impact, shock waves are generated that 
are able to travel through the semisolid substance 
of the brain. These shock waves penetrate and 



/Answers: 24-33 



255 




Figure 11-5. 

Epidural hematoma. CT of the head windowed for brain (left) and bone (right) 
shows and epidural hematoma resulting from an underlying occipital skull fracture. 
This injury was caused by a blow to the back of the head. Notice the classic lens- 
shaped hematoma. The brain window also shows a thin left tentorial subdural 
hematoma appearing as a white line running from the midline posteriorly and curv- 
ing toward the left of the pons. (Reproduced, with permission, from Doherty GM: 
Current Surgical Diagnosis and Treatment, 12th ed. 876. McGraw-Hill, 2006.) 



cause shear and stretch injury to multiple deep 
axonal tracts. DAI represents a severe diffuse 
injury to the entire brain. For this reason, vic- 
tims present with marked neurological dys- 
function. CT scan typically shows no evidence or 
reason to suspect increased ICP; it merely shows 
punctate hemorrhages in many of the tracts that 
are affected. 

30. (C) The presence of a Battle's sign and hemo- 
tympanum is highly suggestive of the possi- 
bility of a left temporal bone fracture. When 
this occurs, it is common for the dura mater at 
this site to be torn. This leads to leakage of CSF 
into the mastoid air cells and middle ear. CSF 
is subsequently able to reach the nasopharynx 
via the eustachian tube, a phenomenon called 
paradoxical rhinorrhea, which is a serious but 
usually self-limiting condition. Most cases of 
traumatic CSF leaks heal spontaneously within 
approximately 1 week. Patients require close 
in-hospital observation, however, because bac- 
terial meningitis readily occurs in the presence 
of CSF leakage to the outside. 



described above are consistent with the diag- 
nosis of spina bifida occulta. This is a congenital 
abnormality that results from abnormalities in 
the development of mesodermal elements (scle- 
rotome) which form the dorsal elements of the 
lumbosacral spine. A burst fracture of the spine 
is found after acute excessive axial loading of the 
spine. The features of such a fracture are reduced 
height of the affected vertebral body and dis- 
placement of bony fragments centrifugally in 
the axial plane (hence the term burst). 

32. (D) Spondylolisthesis occurs when there is dis- 
ruption, most often by a fracture, of the pars 
intra-articularis of the L5 vertebra. The pars is 
the bony element that is found between the 
ascending facets of L5 (that articulate with the 
L4 vertebra) and the descending facets of L5 
(that articulate with SI). The functional result of 
this disruption is that the descending facets are 
"floating" and not able to function in stabiliz- 
ing the L5-S1 joint. If this becomes progres- 
sive, then anterior subluxation of the L5 
vertebral body with respect to that of SI occurs. 



31. (C) Spina bifida occulta does not cause symp- 
toms and is frequently found incidentally in the 
workup of other conditions. The presence of a 
tuft of hair and the radiographic abnormalities 



33. (D) There is a high degree of correlation in the 
occurrence of defects in neural tube closure and 
Arnold-Chiari malformations, and all babies 
born with one should be examined for the other. 



256 



11: Neurosurgery 



Development of communicating hydrocephalus 
is a feature of a type-II Arnold-Chiari abnor- 
mality. Stenosis of the aqueduct of Sylvius and 
the presence of an ependymoma in the fourth 
ventricles are other reasons for the develop- 
ment of hydrocephalus in children. There is, 
however, no incidental correlation between 
these and defects of neural tube closure. 

34. (C) Abnormal elongation of the medulla and 
lower cranial nerves may be evident in Arnold- 
Chiari syndrome. Additional features include 
fusion of the corpora quadrigemina, leading to a 
"beaked" tectum; partial or complete absence of 
the corpus callosum; and microgyria. The cor- 
pora quadragemina are relay stations for hearing 
(inferior corpora quadragemina) and the light 
reflex (superior copora quadragemina), and they 
form the posterior surface of the midbrain. 

35. (A) Noncommunicating hydrocephalus is de- 
fined as hydrocephalus caused by obstruction 
of CSF flow and obstruction within the ventric- 
ular system. In this case, the ventricular system 
is dilated upstream from the obstruction caused 
by stenosis of the aqueduct of Sylvius and col- 
lapsed distally Communicating hydrocephalus 
occurs when the obstruction to CSF flow occurs 
within the subarachnoid space or at the level of 
its resorption into the bloodstream by the arach- 
noid granulations. In this case, all ventricles are 
dilated proportionately. 

36. (B) Normal-pressure hydrocephalus is a con- 
dition seen in the elderly in which there is sym- 
metrical enlargement of the entire ventricular 
system. When patients with this condition are 
studied by lumbar puncture, it is found that 
despite ventriculomegaly, the ICP is abnor- 
mally low. This syndrome presents with a char- 
acteristic triad of symptoms — dementia, ataxia, 
and urinary incontinence. 

37. (A) Pseudotumor cerebri is a condition that 
most commonly occurs in young adults, par- 
ticularly in females. In this condition, ICP as 
measured by a lumbar puncture is elevated, 
while the size of the cerebral ventricles on imag- 
ing studies is small or normal. It is a generally 
progressive condition that causes headache and 



damage to the optic nerve, sometimes leading 
to loss of peripheral vision and blindness. 

38. (A) This abnormality is relatively common and 
occurs in 1 of 1000 pregnancies. It occurs four 
times more commonly in whites than blacks and 
four times more commonly in female fetuses 
than in male fetuses. The abnormality can be 
identified on an x-ray, because the vault of the 
skull is absent. Anencephalus is caused by failure 
of the cephalic part of the neural tube to close off. 

39. (A) This cystic structure is an arachnoid cyst. 
These are CSF-filled cysts that occur when 
leaves of arachnoidal tissue fuse, trapping CSF 
within them. These cysts slowly grow over 
time, sometimes attaining very large size. They 
cause symptoms by virtue of their large size, as 
they are able to compress adjacent structures. 
Patients with these cysts most commonly 
present with a history of chronic headache. 
Neurologic symptoms or deficits are unusual. 
Patients with arachnoid cysts frequently give a 
history of severe blows to the head and skull 
fractures, perhaps implying head trauma as a 
causative agent. The most common locations of 
arachnoid cysts are the middle cranial fossa, 
the cerebellopontine angle, and the suprasellar 
area. Dandy-Walker cysts are the result of an 
intrauterine developmental abnormality in 
which there is failure of proper formation of the 
foramina of Lushka and Magendie. As a con- 
sequence, the main egress of CSF out of the 
ventricular system is obstructed, leading to 
hydrocephalus and a massively enlarged, cyst- 
like fourth ventricle. 

40. (B) Cystic astrocytomas are neoplasms of the 
CNS. They usually consist of a large, nonen- 
hancing cyst on the wall of which is an enhanc- 
ing tumor nodule. They are most commonly 
found within the substance of the cerebellar 
hemispheres of children and young adults. A 
Rathke's cleft cyst is a remnant of the embry- 
ologic Rathke's pouch. These are found within 
the sella turcica. 

41. (B) CTS is a condition in which the median 
nerve is compressed at the level of the wrist by 
a thickened carpal flexor retinaculum. This 



/Answers: 34-46 



257 



leads to numbness and painful paresthesia 
along the median nerve distribution within the 
hand. It also causes weakness and atrophy of 
the thenar muscles within the hand, innervated 
by the superficial recurrent branch of the 
median nerve. Once there is clinical suspicion, 
the best diagnostic test to confirm the presence 
of CTS is a nerve-conduction study. This study 
often shows a block or delay in conduction of 
the median nerve at the level of the carpal 
tunnel. Conduction within all branches of the 
ulnar nerve should be normal. This test is often 
also useful in distinguishing between CTS and 
the possibility of a C6 radiculopathy. 

42. (A) The best prognostic indicator of survival 
and outcome in patients with missile wounds to 
the brain is the mental status and level of 
responsiveness after proper resuscitation. His 
initial poor neurologic grade can be attributed 
to cerebral injury itself or to cerebral hypoper- 
fusion in a patient with clear hemodynamic 
shock. Initial presentation is, thus, of little value 
in judging the prognosis for these types of 
injuries. Other prognostic factors that have been 
identified as important in predicting the out- 
come of gunshot wounds to the head include: 

(a) Path of the bullet. A missile that crosses 
the midline or the midcoronal plane is 
associated with a much worse outcome 
than one that stays unilaterally. 

(b) The presence of an intracranial 
hematoma of greater than 2x2x2 cm is 
ironically a positive prognosticator, 
because it represents a mass lesion that 
can be causing intracranial hypertension 
and can be more readily evacuated via a 
craniotomy. 

43. (B) A markedly diminished level of conscious- 
ness coupled by a CT scan that shows a 
hematoma, edema, and subfalcian herniation 
indicate that the patient is suffering from 
intracranial hypertension. Hyperventilation and 
mannitol are quick and effective ways to reduce 
intracranial pressure temporarily. However, 
these measures are only temporary and the 
patient needs urgent decompression by cran- 
iotomy. Placement of burr holes in the ER is of no 



value in the management of these injuries. 
Placement of an ICP monitor may be helpful for 
the postoperative period, but is likely to be of 
limited help without prior craniotomy. 

44. (C) The ideal intraoperative management of 
this patient would begin by performance of a 
wide craniotomy through which the intracere- 
bral hematoma can be evacuated. Necrotic 
brain tissue if left alone is likely to worsen the 
occurrence of cerebral edema postoperatively, 
and for that reason, every measure should be 
taken to debride it as thoroughly as possible. 
Easily accessible bone and bullet fragments can 
also be removed. Bone and bullet fragments 
that are deeply located and difficult to locate 
should be left intact. Persistence in their 
removal often leads to a greater risk of brain 
injury by intraoperative manipulation and dis- 
section. If problems with raised intracranial 
pressure are expected, placement of a suitable 
ICP monitoring device is highly recommended 
as part of the surgical procedure. 

45. (D) This is the classic history for acute SAH — the 
acute onset of a massive headache. The acuity 
should suggest nothing other than a vascular 
phenomenon. Furthermore, the presence of a 
right occulomotor nerve palsy strongly suggests 
bleeding from an aneurysm of the right poste- 
rior communicating artery. Anatomically, most 
posterior communicating aneurysms point their 
domes laterally and interiorly, in the direction 
toward the occulomotor nerve. In general, when 
the dome of the aneurysm ruptures, the jet of 
blood injures the adjacent nerve. In this situa- 
tion, the lesion results in complete occulomotor 
nerve palsy with a fixed dilated pupil. It is a 
neurosurgic dogma that complete occulomotor 
palsy should be regarded as a ruptured posterior 
communicating artery aneurysm until proved 
otherwise. Acute bacterial meningitis also pres- 
ents with headache and meningism. The onset 
of the symptoms is, however, much more grad- 
ual, and high fever is usually present. 

46. (B) The best test in the diagnosis of an acute 
SAH is a nonenhanced CT of the brain. In this 
study, subarachnoid blood can easily be seen as 
a hyperdense substance filling the otherwise 



258 



11: Neurosurgery 



hypodense cisterns of the subarachnoid space. 
Its sensitivity is greater 95%, but sensitivity 
falls to 50% by 1 week after the hemorrhage. 
Lumbar puncture can also be used to diagnose 
SAH, but it is an invasive procedure that 
should be reserved for cases in which the sus- 
picion of such hemorrhage remains following 
a negative CT scan. MRI (with or without 
gadolinium), despite its exquisite sensitivity 
for the diagnosis of intracerebral lesions, is 
notoriously poor in its ability to detect acute 
blood within the subarachnoid space. EEG is of 
no value for the diagnosis of an acute SAH. 

47. (E) Neostigmine and pyridostigmine are both 
anticholinesterase agents and can be used in 
the reversal of nondepolarizing muscle relax- 
ants. Pyridostigmine causes less muscarinic 
effect than does neostigmine. The effect of pyri- 
dostigmine is more prolonged and produces 
fewer secretions and less severe bradycardia. 

48. (C) Both narcotics and thiopental depress res- 
piration, and the addition of N 2 further aug- 
ments this depressant action. Thus, the response 
to hypercapnea is diminished. 

49. (C) Diazepam is a benzodiazepine derivative 
that seems to have a calming effect on part of the 
limbic system, thalamus, and hypothalamus. It 
should be injected slowly (<1 mg/min) into a 
larger vein to avoid phlebitis and local irritation. 

50. (D) Weight gain, DI, decreased memory, and 
visual field defect are consistent with a suprasel- 
lar hypothalamic lesion. Calcified cystic lesions 
in this location, particularly in adolescents, are 
characteristic of craniopharyngiomas. The rate 
of calcification in childhood is about 85% and in 
adult is about 40%. Craniopharyngiomas are 
pathologically benign but due to their location 
and their firm attachment to critical structures 
surrounding them can result in severe neuro- 
functional impairment. The cyst wall is lined 
with squamous epithelium and the fluid con- 
tains cholesterol crystals. 

51. (D) DI is commonly precipitated by low level of 
ADH secretion. The clinical presentation does 
not manifest until over 85% of ADH secretory 



capacity is damaged. Rarely it is nephrogenic 
and is caused by lack of renal response to ADH 
hormone. Nephrogenic form is often produced 
by toxic effect of certain drugs or familial X- 
linked recessive genetic disorder. DI is defined 
by increased diluted urinary output, constant 
thirst for usually cold water, and high serum 
osmololity If it is not properly treated it can 
lead to extreme dehydration and electrolyte 
imbalance. The best test is water deprivation 
for 4 hours while monitoring the urine output 
and urine and serum osmololity. If urine 
osmololity remains flat or changes less than 30 
mOsm and the serum osmololity approaches 
300 mOsm/L, the diagnosis of DI is confirmed. 
At this point the patient should be given 5 U of 
an exogenous pitressin subcutaneously By 
comparing the urine osmololity after Pitressin 
to the initial values, the extent of the DI can be 
determined. The increase in urine osmololity 
by more than 67% is indicative of severe ADH 
deficiency. The increased levels of 6-67% is sug- 
gestive of partial deficiency. 

52. (B) Trigeminal neuralgia or Tic Douloureux is 
clinically characterized by paroxysmal lanci- 
nating pain in the distribution of one or two 
division of trigeminal nerve. There is commonly 
no sensory or motor impairment on examina- 
tion. The pain is triggered by certain mild stim- 
uli such as touching, chewing, brushing teeth, 
and cold breeze. If any objective neurological 
findings are detected, other pathologies causing 
compression of the nerve at its exit zone from 
the brainstem must be suspected. Such patholo- 
gies as AVM, tumors, and aneurysm must be 
ruled out by MRI. This disease is assumed to be 
caused by a loop of a vessel, often superior 
cerebellar artery or posterior inferior cerebellar 
artery (PICA), compressing the trigeminal 
nerve as it emerges from brainstem. 

53. (B) Most antiepileptic medications are effective to 
control the pain in this condition. The drug of 
choice is Carbamazepin which is effective in two- 
thirds of the patients. Phenytoin is an intravenous 
option in those who cannot take oral medication 
due to severe pain. Baclofen is an effective med- 
ication in conjunction with Carbamazepin. 
Gabapentin is another antiepileptic medication 



/Answers: 47-58 



259 



which is useful in mild forms of the TN or in 
association with other medications. Other med- 
ications that are being used for this condition 
include Amitriptyline (Elavil) and Clonazepam 
(Klonopin). 

54. (D) The most common cause of the spontaneous 
SAH is berry aneurysm and AVM. Aneurysms 
are often located on the circle of Willis in the 
subarachnoid space hence bleeding occurs in 
this space. Massive hemorrhages can break in 
the parenchyma and produce intraparenchymal 
clot. AVMs usually bleed in the parenchyma but 
frequently is superficial and present with asso- 
ciated SAH. Sickle cell angiopathy can also pres- 
ent as SAH from subpial vessels. In a patient 
with history of SCD, angiopathy as the cause of 
SAH should be considered. On other hand, 
bleeding is extremely rare in meningiomas and 
when it occurs it is often intratumoral or intra- 
parenchymal and do not appear as a SAH. 

55. (C) Four vessel angiography remains a gold stan- 
dard vascular study for detecting aneurysms 
and AVMs. It provides the detail and definition 
that are required for surgical intervention. MRA 
and CTA are often very helpful to detect and 
provide some detail. The newer high speed CT 
scans with angiography software can produce 
the definition close to standard angiography. PET 
scan and spectroscopy are primarily used to 
determine the metabolic activities of the brain 
and are incapable of detecting vascular lesions. 

56. (E) The rate of complications in cerebral 
angiography is relatively low and in experi- 
enced hands is less than 1%. Among the poten- 
tial complications, cerebral ischemic or 
hemorrhagic stroke, vascular dissection, and 
aneurysmal rupture are frequently reported. 
In patients with SCD administration of the 
high-osmolar contrast often precipitate sickle 
cell crisis. Therefore, these patients should be 



pretreated with exchange transfusion and 
maintained in a well hydrated state. Steroids 
are also used prior to angiography to reduce 
the postangiography complications. 

57. (C) History of recent onset of headache in adult 
should always raise the suspicion of neoplasm. 
Amyloid angiopathy and hypertension are fre- 
quent cause of the intracerebral hemorrhage in 
elderly, but the critical difference with neo- 
plastic bleed is the presence of edema and mass 
effect which is disproportionate to the size of 
the hemorrhage. The presence of edema sug- 
gests a preexisting lesion with recent bleed. 
Although intraparenchymal hemorrhage can 
produce edema but it takes many hours to 
develop. Therefore, the presence of edema in 
early hours after the ictus is indicative of 
underlying pathology. AVMs and coagu- 
lopathies also can cause intraparenchymal 
bleed without surrounding edema which is the 
hallmark of an underlying lesion. 

58. (C) MRI with contrast is the study of choice to 
determine the presence of underlying pathol- 
ogy. The pattern of enhancement can identify 
such lesions as primary brain tumor or hemor- 
rhage in a metastatic lesion. Although lung and 
breast are the most common neoplasm that 
metastasis to brain, the incidence of bleeding is 
more common in melanomas and lymphomas. 
AVMs also have special MRI features that make 
the diagnosis possible. The vascular details 
nonetheless require angiographic studies. The 
vascular study is ineffective in determining the 
presence of neoplastic lesions unless an AVM or 
aneurysms are suspected. Transcranial Doppler 
is used to determine the circulation velocity in 
the intracranial vessels particularly in middle 
cerebral artery. This test is used to monitor the 
vasospasm occurring after aneurysmal SAH and 
has no role in identifying any other pathology. 



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CHAPTER 12 



Trauma 

C. Gene Cayten and Rao R. Ivatury 

Questions 



DIRECTIONS (Questions 1 through 87): Each of 
the numbered items is followed by five answers. 
Select the ONE lettered answer that is BEST in 
each case. 



1. A 20-year-old unrestrained driver was involved 
in a motor-vehicle crash. A computed tomog- 
raphy (CT) of the abdomen revealed a large 
hematoma in the second portion of duode- 
num. The rest of the abdomen is normal. The 
initial management of this duodenal hematoma 
should be: 

(A) Operative evacuation 

(B) Nasogastric decompression, intravenous 
fluids, and gradual resumption of oral 
diet 

(C) Endoscopic retrograde 
cholangiopancreatogram (ERCP) 

(D) Laparotomy pyloric exclusion, and 
gastrojejunostomy 

(E) Octreotide 

2. In a patient who had a motor-cycle crash, a 
CT of the abdomen revealed a peripancreatic 
hematoma and indistinct pancreatic border. 
The most definitive test for a pancreatic injury 
requiring operative intervention is: 

(A) ERCP 

(B) Ultrasonography 

(C) CT scanning 

(D) Operative exploration 

(E) Amylase test of lavage fluid 

3. A 30-year-old restrained driver was involved in 
a motor-vehicle crash. He is hemodynamically 



stable and has a large seat belt sign on the 
abdomen. His abdomen is tender to palpation. In 
this patient one should be most concerned about: 

(A) Liver and spleen injury 

(B) Transection of the head of the pancreas 

(C) Renal pedicle avulsion 

(D) Hollow -viscus injuries 

(E) Pelvic fracture 

A 45-year-old man skidded from the road at 
high speed and hit a tree. Examples of deceler- 
ation injuries in this patient include: 

(A) Aortic valve rupture 

(B) Kidney injury 

(C) Posterior dislocation of shoulder 

(D) Mesenteric avulsion 

(E) Stomach rupture 

A 25-year-old man fell down from his bicycle 
and hit a concrete wall on his left side. An ultra- 
sound examination showed free fluid in the 
abdomen. A CT scan confirmed a grade III 
splenic injury. The most important contraindi- 
cation for a nonoperative management of the 
splenic injury is: 

(A) Hemodynamic instability 

(B) Active bleeding on CT scan 

(C) Adult patient 

(D) Lack of availability of blood for 
transfusion 

(E) Extensive associated injuries 



267 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



262 



12: Trauma 




Figure 12-1. 

Anteroposterior radiograph demonstrating a comminuted supracondylar femur fracture 
with intra-articular extension. (Reproduced, with permission, from Doherty GM: Current 
Surgical Dignosis & Treatment. 1140. McGraw-Hill, 2006.) 



6. A 40-year-old man is involved in a car crash, 
presenting with blood pressure of 80 mm Hg. 
The patient is found to have subdural hematoma 
and a supracondylar fracture of the left femur 
FAST shows fluid within the abdomen. He is 
taken to the OR, where intra-abdominal bleeding 
is controlled, and the subdural hematoma is 
drained. The femur fracture (Fig. 12-1) should be 
treated by which of the following? 

(A) Long-leg cast 

(B) Steinmann pin insertion and traction 

(C) Operative reduction and internal 
reduction 

(D) Aspiration of knee joint 

(E) Operative reduction with internal fixation 

7. An 18-year-old man is brought to the emergency 
department with a stab wound just to the right 
of the sternum in the sixth intercostal space. His 
blood pressure is 80 mm Hg. Faint heart sounds 
and pulsus paradoxus are noted. Auscultation of 
the right chest reveals decreased breath sounds. 
The initial management of this patient should be 
which of the following? 

(A) Aspiration of the right chest cavity 

(B) Aspiration of the pericardium 

(C) Echocardiogram 



9. 



(D) Pericardial window 

(E) Insertion of central venous access line 

A 60-year-old woman runs her car off the road 
and it hits a telephone pole. She presents to the 
emergency department with severe anterior chest 
pain and a blood pressure of 110/80 mm Hg. 
A chest x-ray shows a questionably widened 
mediastinum. The next step in management 
should be which of the following? 

(A) Transthoracic echocardiogram 

(B) Pericardiocentesis 

(C) Aortogram 

(D) Central venous access line 

(E) CT of chest 

An 18-year-old man presents to the emergency 
department with a gunshot wound to the left 
chest in the anterior axillary line in the seventh 
intercostal space. A rushing sound is audible 
during inspiration. Immediate management is 
which of the following? 

(A) Exploratory laparotomy 

(B) Exploratory thoracotomy 

(C) Pleurocentesis 

(D) Closure of the hole with sterile dressing 

(E) Insertion of chest tube 



Questions: 6-15 



263 



10. A 25-year-old man is shot in the left lateral 
chest. In the emergency department, his blood 
pressure is 120/90 mm Hg, pulse rate is 104 
beats per minute (bpm), and respiration rate is 
36 breaths per minute. Chest x-ray shows air 
and fluid in the left pleural cavity. Nasogastric 
aspiration reveals blood-stained fluid. What is 
the best step to rule out esophageal injury? 

(A) Insertion of chest tube 

(B) Insertion of nasogastric tube 

(C) Esophagogram with gastrografin 

(D) Esophagoscopy 

(E) Peritoneal lavage 

11. A 32-year-old female falls from the tenth floor of 
her apartment building in an apparent suicide 
attempt. Upon presentation, the patient has 
obvious head and extremity injuries. Primary 
survey reveals that the patient is totally apneic. 
By which method is the immediate need for a 
definitive airway in this patient best provided? 

(A) Orotracheal intubation 

(B) Nasotracheal intubation 

(C) Percutaneous cricothyroidotomy 

(D) Intubation over a bronchoscope 

(E) Needle cricothyroidotomy 

12. A 17-year-old girl presents to the emergency 
department with a stab wound to the abdomen 
and a blow to the head that left her groggy. 
Her blood pressure is 80/0 mm Hg, pulse is 
120 bpm, and respiration rate is 28 breaths per 
minute. Her abdomen has a stab wound in the 
anterior axillary line at the right costal margin. 
Two large-bore intravenous lines, a nasogas- 
tric tube, and a Foley catheter are inserted. The 
blood pressure rises to 85 mm Hg after 2 L of 
Ringer's lactate. The appropriate management 
is which of the following? 

(A) Peritoneal lavage 

(B) Ultrasound of the abdomen 

(C) Laparoscopic assessment of the peritoneal 
cavity 

(D) Exploratory laparotomy 

(E) CT of the head 



13. A 22-year-old woman presents to the emer- 
gency department with a chief complaint of 
severe left upper quadrant (LUQ) pain after 
being punched by her husband. Her blood 
pressure is 110/70 mm Hg, pulse is 100 bpm, 
and respiration rate is 24 breaths per minute. 
The best means to establish a diagnosis is 
which of the following? 

(A) FAST 

(B) Physical examination 

(C) CT of the abdomen 

(D) Peritoneal lavage 

(E) Upper gastrointestinal (GI) series 

14. A 60-year-old man is attacked with a baseball 
bat and sustains multiple blows to the abdomen. 
He presents to the emergency department in 
shock and is brought to the operating room (OR), 
where a laparotomy reveals massive hemoperi- 
toneum and a stellate fracture of the right and left 
lobes of the liver. Which of the following tech- 
niques should be used immediately? 

(A) Pringle's maneuver 

(B) Packing the liver 

(C) Suture ligation 

(D) Ligation of the right hepatic artery 

(E) Ligation of the proper hepatic artery 

15. A 23-year-old man is shot with a handgun and 
found to have a through-and-through injury 
to the right transverse colon. There is little fecal 
contamination and no bowel devasculariza- 
tion. At operation, what does he require? 

(A) Right hemicolectomy with ileotransverse 
colon anastomosis 

(B) Right hemicolectomy with ileostomy 
and mucous fistula 

(C) Debridement and closure of wounds 
with exteriorization of colon 

(D) Debridement and closure of wounds 

(E) Segmental resection with primary 
anastomosis 



264 



12: Trauma 



16. A 20-year-old woman presents to the emergency 
department with a stab wound to the abdomen. 
There is minimal abdominal tenderness. Local 
wound exploration indicates that the knife pen- 
etrated the peritoneum. What is the ideal use of 
antibiotic administration? 

(A) Preoperatively 

(B) Intraoperatively, if a colon injury is 
found 

(C) Postoperatively if the patient develops 
fever 

(D) Postoperatively based on culture and 
sensitivity of fecal contamination found 
at the time of surgery 

(E) Intraoperatively if any hollow viscus is 
found to be injured 

17. A 70-year-old woman is hit by a car and injures 
her midabdomen. The best way to rule out a 
rupture of the second part of the duodenum is 
by which mode? 

(A) Repeated physical examinations 

(B) Ultrasound 

(C) Repeated amylase levels 

(D) CT with oral and intravenous contrast 

(E) Peritoneal lavage 

Questions 18 and 19 

18. A 35-year-old woman was punched in the right 
side of the abdomen and chest. There was some 
right upper abdomen tenderness but no guard- 
ing or rebound. Results of a gastrografin upper 
GI study showed a coiled-spring (stack of coins) 
appearance of the second and third part of the 
duodenum. What is the most likely diagnosis? 

(A) Rupture of the duodenum 

(B) Contusion to the head of the pancreas 

(C) Intraluminal blood clot 

(D) Retroperitoneal hematoma 

(E) Duodenal hematoma 

19. Which would be the appropriate management 
of the patient described above? 

(A) Exploratory laparotomy and drainage 

(B) Duodenal diverticularization 



(C) Pyloric exclusion 

(D) Repeat upper GI series at 5- to 7-day 
intervals 

(E) CT-guided percutaneous drainage 

20. A 15-year-old girl had an injury to the right 
retroperitoneum with duodenal contusion. What 
is the test required to exclude a rupture of the 
duodenum? 

(A) Serum amylase 

(B) Dimethyliminodiacetic acid (HIDA) 
scan 

(C) Gastrografin study 

(D) Upper GI with barium 

(E) ERCP 

21. A 33-year-old man presents to the emergency 
department with a gunshot injury to the abdo- 
men. At laparotomy a deep laceration is found 
in the pancreas just to the left of the vertebral 
column with severance of the pancreatic duct. 
What is the next step in management? 

(A) Intraoperative cholangiogram 

(B) Debridement and drainage of defect 

(C) Distal pancreatectomy 

(D) Closure of abdomen with J-P drains 

(E) Vagotomy 

22. A 40-year-old man is hit by a car and sustains 
an injury to the pelvis. Which of the following 
is most indicative of a urethral injury? 

(A) Hematuria 

(B) Scrotal ecchymosis 

(C) Oliguria 

(D) High-riding prostate on rectal 
examination 

(E) Intravenous pyelography (IVP) showing 
dye extravasation in the pelvis 

23. For the patient described in question 18, urine 
did not extend to the leg because the membra- 
nous layer (Scarpa's fascia) is fused interiorly 
with which of the following? 

(A) Femoral sheath 

(B) Fascia lata 

(C) Femoral fascia 



Questions: 16-28 



265 



24. 



25. 



26. 



(D) Deep inguinal ring 

(E) Superficial inguinal ring 

A 70-year-old man is brought to the emer- 
gency department following a car crash. X-rays 
revealed a fractured rib on the left and a fracture 
of the right femur. A CT scan of the abdomen 
showed a left-sided retroperitoneal hematoma 
adjacent to the left kidney and no evidence of 
urine extravasation. The hematoma should be 
managed by which of the following? 

(A) Observation 

(B) Exploratory laparotomy through a 
midline incision 

(C) CT scan-guided aspiration 

(D) Surgical exploration through a left-flank 
retroperitoneal approach 

(E) Pneumatic antishock garment (PASG) 

A 60-year-old man is hit by a pickup truck and 
brought to the emergency department with a 
blood pressure of 70/0 mm Hg. Peritoneal 
lavage showed no blood in the abdomen. The 
blood pressure is elevated to 85 systolic fol- 
lowing the administration of 2 L of Ringer's 
lactate. An x-ray showed a pelvic fracture. 
What is the next step in management? 

(A) Exploratory laparotomy with packing of 
the pelvis 

(B) CT scan of the pelvis 

(C) External fixation of the pelvis 

(D) Open reduction and internal fixation 
(ORIF) of the pelvis 

(E) Exploratory laparotomy with bilateral 
ligation of the internal iliac arteries 

An 18-year-old man is brought to the emer- 
gency department after falling down a flight of 
stairs and losing consciousness for 3 minutes. 
A cervical collar is in place. The cervical spine 
is considered to be free of serious injury fol- 
lowing which procedure? 



(A) A physical examination revealing no 
pain or tenderness 

(B) A lateral cervical spine x-ray 

(C) Completely negative findings on 
neurological examination 

(D) Anteroposterior (AP), lateral, and 
odontoid views of the neck 

(E) Flexion and extension views of the neck 

27. A 16-year-old boy presents to the emergency 
department with a stab wound to the anterior 
midneck. On physical examination, it is diffi- 
cult to determine if the plane of the platysma 
has been violated. However, subcutaneous 
emphysema is found on palpation. What is the 
next management step? 

(A) Esophagogram 

(B) Arteriography 

(C) Surgical exploration 

(D) Esophagoscopy 

(E) CT scan of the neck with oral and 
intravenous contrast 

28. A 20-year-old woman presents to the emer- 
gency department after being hit in the face 
during a baseball game. On physical examina- 
tion, the patient's blood pressure is 90 mm Hg, 
and there is significant bleeding from the nose 
that cannot be controlled either by fracture 
reduction or by anterior and posterior nasopha- 
ryngeal packing. What is the next step in man- 
agement? 

(A) External carotid artery ligation 

(B) Bilateral internal maxillary artery ligation 

(C) Angiographic evaluation and 
embolization 

(D) Foley catheter balloon tamponade of 
bleeding 

(E) Insertion of nasogastric tube 



266 



12: Trauma 



29. 



30. 



31. 



A 65-year-old man is brought to the hospital 
after being hit by a car. His blood pressure is 
150/90 mm Hg, and pulse is 120 bpm. There is 
deformity just below the left knee and no distal 
pulses palpable in that leg. Plain films show 
proximal tibia and fibula fractures. What is the 
next step in management? 

(A) Operative intervention to restore flow 
with an arterial shunt 

(B) Angiography 

(C) Doppler ultrasound 

(D) Operative reduction and internal fixation 

(E) Heparinization 

A 70-year-old man is brought into the emer- 
gency department following his injury as a 
passenger in a car crash. He complains of right 
side chest pain. Physical examination reveals 
a respiratory rate of 42 breaths per minute and 
multiple broken ribs of a segment of the chest 
wall that moves paradoxically with respira- 
tion. What should the next step be? 

(A) Tube thoracostomy 

(B) Tracheostomy 

(C) Thoracentesis 

(D) Endotracheal intubation 

(E) Intercostal nerve blocks 

A 30-year-old man is brought to the emergency 
department in respiratory distress following a 



shotgun wound to the face. There is a possible 
cervical spine injury. Which is the best way to 
gain rapid control of the airway? 

(A) Nasotracheal intubation 

(B) Percutaneous jet ventilation 

(C) Cricothyroidotomy 

(D) Endotracheal intubation 

(E) Aspiration of blood from pharynx and 
jaw thrust 

32. A 14-year-old boy is hit in the right eye with a 
stick. There is extensive ecchymosis. On phys- 
ical examination, upward gaze is found to be 
lost. The most likely diagnosis is injury to 
which of the following (Fig. 12-2)? 

(A) Superior rectus muscle 

(B) Inferior rectus muscle 

(C) Superior oblique muscle 

(D) Levator palpebrae superioris muscle 

(E) Medial rectus muscle 

33. Following a car crash in which her face hit the 
steering wheel, a 37-year-old woman presents 
to the emergency department with facial defor- 
mity. Facial x-rays showed a transverse fracture 
through the articulation of the maxillary and 
nasal bones with the frontal bone. The fracture 
also passed below the zygomatic bone. What is 
the diagnosis? 



(C) Superior oblique muscle 
(IV) 




Lateral rectus muscle 

Abducens nerve (VI) 

(D) 



Levator palpebrae 
superioris muscle 

(A) Superior rectus muscle 

(III) 

(E) Medial rectus muscle 

(III) 

(B) Inferior rectus muscle 

(III) 

Inferior oblique muscle 

(III) 



Figure 12-2. 

The muscles of extraocular movement. (Reproduced, with permission, from Lindner HH: 
Clinical Anatomy. Appleton & Lange, 1989.) 



Questions: 29-39 



267 



(A) Sphenoid wing fracture 

(B) LeFort II fracture 

(C) Petrous temporal fracture 

(D) Palatal split 

(E) Mandibular disruption 

34. A 43-year-old man is hit in the face with a base- 
ball bat and presents to the emergency depart- 
ment with massive facial swelling, ecchymosis, 
and an elongated face. There is mobility of the 
middle third of the face on digital manipulation 
of the maxilla. What is the likely diagnosis? 

(A) Lambdoid injury 

(B) Odontoid fracture 

(C) LeFort III fracture 

(D) Palatal split 

(E) Mandibular disruption 

35. A 26-year-old man is stabbed in the right 
intercostal space in the midclavicular line 
and presents to the emergency department. On 
examination, subcutaneous emphysema of the 
right chest wall, absent breath sounds, and a tra- 
chea shifted to the left are noted. What is the 
most likely serious diagnosis? 

(A) Pneumothorax 

(B) Tension pneumothorax 

(C) Massive hemothorax 

(D) Hemopneumothorax 

(E) Chest wall laceration 

Questions 36 and 37 

36. A 31-year-old man is shot in the back of the left 
chest, and the bullet exits the left anterior chest. 
The patient's blood pressure is 130/90 mm Hg, 
respiration rate is 28 breaths per minute, and 
pulse is 110 bpm. A chest x-ray reveals hemoth- 
orax. A chest tube is inserted and yields 800 mL 
of blood; the first and second hour drainage is 
200 mL/h and 240 mL/h, respectively. What is 
the next step in management? 

(A) Place a second chest tube. 

(B) Collect the blood for autotransfusion. 



(C) Transfuse and observe drainage for 
another hour. 

(D) Insert a Swan-Ganz catheter. 

(E) Perform a left thoracotomy. 

37. In the patient described above the most likely 
cause of the bleeding in the patient is injury to 
which of the following? 

(A) Pulmonary artery 

(B) Lung parenchyma 

(C) Internal thoracic (mammary) and/or 
intercostals arteries 

(D) Pulmonary vein 

(E) Left atrium 

38. A 60-year-old man crashes his car into a bridge 
abutment and is found slumped over his steer- 
ing wheel. In the emergency department, the 
signs and symptoms of pericardial tamponade 
are evident. These findings are most likely 
attributable to which of the following? 

(A) Coronary artery laceration 

(B) Left atrial rupture 

(C) Right atrial rupture 

(D) Coronary vein laceration 

(E) Intrapericardial vena cava injury 

39. Following an injury to the shoulder joint, a 
New York Yankees catcher developed a 
"catcher's mitt hand" or shoulder and hand 
syndrome. There was swelling of the right 
upper extremity, skin atrophy, and vasomotor 
instability. He also complained of a burning 
sensation in the involved extremity. What 
would be the next step in management? 

(A) Immobilization of right arm in cast 

(B) To avoid physical therapy for 3 months 

(C) Forceful shoulder joint manipulation 

(D) Prednisone for 2 weeks in resistant cases 

(E) Surgical procedure on wrist joint 



268 



12: Trauma 



40. A 47-year-old woman involved in a skiing acci- 
dent suffered a severe blow to the middle upper 
abdomen. Physical examination revealed dif- 
fuse tenderness, but there was no evidence 
of rebound tenderness or guarding. What test 
would be performed to rule out traumatic 
pancreatitis? 

(A) Peritoneal lavage 

(B) Serum amylase 

(C) CT scan with oral and intravenous 
contrast 

(D) Upper GI study 

(E) ERCP 

41. A 19-year-old man presents to the emergency 
department with a gunshot wound through 
the umbilicus. The systolic blood pressure is 
70 mm Hg on palpation, and his abdomen is 
tightly distended. Large-bore intravenous lines 
are placed, and Ringer's lactate is infused. 
What should be the next step? 



(A) 
(B) 
(C) 
(D) 



(E) 



Peritoneal lavage 

CT scan of the abdomen 

Exploratory laparotomy 

Transfusion of the patient until the 

systolic blood pressure reaches 

90mmHg 

PASG 



tibial pulses are palpable. The patient complains 
of severe pain that is accentuated with dorsi- 
flexion of the foot. The calf feels tense. What is the 
appropriate step? 

(A) ORIF of fracture 

(B) ORIF of fracture plus three-compartment 
fasciotomy 

(C) Closed reduction and observation 

(D) ORIF only if pulses become weak 

(E) Arteriogram 

44. An 18-year-old woman who is 8-month preg- 
nant is brought into the emergency depart- 
ment. She was hit by a car and now complains 
of abdominal pain. Her blood pressure is 
80/60 mm Hg, pulse is 120 bpm, and respira- 
tion rate is 30 breaths per minute. Large-bore 
intravenous lines are placed through the ante- 
cubital fossa. The fetal heart rate is 160 bpm. 
What is the next step? 

(A) Infuse 2000 mL of Ringer's lactate over 
10-15 minutes. 

(B) Apply a PASG, inflating only the legs. 

(C) Displace the uterus to the left. 

(D) Order an ultrasound of abdomen and 
pelvis to rule out free blood. 

(E) Perform peritoneal lavage 2 cm above 
the umbilicus. 



42. 



43. 



A 34-year-old man is brought into the emergency 
department with a large open knife wound to the 
left thigh. The patient's systolic blood pressure is 
90 mm Hg. Blood is spurting from the wound. 
What is the initial management step? 

(A) Clamp the bleeding artery with a 
vascular clamp. 

(B) Apply a tourniquet 7.5 cm above the 
wound. 

(C) Apply direct pressure with sterile gauze. 

(D) Apply PASG, and inflate both legs. 

(E) Insert central venous access line. 

A 40-year-old construction worker is pulled from 
the rubble after a building collapses and pins his 
right lower leg. X-rays in the emergency depart- 
ment reveal a comminuted fracture of the right 
tibia and fibula. The dorsal pedis and posterior 



45. A 60-year-old man is a front-seat passenger in 
a car crash. He is found to have three fractured 
ribs on the right, rupture of the liver, pelvic 
fracture, right femoral fracture, and a left tibial 
fracture. The patient is given broad-spectrum 
antibiotics, and his injuries are managed by 
surgery, requiring 12 U of blood. The patient 
improves initially, but on the third postopera- 
tive day, he develops hypoxia (PaO„ 55 mm Hg), 
with confusion, tachypnea, and petechia. What 
is the most likely diagnosis? 

(A) Recurrent intra-abdominal hemorrhage 
from dilutional thrombocytopenia 

(B) Transfusion reaction 

(C) Antibiotic allergy 

(D) Fat embolus 

(E) Disseminated intravascular clotting 
(DIC) 



Questions: 40-48 



269 




Figure 12-3. 

AP radiograph of a patient with a fractured pelvis. There is widening of the symphysis pubis and a dis- 
placed fracture of the right ilum. (Reproduced, with permission, from Brunicardi FC et al.: Schwartz's 
Principles of Surgery, 8th ed. 1683. McGraw-Hill, 2005.) 



46. A 43-year-old woman is thrown from a car 
following a car crash. She presents to the 
emergency department with a fracture of 
the pelvis (Fig. 12-3). Her blood pressure is 
80/60 mm Hg, pulse is 110 bpm, and respira- 
tory rate is 26 breaths per minute. Bright red 
blood is found on rectal examination and 
bony fragments can be palpated through the 
rectal wall. The patient remains hypotensive 
despite 3 L of Ringer's lactate and 2 U of type- 
specific blood. What is the most important 
step in management? 

(A) Exploratory laparotomy and colostomy 

(B) External fixation of the pelvic fracture 

(C) PASG 

(D) Fresh-frozen plasma 

(E) Wiring of symphysis pubis 

47. With regard to neck injuries, which of the fol- 
lowing is true? 



(A) The internal jugular vein may be ligated 
unilaterally without unfavorable 
sequelae. 

(B) Unilateral ligation of the common 
carotid artery results in a neurologic 
deficiency in 90% of cases. 

(C) Esophageal injuries should be drained 
externally only when extensive devital- 
ization is present. 

(D) Tracheostomy is indicated in dealing 
with most laryngeal or tracheal injuries. 

(E) Injuries to the trachea must be drained 
externally. 

48. The injury most often missed by selective 
nonoperative management of abdominal stab 
wounds is to which of the following? 



(A) 


Colon 


(B) 


Spleen 


(C) 


Ureter 


(D) 


Diaphragm 


(E) 


Small bowel 



270 



12: Trauma 



49. A 40-year-old woman is brought to the emer- 
gency department following a car crash in which 
she was the driver. In the emergency depart- 
ment, her blood pressure is 80/60 mm Hg, pulse 
is 128 bpm, and respiratory rate is 32 breaths per 
minute. She complains of right lower chest wall 
and severe right upper quadrant (RUQ) tender- 
ness. Her breath sounds are questionably dimin- 
ished. The immediate priority is to perform 
which of the following? 

(A) Peritoneal lavage 

(B) Chest x-ray 

(C) CT scan of chest and abdomen 

(D) Thoracentesis with an 18-gauge needle 

(E) Endotracheal intubation 

50. A 30-year-old woman is brought to the emer- 
gency department after she stepped on a rusty 
nail and sustained a puncture wound to the 
foot. The patient has been on a therapeutic dose 
of steroids for the past 5 years for ulcerative 
colitis. Her last tetanus toxoid booster was 
8 years ago. What should the patient receive? 

(A) Tetanus toxoid booster 

(B) Human immunoglobulin 

(C) Antibiotics with anaerobic coverage 

(D) Tetanus toxoid plus human 
immunoglobulin 

(E) Tetanus toxoid plus human 
immunoglobulin and antibiotics with 
aerobic and anaerobic coverage 

51. A 24-year-old woman with blunt trauma to the 
head sustained in a car accident presents with 
a history of loss of consciousness for approxi- 
mately 10 minutes at the scene of the accident. 
She is currently fully awake, oriented, and 
responsive. With regard to the appropriate care 
of this woman, which of the following state- 
ments is true? 

(A) In this setting, a fully awake patient who 
has a normal examination does not 
require hospital admission for 
observation. 

(B) If skull x-rays show no fracture, the 
likelihood of a significant intracranial 
injury is low, and hospital admission is 
unwarranted. 



(C) If fundoscopic examination of this 
patient shows no papilledema, elevated 
intracranial pressure can be ruled out. 

(D) The initial effects of elevated 
intracranial pressure are bradycardia 
and hypertension. 

(E) If this patient were to exhibit a sudden 
fall in blood pressure and alteration in 
mental status, spinal cord, or brainstem 
injury would be most likely. 

52. A 12-year-old girl is brought into the emergency 
department after an unprovoked attack and bite 
by a raccoon. The bite is on the left lower leg. 
Which treatment should be provided? 

(A) Administration of human rabies 
immunoglobulin (HRIG) into the left 
gluteal area 

(B) Administration of a five-dose course of 
human diploid cell rabies vaccine 
(HDCV) 

(C) Administration of a 5-day course of 
HDCV and a 3-day course of HRIG 

(D) Administration of a 5-day course of 
HDCV and a single dose of HRIG with 
up to half of the dose administered 
directly around the wound 

(E) Administration of a 5-day course of 
HDCV and a single dose of HRIG 
administered into the gluteal area 

53. An 18-year-old man is bitten on the leg by what 
appears to be a rattlesnake. A tourniquet has 
been placed above the wound, and the patient 
arrives at the emergency department 70 min- 
utes after the injury. There are two fang marks 
with 15 cm of edema and erythema surround- 
ing the wound. What should immediate treat- 
ment include? 

(A) Suction applied through longitudinal 
incisions directly through the fang marks 

(B) Suction applied through longitudinal 
incisions proximal to the bite 

(C) Excision of the fang mark, including 
skin and subcutaneous tissues 

(D) Administration of four ampules of 
antivenin 

(E) Removal of tourniquet 



Questions: 49-57 



271 



54. A 20-year-old woman presents to the emergency 
department with a stab wound to the neck 
above the angle of the mandible. The patient's 
blood pressure is 110/80 mm Hg, pulse rate is 
100 bpm, and respiration rate is 24 breaths per 
minute. Between initial presentation and inser- 
tion of intravenous lines, the hematoma in the 
upper neck enlarges significantly. What should 
be the next step in the patient's management? 

(A) Barium swallow 

(B) Flexible endoscopy 

(C) Operative exploration 

(D) Doppler ultrasound 

(E) Angiography 

55. A 65-year-old man is brought into the emer- 
gency department with a gunshot wound to 
the neck. His blood pressure is 80/50 mm Hg. 
The patient undergoes rapid resuscitation and 
is brought immediately to the OR, where a 
carotid artery injury is found in zone II (between 
the angle of mandible and cricoid) (Fig. 12-4). 
The patient has no internal carotid flow; just 
before surgery, his neurological status deterio- 
rates, and he becomes unresponsive. The oper- 
ative management should be which of the 
following? 

(A) Immediate intravascular bypass shunt 

(B) Ligation of the internal carotid artery 

(C) Primary anastomosis 

(D) Interposition saphenous vein graft 

(E) Patch vein graft 

56. A 19-year-old man is brought to the emergency 
department with a stab wound at the base of 
the neck (zone I) (Fig. 12^). The most impor- 
tant concern for patients with such injuries is 
which of the following? 

(A) Upper extremity ischemia 

(B) Cerebral infarction 

(C) Exsanguinating hemorrhage 

(D) Mediastinitis 

(E) Tracheal stenosis 




Figure 12-4. 

For the purpose of evaluating penetrating injuries, the neck is divided 
into three zones. Zone I is below the clavicles an is also known and the 
thoracic outlet. Zone II is located between the clavicles and hyoid 
bone, and Zone III is above the hyoid. (Reproduced, with permission, 
from Brunicardi FC et a!.: Schwartz's Principles of Surgery, 8th ed. 
140. McGraw-Hill, 2005.) 



57. A 42-year-old man is hit on the left side of his 
body by a car and is brought to the emergency 
department with fractures of the left tenth, 
eleventh, and twelfth ribs and left tibia and 
fibula fractures. The patient's blood pressure is 
120/90 mm Hg, pulse rate is 100 bpm, and res- 
piration rate is 24 breaths per minute. He has 
hematuria and left flank pain. Intravenous lines 
are inserted. IVP shows no excretion from the 
left kidney but normal excretion from the right. 
What would be the next step in management? 

(A) Exploratory laparotomy 

(B) CT scan with intravenous contrast 

(C) Arteriography 

(D) Cystogram 

(E) Peritoneal lavage 



272 



12: Trauma 



58. A 26-year-old man is brought to the emergency 
department with a stab wound to the right side 
of the back just medial to the posterioraxillary 
line. His blood pressure is 120/80 mm Hg, pulse 
rate is 98 bpm, and respiration rate is 22 breaths 
per minute. Physical examination reveals no 
abdominal tenderness, guarding, or neurologic 
changes. Local exploration of the stab wound is 
performed using local anesthesia. The track 
to the wound ends in the paraspinal muscles. 
What would be the next step in management? 

(A) Admit the patient for 24 hours of 
observation. 

(B) Perform peritoneal lavage. 

(C) Perform CT scan with rectal and 
intravenous contrast. 

(D) Discharge to outpatient clinic for 
follow-up monitoring. 

(E) Perform ultrasound. 

59. A 25-year-old woman is brought to the emer- 
gency department with multiple gunshot 
wounds to her abdomen. Her blood pressure is 
70 mm Hg. Her abdomen is massively dis- 
tended. Large intravenous lines are placed, 
and a nasogastric tube and Foley catheter are 
inserted. The patient is brought immediately to 
the OR. After 2 L of normal saline, her blood 
pressure is 75/0 mm Hg, pulse rate is 140 bpm, 
and respiration rate is 30 breaths per minute. 
The next step in management should be which 
of the following? 

(A) Open the abdomen and use a large 
Richardson retractor to compress the 
abdominal aorta against the vertebrae 
just below the diaphragm. 

(B) Perform left thoracotomy, and 
cross-clamp the descending aorta just 
above the diaphragm. 

(C) Apply the PASG to elevate blood 
pressure before incision. 

(D) Infuse 4 U of whole blood before incision. 

(E) Perform exploratory laparotomy and 
pack obvious bleeding sites. 

60. A 30-year-old woman involved in a car crash is 
brought into the emergency department. Her 
blood pressure is 90/60 mm Hg, pulse rate is 



120 bpm, and respiration rate is 18 breaths per 
minute. On peritoneal lavage, she is noted to 
have free blood in the peritoneal cavity. At the 
time of exploratory laparotomy, a liver lacera- 
tion is noted, and there is a 2.5-cm-diameter 
contusion to an area of small bowel. How should 
the small-bowel contusion be treated? 

(A) Transillumination evaluation of 
hematoma with meticulous hemostasis 

(B) Resection of the bowel with single-layer 
anastomosis 

(C) Inversion of the area of contusion with a 
row of fine nonabsorbable mattress 
sutures 

(D) Resection of the bowel and ileostomy 

(E) Observation (no surgical therapy) 

61. A 19-year-old man is brought into the emer- 
gency department with a gunshot wound 
that occurred 4 hours before admission. At 
exploratory laparotomy, an injury is noted in 
the transverse colon with extensive tissue des- 
truction. There is a large amount of fecal con- 
tamination. Management of this injury should 
include which of the following? 

(A) Debridement and closure of wound 
with a proximal colostomy 

(B) Resection with proximal colostomy and 
distal mucous fistula 

(C) Resection of the injured colon with 
primary anastomosis and proximal 
colostomy 

(D) Resection of the wound with primary 
anastomosis and proximal cecostomy 

(E) Exteriorization of repaired colon 

62. A 60-year-old man is brought into the emer- 
gency department after being hit by a car. 
His blood pressure is 70 mm Hg palpable, and 
abdomen is massively distended and tender. 
A large, stellate fracture of the right lower 
liver is noted, and despite repeated attempts 
at suturing, bleeding persists. The anesthesi- 
ologist notes that the pH of arterial blood is 
7.2 and that the patient has become hypother- 
mic. A total of 8 U of blood have been trans- 
fused. What is the next step in management? 



Questions: 58-66 



273 



(A) Insert an atriocaval shunt. 

(B) Perform a right hepatic lobectomy. 

(C) Pack the RUQ for 15-20 minutes while 
the anesthesiologist transfuses more 
blood. 

(D) Perform a right hepatic artery ligation. 

(E) Firmly pack the RUQ, close the 
abdomen, and plan to return to the OR 
within 36-72 hours. 

63. A 40-year-old man sustained injuries to the 
liver, gallbladder, small intestine, and colon 
from gunshot wounds. At the time of surgery, 
a cholecystostomy was placed in the injured 
gallbladder to expedite operative management. 
Four weeks later, the patient is doing well. 
Which is the next step in management? 

(A) Remove the cholecystostomy tube. 

(B) Perform a cholangiogram through the 
cholecystostomy tube. 

(C) Perform a cholecystectomy. 

(D) Perform a choledochoduodenostomy. 

(E) Perform a permanent cholecystostomy. 

64. A 22-year-old man is found to have a complete 
transection of the common bile duct following 
a gunshot wound to the abdomen. There is also 
a through-and-through wound to the edge of 
the right lobe of the liver that is not bleeding at 
the time of surgery. How should the bile duct 
injury be managed? 

(A) Choledochojejunostomy and 
cholecystectomy 

(B) Whipple operation 

(C) Primary repair with a cholecystostomy 
tube decompressing the gallbladder 

(D) Cholecystectomy alone 

(E) Choledochoileostomy 

65. An 18-year-old man presents to the emergency 
department with a stab wound to the abdomen. 



66. 



His blood pressure is 80/50 mm Hg. He is 
brought immediately to the OR, where an 
enlarged hemoperitoneum is found at laparo- 
tomy. Primary repair of the hepatic artery is 
performed, but because of ongoing blood loss 
resulting in an unstable hemodynamic situa- 
tion, the portal vein injury is simply ligated. 
Bleeding is well controlled. The patient is 
brought to the recovery room, where his blood 
pressure drops to 80/60 mm Hg and central 
venous pressure is 2 cm H 2 0. What should be 
the next step in management? 

(A) Transfusion of whole blood to elevate 
blood pressure 

(B) Reexploration to determine site of 
bleeding 

(C) Reexploration to repair portal vein 

(D) Vasopressor to increase blood pressure 

(E) Ringer's lactate to increase blood 
pressure 

A 25-year-old man presents to the emergency 
department with a gunshot wound to the abdo- 
men. On exploratory laparotomy, he is found to 
have multiple small-bowel enterotomies, trans- 
verse colon enterotomy, and a partial injury 
just to the left of the midline of the pancreas. 
The pancreatic duct appears intact. What is the 
appropriate management of the pancreatic 
injury? 

(A) Closed-suction drainage and lavage 

(B) Drain with sump drains 

(C) Distal pancreatectomy 

(D) Operative pancreatogram followed by 
distal pancreatectomy if ductal injury is 
noted 

(E) Transection of injured area of pancreas 
with Roux-en-Y (jejunal) anastomosis to 
the transected tail of the pancreas 



274 



12: Trauma 



67. A 29-year-old woman is brought to the emer- 
gency department with a gunshot wound to the 
abdomen. Her blood pressure is 80/60 mm Hg, 
pulse rate is 118 bpm, and respiration rate is 24 
breaths per minute. She is brought immediately 
to the OR, where a large amount of blood and 
clots are found within the abdomen. After initial 
packing of the abdomen and stabilization of the 
patient, a retroperitoneal hematoma is found 
just above the renal veins. Proximal and distal 
control of the inferior vena cava is obtained and 
the blood pressure comes up to 100/60 mm Hg. 
Which is the most appropriate management? 

(A) Vascular repair of the injury 

(B) Packing of the area with a definitive 
plan to return to the OR in 48 hours 

(C) Ligation of the inferior vena cava 

(D) Use of intracava shunt to allow venous 
return while repairing the injury 

(E) Use of Gore-Tex interposition graft to 
restore continuity 

68. A 26-year-old woman in her sixth month of 
pregnancy is brought to the emergency depart- 
ment. She had been punched in the abdomen. 
She is found to have generalized abdominal 
pain, tenderness, abdominal distention, ileus, 
and absent fetal heart sounds. The patient's 
blood pressure is 80/60 mm Hg; despite admin- 
istration of 3 L of Ringer's lactate, her blood 
pressure only comes up to 90/60 mm Hg. What 
is the next step in management? 

(A) Application of PASG 

(B) Transfusion of 2 U of blood and 
reevaluate 

(C) Exploratory laparotomy and vaginal 
hysterectomy 

(D) Exploratory laparotomy with evacuation 
of the uterus and closure of the uterus 
disruption 

(E) CT scan of the abdomen 

69. A 52-year-old secretary generally wears high 
heels and tight-fitting shoes. She saw her prac- 
titioner because of foot pain. His diagnosis of 
plantar fasciitis is characterized by which of 
the following? 



(A) It is an uncommon cause of persistent 
heel pain. 

(B) It causes pain on the lateral aspect of the 
calcaneum. 

(C) It results in part from poor selection of 
footwear. 

(D) It does not reveal abnormality on x-ray. 

(E) It occurs usually at rest. 

70. A 43-year-old male clerk cuts his right hand 
on a broken glass door. In evaluating the hand, 
what should be kept in mind? 

(A) The proximal wrist crease corresponds 
with the wrist joint. 

(B) The distal wrist crease corresponds with 
the deep palmar arch. 

(C) Hypothenar muscles are the short 
muscles of the thumb. 

(D) The ulnar nerve supplies the medial 
three and one-half fingers on the palmar 
surface. 

(E) The radial artery is the sole source of 
arterial supply to the hand. 

71. A newborn boy was examined to exclude con- 
genital dislocation of the hip (CDH). Which of 
the following tests is relative to the manage- 
ment of CDH? 

(A) The diagnosis should be established 
between 2 and 4 years of age. 

(B) Abduction of the flexed hip causes a 
click (Ortolani's sign) (Fig. 12-5). 

(C) Abduction of the hip is not limited. 

(D) Apparent lengthening of the thigh with 
the hip and knee flexed may be seen. 

(E) Open reduction usually is required. 

72. A football player extends his right arm to make 
a tackle but experiences intense pain on tackle 
contact with subsequent inability to move the 
right arm. Examination reveals swelling and 
tenderness about the shoulder with loss of the 
normal deltoid contour. Which is the most likely 
diagnosis? 

(A) Brachial plexus injury 

(B) Anterior dislocation of the shoulder 



Questions: 67-75 



275 




73. 



Figure 12-5. 

In Ortolani's sign, abduction and lifting with the 
fingers produces a corresponding jerk when 
the dislocated femoral head slides back into 
the acetabulum. (Reproduced, with permission, 
from Doherty GM: Current Surgical Dignosis & 
Treatment. 1170. McGraw-Hill, 2006.) 



(C) Fracture of the proximal posterior portion 
of the humerus 

(D) Deltoid muscle rupture 

(E) Posterior dislocation of the shoulder 

A 7-year-old boy falls off his bicycle, landing on 
the left elbow. He presents to the emergency 
room with massive, tense swelling of the elbow 
with painful and restricted elbow motion. 
X-rays show a displaced fracture of the distal 



end of the humerus. Which of the following is 
the most serious complication of this fracture? 

(A) Nonunion of fracture fragments 

(B) Nonunion of fracture fragments with 
deformity 

(C) Disruption of the growth plate at the 
distal end of the humerus 

(D) Forearm compartment syndrome 
(Volkmann's ischemia) 

(E) Ankylosis of the elbow joint 

74. A 25-year-old man experiences pain in the right 
knee while skiing, causing his knee to twist 
and him to fall to the ground. His knee is 
swollen. He cannot bear full weight or fully 
extend or bend his leg. There is tenderness over 
the medial joint line (Fig. 12-6). Emergency- 
room x-ray findings were normal, and the 
range of motion (ROM), although restricted, is 
stable to varus and valgus stress. Straight-leg 
raise is unrestricted. Which is the most likely 
type of injury? 

(A) Anterior cruciate ligament 

(B) Tuberosity 

(C) Transverse genicular ligament 

(D) Medial meniscus 

(E) Posterior cruciate ligament 

75. A 50-year-old man hears a "snap" and then 
feels pain in his right leg while lunging for a 
forearm drive playing tennis. He walks off the 
court with difficulty, but his leg is swollen and 
painful. Findings on x-rays of the leg and ankle 
in the emergency room are negative. Foot sen- 
sation is normal, but findings on the Thompson 
test (failure of plantar flexion to occur after 
squeezing the gastrocnemius) are positive. What 
is the diagnosis? 

(A) Gastrocnemius muscle tear 

(B) Acute thrombophlebitis 

(C) Rupture of the Achilles tendon 

(D) Acute compartment syndrome 

(E) Fibula fracture 



276 



12: Trauma 



(C) Transverse genicular 
ligament 



(D) 

Medial meniscus 



(B) Tuberosity 




Anterior cruciate (A) 
ligament 



(E) Posterior cruciate 
ligament 

Figure 12-6. 

Superior aspect of the right tibia showing ligaments. (Reproduced, with permission, from 
Lindner HH: Clinical Anatomy. Appleton & Lange, 1989.) 



76. A 40-year-old housewife trips over the garden 
hose, landing on the patio with an outstretched 
hand. Swelling and pain in the wrist rapidly 
occur, but findings on emergency room x-rays 

are negative for fracture or dislocation. In addi- ™ 

tion to the swelling, there is restriction of wrist 
dorsiflexion and palmar flexion as well as some 
tenderness of the anatomic snuffbox at the base 
of the thumb. What is the best treatment? 

(A) Splint the wrist for 4 days until the 
swelling and wrist pain subside. 

(B) Apply a cast to the wrist and repeat the 
wrist x-ray in 10-14 days. 

(C) Apply a cast to the wrist for 8 weeks. 

(D) Apply an Ace wrap to the wrist and 
remove daily for range of motion and 
exercise in warm water. 

(E) Perform open exploration of the wrist. 

77. A 55-year-old right-handed woman has left 
elbow pain laterally after cleaning up a flooded 
basement by wringing out water-soaked rags. 
X-ray findings are negative. There is tenderness 
and slight swelling over the lateral epicondyle 
of the humerus. Anatomically, this condition 

can be explained by which of the following? p™ 

(A) Sprain of the lateral collateral elbow 
ligament 

(B) Rupture of the triceps muscle 



(C) Tendinitis of the wrist extensors 

(D) Synovitis of the left elbow joint 

(E) Rupture of pronator teres muscle 

A 16-year-old cross-country runner experiences 
right midleg pain during workouts. Sometimes 
the pain prevents him from completing the pre- 
scribed mileage. There is midtibial tenderness 
but no deformity. ROM of the ankle and knee 
are full and painless. There is no calf tenderness 
or fullness, and the Achilles tendon is intact. 
X-ray findings for the tibia and fibula, includ- 
ing both the ankle and knee joints, are normal. 
What should the patient be advised to do? 



(A) 

(B) 
(C) 

(D) 



(E) 



Rest, take anti-inflammatory agents, and 

use crutches for 2 weeks. 

Wear a short leg cast for 3 weeks. 

Rest, take anti-inflammatory agents, use 

crutches, and undergo a bone scan. 

Continue running but increase stretching 

exercises before and after workout and 

apply analgesics to the painful area for 

20 minutes after workout. 

Use steroids. 



A 47-year-old man awakens with low back pain 
after a weekend of gardening. He recalls no 
specific incident of trauma and has never had 
back pain before. There is no radiation of the 



Questions: 76-83 



277 



pain and no disturbance of normal bowel or 
bladder function. The ROM of the low back is 
painful and restricted in all planes, and there is 
paraspinal tenderness from L2 to L5 on the 
right. Scoliosis and kyphosis are absent. Findings 
on straight-leg-raising test are negative, reflexes 
are active and equal, and the patient can walk 
on his heels and toes. Findings on x-rays of the 
lumbar spine are normal. Which is the best 
treatment? 

(A) Bed rest for 48 hours, anti-inflammatory 
agents, heat to the low back, and 
nonnarcotic analgesics 

(B) Bed rest for 7-10 days, heat to the lower 
back, anti-inflammatory agents, muscle 
relaxants, and analgesics 

(C) Hospitalization for pelvic traction, 
physical therapy, anti-inflammatory 
agents, intramuscularly analgesics, and 
muscle relaxants 

(D) Immediate magnetic resonance image 
(MRI) for the lumbar spine 

(E) Lumbar puncture 

80. An 86-year-old woman experiences left hip 
pain after a fall at home. She cannot ambulate, 
her hip area is swollen and painful, and her 
left lower extremity is shortened and externally 
rotated. Before the fall, she was ambulatory 
and had no complaint of hip, pelvic, or knee 
pain. In addition to the fracture of the proximal 
portion of the left femur, the x-ray would show 
which of the following? 

(A) Arthritis of the left hip 

(B) Calcific bursitis of the left hip 

(C) Osteoporosis 

(D) Fracture of the pelvis 

(E) Dislocation of the head of the femur 

81. A 70-year-old man has had a long-term "bow- 
legged" condition but recently his right knee 
has become warm, swollen, and tender. He 
reports no recent trauma and gets no relief with 
rest or Tylenol (paracetamol). He is otherwise 
in good health and takes no medication. X-rays 



show arthritis of the knee. Which would be the 
best treatment? 

(A) Bed rest, anti-inflammatory agents, 
analgesics, and a knee brace 

(B) Use of a cane for ambulating, restriction 
of knee-bending activities, and 
implementation of muscle-strengthening 
exercises 

(C) Intra-articular steroid injection, bed rest, 
and analgesics 

(D) Long-leg cast and crutches for 3 weeks, 
analgesics, and anti-inflammatory 
agents 

(E) Urgent surgical correction 

82. A 64-year-old woman is admitted to the emer- 
gency department with multiple injuries. She 
requires a central venous pressure line. To min- 
imize the possibility of infection, the principal 
management of the catheter should be which of 
the following? 

(A) Repeated attempts via the same cannula 
in the neck 

(B) After failure at one site, use of same 
cannula at another site 

(C) Use of multiport catheters 

(D) Avoidance of wound contamination by 
application of tincture of iodine for 
more than 4 seconds 

(E) Selection of subclavian vein over 
femoral vein 

83. A 40-year-old woman was involved in a car 
crash. She was unconscious for 5 minutes. X- 
ray revealed a depressed fracture in the frontal 
region. Which of the following statements is 
true of skull fracture? 

(A) It always requires surgical exploration. 

(B) It is compound if multiple. 

(C) It requires burr holes if compound. 

(D) In the anterior cranial fossa, it may 
produce rhinorrhea. 

(E) It requires steroid administration. 



278 



12: Trauma 



84. A 32-year-old man underwent laparotomy for 
trauma because of multiorgan injuries. He was 
discharged after 2 weeks in the hospital only to 
be readmitted after 3 days because of abdomi- 
nal pain and sepsis. The CT scan showed an 
accumulation of fluid in the subhepatic space. 
This space is likely to be directly involved fol- 
lowing an injury to which of the following? 

(A) Inferior pole of the right kidney 

(B) Stomach 

(C) Superior mesenteric artery 

(D) Inferior mesenteric vein 

(E) Right psaoas muscle 

85. Following a bullet wound penetrating the 
descending colon, necrotizing fasciitis of the 
anterior abdominal wall occurred postopera- 
tively. Which of the following is true for this 
condition? 

(A) It does not involve the superficial fascia. 

(B) It causes extensive localized abscess. 

(C) It is silent without pain in the majority 
of patients. 

(D) It is treated by wide excision and 
broad-spectrum antibiotics. 

(E) It is treated by immediate incision and 
drainage. 

86. A 30-year old man sustained a pelvic fracture 
with a large pelvic hematoma. Rectal exami- 
nation reveals a large laceration in the rectal 
wall and a nonpalpable prostate. His vital signs 
have stabilized with multiple transfusions. This 
patient requires which of the following? 

(A) Resuscitation, blood transfusions, 
external fixature, and exploratory 
laparotomy 

(B) Resuscitation, angiography, embolization 
of the pelvic bleeders, exploratory 
laparotomy 

(C) Resuscitation, broad-spectrum antibiotics, 
retrograde cystourethrogram, CT of 
abdomen and pelvis, suprapubic 
cystostomy, and diverting colostomy 



(D) Exploratory laparotomy, urinary 
diversion, sigmoid colostomy presacral 
drainage, and debridement of the rectal 
wall 

(E) ORIF of pelvic fracture by a posterior 
approach, colostomy, and suprapubic 
cystostomy. 

87. Which is true of intraperitoneal colon injuries? 

(A) They should never be repaired primarily. 

(B) They may be treated by exteriorization 
of the repair. 

(C) They should be treated with resection 
and colocolostomy 

(D) They require drainage after repair. 

(E) Most can be treated by debridement and 
repair. 

DIRECTIONS (Questions 88 through 101): Each 
set of matching questions in this section consists 
of a list of lettered options followed by several 
numbered items. For each numbered item, select 
the appropriate lettered option. Each lettered option 
may be selected once, more than once, or not at all. 
Select the most appropriate option for each case. 

Questions 88 through 90 

(A) Peritoneal lavage 

(B) Wound exploration 

(C) Sonogram 

(D) Paracentesis 

(E) CT with intravenous and oral contrast 

(F) IVP 

(G) Exploratory laparotomy 
(I) Angiogram 

88. A 16-year-old boy presents to the emergency 
department with a gunshot wound to the abdo- 
minal cavity. 

89. A 60-year-old woman presents with a stab 
wound to the back just above the iliac crest. 
She is in stable condition. 



Questions: 84-96 



279 



90. A 26-year-old man presents with a tangential 
small-caliber gunshot wound of the anterior 
abdominal wall. 

Questions 91 through 93 



91. 



92. 



93. 



(A 
(B 
(C 
(D 
(E 
(F 
(G 
(H 
(I 
(J 
(K 
(L 



Splenorrhaphy with one suture 

Partial splenectomy 

Splenectomy 

Splenorrhaphy with Dexon mesh 

Packing 

Subphrenic abscess 

Pancreatitis 

Left lower lobe pneumonia 

Postsplenectomy sepsis 

Gastric wall ulcer 

Left colon perforation 

Pneumococcal infection 



A 48-year-old woman was brought to the emer- 
gency department after sustaining a stab wound 
to the left side of the abdomen. Exploration of 
the abdomen shows 1000 mL of blood, clot, and 
feces. There is a bleeding laceration across the 
middle third of the spleen but not involving the 
pedicle, a 3-cm laceration of the left transverse 
colon, and through-and-through lacerations of 
the stomach and the left lobe of the liver. What 
should be the management of the splenic injury? 

One week following splenectomy, a 12-year-old 
girl presents with nausea, vomiting, headache, 
and confusion. What is the most likely diagnosis? 

Nine days following splenectomy, a 13-year- 
old patient presents with fever and leukocys- 
tosis. The chest x-ray shows free air under the 
diaphragm. What is the most likely diagnosis? 



Question 


94 


(A) 


Flail chest 


(B) 


Empyema 


(C) 


Diaphragm rupture 


(D) 


Cervical rib 


(E) 


Hemothorax 


(F) 


Chylothorax 


(G) 


Pectus excavation 


(H) 


Paradoxical respiration 



94. A 60-year-old man is in a car crash in which he 
is the driver. He did not have a seat belt or an 
airbag. He is found to have multiple rib frac- 
tures over his right chest. His pulse is weaker 
during inspiration. What are the most likely 
diagnoses? 



Questions 95 


(A) 


Sacroiliac joint 


(B) 


Neck of femur 


(C) 


Lateral meniscus 


(D) 


Intertrochanteric 


(E) 


Pubic tuberosity 


(F) 


Spine of ischium 


(G) 


Ischial cruciate ligament 


(H) 


Anterior cruciate ligament 


(I) 


Posterior cruciate ligament 


(J) 


Biceps femora 


(K) 


Pectineal line 



95. An 81-year-old female falls and presents to the 
emergency department. What injury to this 
tissue or structure causes lower leg extremities 
to be externally rotated? 

DIRECTIONS (Questions 96 through 98): The 
response options for items 96-98 are the same. You 
will be required to select one answer from each 
item in the set. For each patient with dyspnea, 
select the most likely diagnosis. 

Questions 96 through 98 

(A) Tension pneumothorax 

(B) Cardiac tamponade 

(C) Spontaneous pneumothorax 

(D) Open pneumothorax 

(E) Massive hemothorax 

(F) Flail chest 

(G) Rupture diaphram 

96. A 23-year-old man, tall and thin, was jogging 
one evening when he suddently felt a sharp 
pain in the left chest, worse on taking a deep 
breath and shortness of breath. 



280 



12: Trauma 



97. A 45-year-old man was a passenger in a car 
when he was T-boned by a truck at a high 
speed. He is short in breath, complains of 
severe pain in the chest, and is hypoxic on the 
pulse oximeter. The breath sounds are dimin- 
ished on the left and the percussion note is 
completely dull. He rapidly becomes tachy- 
cardic and hypotensive. 

98. A 25-year-old woman was stabbed by her 
boyfriend in the left chest. On examination, she 
has a 1-cm stab wound just inferior to her left 
breast in the mid-clavicular line. There is jugu- 
lar venous distension and breath sounds are 
completely absent on the left side. She is becom- 
ing extremely dyspneic and hypoxic. 

DIRECTIONS (Questions 99 through 101): The 
response options for items 99-101 are the same. 
You will be required to select one answer from 
each item in the set. For each patient who was 
involved in a motor-vehicle crash, match the 
most likely injury. 



Questions 99 through 101 

(a) Diffuse axonal injury 

(b) Acute extradural hematoma 

(c) Acute subdural hematoma 

(d) Tentorial herniation 

(e) Flail chest 

(f) Posterior dislocation of the hip 

(g) Fracture of the pelvis 
(h) Diaphragmatic rupture 



99. 



100. 



101. 



A 45-year-old man with a skull fracture of the 
temporal bone 

A 23-year-old man with a head-on collision, bent 
steering wheel and knee imprint on dashboard. 

A 30-year-old with a side impact injury, has 
multiple rib fractures on the left side with pain 
and hypoxia. 



Answers and Explanations 



1. (B) Intramural duodenal hematoma may occur 
secondary to blunt trauma of the abdomen. 
Usually this hematoma is submucosal and the 
injury is not transmural. It may cause a tempo- 
rary obstruction of the duodenum and usually 
responds to nasogastric suction and intravenous 
fluids. Only if the patient has persistent obstruc- 
tion (as demonstrated by an upper GI study) 
beyond 2 weeks, a surgical approach may be 
required. 

2. (A) The most definitive test for a lesion requir- 
ing operative correction is demonstration of a 
disrupted major pancreatic duct. While CT 
scanning may give a suggestion of a ductal 
injury and operative exploration of the area of 
injury may be inconclusive, ERCP is very reli- 
able in showing a disrupted duct. Amylase test- 
ing of lavage effuent is nonspecific. 

3. (D) While all the injuries listed are potential 
problems in this patient, the most severe is 
blunt hollow viscus injury. A delay in diagno- 
sis beyond 12 hours is associated with increased 
morbidity and mortality. There may be very 
few physical signs of a viscus perforation and 
CT findings may be subtle and not definitive. 
A seat belt sign across the abdomen should 
raise suspicion of this injury and prompt an 
aggressive pursuit of diagnosis by serial exam- 
ination and a consideration of a peritoneal 
lavage or repeat CT scan. 

4. (E) Deceleration injuries occur when the body 
is subjected to a sudden stop when traveling at 
a high speed (e.g., high-speed automobile hit- 
ting a tree, fall from a height). As the impacting 



part of the body comes to a sudden halt, the 
organs behind continue to travel forward, thus 
causing shearing injuries at the junction of 
mobile and fixed parts; such as mesenteric 
avulsion. The other choices are possible but 
much less common. 

5. (A) While all other choices may be relative, 
hemodynamic instability is the prime con- 
traindication for nonoperative treatment. 

6. (B) The priorities in patient care are to control 
hemorrhage in the abdomen and decompress 
the subdural hematoma. The optional initial 
surgical therapy of the supracondylar femur 
fracture is the insertion of a Steinmann pin for 
traction. If traction fails to produce adequate 
alignment, open reduction can be performed at 
a later date. 

7. (A) In a patient presenting with a chest wound in 
shock, the priorities are airway, breathing, and 
circulation. Thus, aspiration of the right chest to 
rule out a tension pneumothorax should be per- 
formed first. Aspiration of the pericardium does 
not definitively rule out cardiac injury; a peri- 
cardial window provides both diagnosis and 
decompression. An echocardiogram is not indi- 
cated in an unstable patient. 

8. (C) The most definitive test for aortic injury is 
the aortogram, even though only 20-30% of 
patients with widened mediastinum demon- 
strate it. A transthoracic echocardiogram does 
not image the aorta wall; however, a trans- 
esophageal echocardiogram may have more 
value in experienced hands. 



281 



282 



12: Trauma 



9. (D) The immediate treatment is the closure of 
the hole by any means available. Sucking chest 
wounds allow shift of the mediastinum to the 
opposite side. Thoracotomy is not usually 
required. Laparotomy is indicated for a gun- 
shot wound below the fourth intercostal space, 
but it should follow respiratory stabilization. A 
chest tube will be required, following closure of 
the sucking wound, to prevent a tension pneu- 
mothorax. 

10. (D) Either an esophagoscopy or a barium 
swallow — or both — can be used to rule out 
esophageal injury. The esophagogram should 
not be performed with Gastrografin because of 
its deleterious effects if aspirated into the lungs. 
Nasogastric tube aspiration showing blood is 
suggestive of an esophageal injury in this patient 
but is not specific. Peritoneal lavage is sensitive 
for an intra-abdominal injury, causing bleeding. 




Figure 12-7. 

The Pringle maneuver. (Reproduced, with permission, from Brunicardi 
FC et al: Schwartz's Principles of Surgery, 8th ed. 160. McGraw-Hill, 
2005.) 



11. (A) In a patient with significant blunt mecha- 
nism of injury and head injury, the cervical 
spine should be protected against further 
injury. In an apneic patient with the potential 
for cervical spine injury, orotracheal intubation 
may be attempted with in-line stabilization of 
the neck. If this is unsuccessful, percutaneous 
cricothyroidotomy is the best definitive step. 

12. (D) A patient without other sources of blood 
loss who presents to the emergency depart- 
ment with a stab wound to the abdomen and in 
shock should have an expeditious exploratory 
laparotomy. Hemorrhage control should take 
precedence over definitive management of a 
concomitant head injury. The other tests will 
waste precious time and are contraindicated 
in a patient in shock. 

13. (C) The best means to establish the diagnosis is 
CT scan of the abdomen. It will demonstrate 
solid-organ injury and the appropriate amount 
of fluid (blood) in the peritoneal cavity. It also 
serves as a baseline for a patient being treated 
conservatively for spleen and liver injuries. 

14. (B) The initial operative step is packing of the 
liver to obtain control of the bleeding. A 
Pringle maneuver can then be performed. In 



this procedure, the proper hepatic artery is com- 
pressed between one finger inserted into the 
foramen omentalis (Winslow, epiploic) and 
another anterior to the free edge of the lesser 
(gastrohepatic omentum) (Fig. 12-7). Selective 
right hepatic artery is rarely useful, and ligation 
of the proper hepatic artery is contraindicated. 

15. (D) Most gunshot injuries to the right side of 
the colon should be closed primarily. Resection 
is required only where there is extensive devi- 
talization of tissue or injury to the mesocolon 
causing devascularization of the bowel. 

16. (A) Antibiotics should be given preoperatively 
to all patients with wounds penetrating the 
peritoneal cavity. Intraoperative and postop- 
erative antibiotics fail to reduce postoperative 
abscesses and wound infections adequately. 

17. (D) CT scan with oral and intravenous contrast 
is the most sensitive and specific study to diag- 
nose injuries to the retroperitoneal duodenum. 
Findings on physical examination and peri- 
toneal lavage are generally negative because 
of the retroperitoneal location of the posterior 
wall of the second portion of the duodenum. 
Rising amylase levels may increase suspicion of 
the injury but are not specific. 



/Answers: 9-26 



283 



18. (E) The coiled-spring or stacked-coin appear- 
ance of the duodenum is diagnostic of a duo- 
denal hematoma. 



a urethrogram. Inability to void and a crushed 
pelvis also should raise the possibility of a ure- 
thral injury. 



19. (D) Oral feeds and fluids are withheld, and 23. 
hyperalimentation is administered. The upper 

GI study is repeated at 5- to 7-day intervals. 
Surgery can usually be avoided. 

20. (C) Rupture of the duodenum would show in 

an extravasate Gastrografin study. Contusion of 24. 

the head of the pancreas might show a widen- 
ing of the duodenal C-loop. If barium enters the 
peritoneal cavity it causes severe peritonitis. 

21. (C) Distal pancreatectomy is the procedure of 
choice for distal pancreatic injuries. It is essential 

to avoid creation of an intestinal anastomosis 25. 

(such as in pancreaticojejunostomy), which can 
leak. An intraoperative pancreatogram is indi- 
cated to rule out more proximal duct injuries. 
Debridement and drainage of the defect alone 
may result in a pancreatic fistula. 

22. (D) A high-riding prostate on rectal examina- 
tion indicates that the urethra has been torn 

and the prostate rides up with the bladder. The 26. 

definitive study for suspected urethral injury is 



(B) Urine may extend in the subcutaneous layer 
to the anterior abdominal wall and scrotal skin. 
Fusion of Scarpa's fascia (part of superficial 
fascia) with fascia lata (deep fascia) explains why 
urine does not extend down the thigh (Fig. 12-8). 

(A) A small nonexpanding hematoma with no 
associated urine extravasation can be managed 
by observation with repeat CT scan or ultra- 
sound. If the patient becomes hypotensive, 
exploration through a midline incision would 
be indicated. 

(C) Early external fixation of the pelvis has 
been shown to reduce bleeding and mortality 
in patients in shock consequent to pelvic frac- 
tures. An unstable patient should not be sent 
for a CT scan. Selective angiography with 
embolization of the bleeding vessel may also be 
helpful in these patients. Laparotomy usually 
results in uncontrollable pelvic bleeding. 

(D) Clearing the cervical spine usually consists 
of obtaining normal findings on AP, lateral, 



Cowering of penis 



Covering of scrotum 

contributes to formation 

of tunica dartos 

Colles' fascia in tfie 
anterior perineum 




Subcutaneous tissue 



Scarpa's fascia 



Fascia continues over inguinal 
ligament and attaches to deep 
fascia of thigh 



Line of fusion of Scarpa's 
fascia with base of urogenital 
diaphragm 



Figure 12-8. 

Scarpa's fascia showing continuation into the anterior male perineum. (Reproduced, with permission, from 
Way LW: Current Surgical Diagnosis & Treatment, 10th ed. Appleton & Lange, 1994.) 



284 



12: Trauma 



and odontoid views of the cervical spine. 
Flexion and extension views are rarely indi- 
cated and must be performed under careful 
supervision. Negative findings on physical 
examination alone are not reliable in a patient 
with an impaired sensorium. 

27. (C) Midneck (zone II) stab wounds should be 
surgically explored if subcutaneous emphy- 
sema or expanding hematoma are found. Zone 
II midneck lesions are those between the lower 
border of the mandible and hyoid cartilage. 
Further studies are indicated if the findings 
just listed are not present or the platysma has 
not been clearly violated. 

28. (C) Because it is not possible to identify the spe- 
cific vessels injured by physical examination, 
angiography with embolization is indicated. 
Insertion of a nasogastric tube in patients with 
midfacial trauma should be avoided because 
of the presence of a false passage to the brain. 



circulation. Immediate operation to control 
bleeding and restore flow is indicated if the 
patient's condition is unstable. 

30. (C) Thoracentesis should be performed first to 
rule out a tension pneumothorax or hemotho- 
rax. However, if the patient does not respond 
rapidly, early endotracheal intubation is nec- 
essary for patients with a flail segment of the 
chest wall. Intercostal nerve blocks and other 
means to control pain are important but should 
be performed after respiratory problems have 
been brought under control. 

31. (C) In a patient with a massive midface injury, 
cricothyroidotomy or tracheostomy should 
be performed, depending on the urgency of 
the need for airway control (Fig. 12-9). Cricothy- 
roidotomy can usually be performed more 
quickly than tracheostomy. Nasotracheal and 
endotracheal intubation may push blood and 
debris into the trachea. 



29. (B) In a stable patient presenting with periph- 
eral vessel occlusion following blunt trauma, 
angiography is indicated to plan the appro- 
priate operative approach. An angiogram can 
also document preexisting arterisclerosis, col- 
lateral circulation, and distal runoff. Doppler 
ultrasound is useful to localize the injury site 
but gives less information regarding collateral 



32. (A) Loss of upward gaze is attributable to 
impairment of the superior rectus muscle and 
occasionally the inferior oblique muscle. Loss of 
upward gaze of the eye should not be confused 
with failure to elevate the upper eyelid (levator 
palpebrae superioris muscle), which contains 
both striated and nonstriated components. 




Figure 12-9. 

Cricothyroidotomy is recommended for an emergency surgical air- 
way. Vertical incisions are perferred to avoid injury to the anterior 
jugular veins, which are located just lateral to the midline. 
Hemorrahage from these vessels will obscure vision and prolong the 
procedure. When making an incision in the cricothyroid membrance, 
the blade of the knife should be angled interiorly to avoid injury to the 
vocal cords. A. Heavy silk suture for traction on the thyroid cartilage. 
B. Insertion of the cricothyroid tube. (Reproduced, with permission, 
from Brunicardi FC et al.: Schwartz's Principles of Surgery, 8th ed. 
130. McGraw-Hill, 2005.) 



Answers: 27-41 



285 



33. (B) The bones injured describe a Le Fort II frac- 
ture,(Fig. 12-10) occasionally associated with a 
palatal split, where the right and left maxillary 
are completely separated at the midline or the 
hard palate. Gently rocking the maxillary arch 
causes the maxilla and nasofrontal areas to 
move in concert. If there is a Le Fort III fracture, 
the entire face is detached from the cranial base. 




Figure 12-10. 

Classic Le Fort fracture patterns. (Reproduced, with per- 
mission, from Brunicardi FC et a!.: Schwartz's Principles 
of Surgery, 8th ed. 514. McGraw-Hill, 2005.) 



34. (C) The physical findings are characteristics of 
a Le Fort III fracture (Fig. 12-10). In this injury, 
the fracture passes through maxilla and nasal 
bones and above the zygomatic bone. 

35. (B) Shift of the trachea strongly suggests a ten- 
sion pneumothorax. Subcutaneous emphy- 
sema is also more common with a tension 
pneumothorax than with the other conditions 
listed. Simple pneumothorax and chest wall 
laceration are much less serious injuries than 
tension pneumothorax. 

36. (E) A patient bleeding at a rate of more than 
200 mL/h should have an emergency thoraco- 
tomy. Autotranfusion of blood collected through 
chest tube should be considered for lesser 



degree of bleeding but is less reliable to suc- 
ceed if bleeding does not decrease. 

37. (C) Bleeding that is sufficient to require thora- 
cotomy usually comes from vessels in the 
systemic circulation, particularly the internal 
thoracic (mammary) and intercostal arteries. 

38. (A) Tamponade from blunt trauma to the heart 
is usually attributable to myocardial rupture 
or coronary artery laceration. The left coronary 
artery gives off the left anterior interventricu- 
lar artery that passes between the left and right 
ventricle on the anterior surface of the heart. 
The right main coronary artery passes in the 
sulcus between the right atrium and the right 
ventricle on the anterior surface of the heart. 

39. (D) Prednisone for 2 weeks in resistant cases is 
given and then tapered. The "shoulder-hand" 
syndrome is a reflex autonomic dystrophy 
occurring after an injury (usually shoulder) 
that causes immobilization of the ipsilateral 
extremity. Treatment is directed toward gradual 
physical therapy and nonsteroidal analgesic 
drugs. Stellate ganglion block may be helpful in 
resistant cases. 

40. (C) CT scan with oral and intravenous contrast 
gives the best sensitivity and specificity in diag- 
nosing blunt trauma to the pancreas. ERCP 
could be useful in studying the integrity of the 
pancreatic duct, but a CT scan is more accurate 
in revealing traumatic pancreatitis without 
major ductal injury. An upper GI series may 
show widening of the duodenal C-loop. An 
isolated serum amylase elevation is not diag- 
nostic of pancreatic injury. Repeated testing of 
amylase levels, if amylase levels increase with 
time, may be more diagnostic of traumatic pan- 
creatitis than a single value. 

41. (C) The patient should be brought to the OR 
prepared and draped, with the nasogastric tube 
and Foley catheter inserted, and then anes- 
thetized immediately prior to laparotomy. 
Some surgeons initially control the aorta through 
a thoracotomy incision through the seventh 
intercostal space. Transfusion before control of 
bleeding causes more bleeding. 



286 



12: Trauma 



42. (C) Apply direct pressure with sterile gauze. 
Direct pressure is the best choice. Attempting to 
clamp vessels can cause further vascular or 
nerve injury. Tourniquet is used only if direct 
pressure fails. As soon as direct pressure is 
attempted, a second person should insert a 
large-bore peripheral intravenous line. 

43. (B) A tense calf with comminuted fractures 
(fractures exposed to exterior) and pain on dor- 
siflexion necessitates a fasciotomy because of 
the very high probability of a compartment 
syndrome. Arterial injury is possible (but rare) 
in lower leg injuries if the pulses are palpable. 

44. (C) Displace the uterus to the left. The first step 
in restoring cardiac return in a patient in the 
third trimester who has become hypovolemic is 
to displace the gravid uterus off the vena cava 
by pushing it to the left. The other choices 
(except for the use of the PASG) should be con- 
sidered following displacement of the uterus. 

45. (D) Fat embolus is usually associated with long 
bone or pelvic fractures and is associated with 
petechiae. Transfusion and antibiotic reactions 
causing hypotension would occur relatively 
quickly following administration. 

46. (B) The most likely cause of the patient's per- 
sistent hypotension is the pelvic fracture; there- 
fore, external fixation should be performed 
promptly. While the patient is undergoing 
external fixation in the OR, an exploratory 
laparotomy and colostomy should be per- 
formed for the rectal injury. 

47. (A) In the patient who has no neurologic deficit 
preoperatively every effort should be made to 
repair a carotid artery injury. Four-vessel angiog- 
raphy should be performed in stable patients 
with injuries in zones I and III. Careful judgment 
should be exercised in selecting patients with 
zone II injuries who are to have angiography 
(i.e., suspected injuries to bilateral carotid arter- 
ies or vertebral arteries) and in selecting those for 
observation. Carotid artery ligation might also be 
employed in patients who are unstable without 
a high incidence of neurologic deficit. 



48. (D) Selective management of abdominal stab 
wounds, especially to the lower chest and 
upper abdomen, relies on physical examination 
and diagnostic peritoneal lavage (DPL) to 
identify the need for operative exploration. 
Small, isolated diaphragmatic lacerations 
may be asymptomatic and may not result in 
red blood cell counts required to cause a pos- 
itive DPL These small diaphragmatic wounds 
are best detected by laparoscopy. Missed dia- 
phragmatic injuries may cause late diaphrag- 
matic hernias with potential morbidity and 
mortality. 

49. (D) In a patient with respiratory distress and 
shock, adequate breathing is of higher priority 
than circulation. Insertion of an 18-gauge needle 
to rule out and/or treat a pneumothorax takes 
precedence over diagnostic tests. 

50. (E) Tetanus toxoid plus human immunoglobu- 
lin and antibiotics with aerobic and anaerobic 
coverage. Patients who are taking steroids or 
who are immune suppressed should receive 
human immunoglobulin even though previ- 
ously immunized. Tetanus booster and antibi- 
otic therapy are also necessary. 

51. (D) In general, most patients with significant 
head injury should be admitted for observa- 
tion. Skull x-rays cannot be relied upon for the 
diagnosis of intracranial injury, because lesions 
may still be present, even with normal skull x- 
ray Elevated intracranial pressure may be pres- 
ent, even with the absence of papilledema. 
Bradycardia and hypertension (not hypoten- 
sion) are the features of elevated intracranial 
pressure. 

52. (D) Raccoons should be regarded as rabid ani- 
mals unless the geographic area is known to be 
free of rabies. A 5-day course of vaccine and a 
single dose of HRIG should be administered. 
They should not be administered jointly into 
the gluteal area, because administration in this 
area results in lowering neutralizing antibody 
titers. Where feasible, up to half of the dose of 
HRIG should be infiltrated into the area around 
the wound. 



/Answers: 42-61 



287 



53. (D) This patient's response is considered mod- 
erate to great in regard to envenomation and 
requires 3-5 vials of antivenin IV in 500 mL of 
normal saline. The tourniquet should not be 
removed until the antivenin therapy is insti- 
tuted. Incision and suction will be of benefit 
only if accomplished within 30 minutes of sus- 
taining the bite, and excision of the bite area is 
valuable only if performed within 1 hour. 

54. (E) In considering management of neck wounds, 
three zones are described. Zone III refers to the 
area above and posterior to the angle of the 
mandible (see Fig. 12-4). Angiographic defini- 
tion of the site and extent of arterial injury is 
important because of the difficulty in exposure 
of internal carotid injuries near the base of the 
skull. Such injuries may require the use of 
extracranial-intracranial arterial bypass. 

55. (B) Even those who advocate reconstruction of 
carotid arteries in patients with neurological 
deficit do not recommend attempted recon- 
struction in patients who are comatose. If the 
patient were not comatose, proximal and distal 
control with stenting and interposition graft 
would be the procedure of choice. 

56. (C) Exsanguinating hemorrhage is the pre- 
dominant risk, because bleeding may not be 
easily recognized, given that bleeding into the 
pleural cavity and mediastinum can occur. The 
abundant collateral blood supply generally 
protects against upper extremities or cere- 
brovascular compromise. 

57. (C) Arteriography is used to assess possible 
renal artery injury in these circumstances. It is 
used if the kidney is not visualized with an 
IVP or CT a scan. Operative intervention with- 
out arteriography is not necessary in a stable 
patient. Peritoneal lavage is useful in deter- 
mining the presence of intraperitoneal bleed- 
ing; if arteriography shows a need for surgery, 
peritoneal lavage will not be necessary. 

58. (D) A patient with definitive negative findings 
on wound exploration can be discharged from 
the hospital for outpatient follow-up care. It is 
sometimes difficult to determine the depth of a 



stab wound to the back because of the thickness 
of the paraspinal muscles. Some authors have 
found that nearly 20% of patients with such 
injuries have negative findings on exploration. 
Such patients can be discharged. Deeper stab 
wounds to the back may injure peritoneal 
structures without penetration of the peritoneal 
cavity. Thus, peritoneal lavage is less useful 
than a CT scan with intravenous, oral, and (par- 
ticularly) rectal contrast to rule out retroperi- 
toneal colon injuries. 

59. (A) Open the abdomen and use a large 
Richardson retractor to compress the abdomi- 
nal aorta against the vertebrae just below the 
diaphragm. The advantages of occluding the 
subdiaphragmatic aorta (as opposed to the supra- 
diaphragmatic aorta) are that it: (a) avoids open- 
ing another major cavity; and (b) results in less 
diminution of blood flow to the spinal cord and 
renal circulation. Further attempts to resuscitate 
the patient with whole blood will not be suc- 
cessful until bleeding sites are controlled; such 
measures may even increase bleeding by elevat- 
ing blood pressure, which reopens vessels that 
have already stopped bleeding. Attempting to 
control individual bleeding sites with packing is 
difficult in a patient with multiple gunshot 
wounds who is exsanguinating. 

60. (D) Contusion of the small bowel may be larger 
than apparent and may lead to necrosis and per- 
foration. Contusions of 1 cm or less in diame- 
ter may be turned in with mattress sutures. 
However, larger contusions should be resected. 
The advantage of a single-layer anastomosis is 
the speed of performance and the reduced like- 
lihood of compromising the muscularis mucosa. 

61. (B) The necrotic bowel is resected, the proximal 
end is constructed as an end colostomy, and 
the distal end is constructed as a mucous fis- 
tula. This is the best procedure, because it will 
avoid an anastomosis in a contaminated 
abdomen. Any procedure that involves either 
wound closure or anastomosis in an abdomen 
with extensive fecal contamination presents a 
significant risk of leakage and therefore should 
not be performed. Exteriorization should not be 
performed unless ischemic bowel is resected. 



288 



12: Trauma 



62. (E) Once a patient shows acidemia and hypother- 
mia from significant blood loss, further operative 
manipulations will not likely result in control of 
persistent bleeding. It is best to pack the RUQ 
firmly and return to the OR in 36 hours. It is pos- 
sible that the patient has a retrocaval hepatic vein 
injury but attempting to insert an intracaval 
shunt in the presence of acidemia and hypother- 
mia is not likely to be successful. Hepatic artery 
ligation has been used infrequently in recent 
years, because in most cases, hepatic bleeding 
is venous and, therefore, not altered by the 
ligation. 

63. (B) A cholecystocholangiogram must be per- 
formed to ensure that the gallbladder is not 
leaking, and that there is free flow of dye in the 
duodenum if no abnormality is detected on the 
cholangiogram, the cholecystomy tube is 
removed. The patient should undergo follow- 
up gallbladder studies several months later, 
but routine removal of the gallbladder is not 
necessary. 

64. (A) Although it may be technically possible to 
perform a primary anastomosis for a complete 
transection, these invariably lead to bile duct 
structure. It is important to remember that 
debridement of the duct following a gunshot 
wound increases the tension on the anastomo- 
sis. The best method for the early treatment of 
injuries to the common bile duct is a duct-to- 
small bowel anastomosis. 



65. (A) Obstruction to the portal outflow causes 
acute splenic hypervolemia simultaneously 
with systemic hypovolemia. If not treated by 
overtransfusion of blood volume (in some cases, 
almost equal to the patient's normal blood 
volume), death may occur from hypovolemia. 
Vasopressors should never be used to correct 
blood pressure in the face of hypovolemia. 

66. (A) Routinely performing distal pancreatectomy 
for all penetrating injuries to the body or tail of 
the pancreas significantly prolongs the operative 
time and contributes to additional hemorrhage 
and possible hypothermia. Approximately 25% 
of patients undergoing distal pancreatectomy 



develop an intra-abdominal abscess. Distal pan- 
createctomy is the procedure of choice if there is 
an obvious disruption of the pancreatic duct in 
the body or tail. Closed-suction drainage is pre- 
ferred to suction drainage because of the lower 
incidence of abscess formation with closed- 
suction drainage. If there is an injury to the duo- 
denum, a pancreaticogram can be performed 
through the injury site; however, a normal duo- 
denum should not be opened to secure an intra- 
operative pancreaticogram. 

67. (A) Although injuries in the inferior vena cava 
can be ligated if the repair is unduly time con- 
suming for the patient with continued hypoten- 
sion, every attempt must be made to repair a 
suprarenal vena cava injury. Packing of the 
injury should be performed only if acidemia 
and/or hypothermia develop, because packing 
of the vena cava is not likely to be effective for 
a very long period. If an interposition graft is 
necessary, vein graft should be obtained from 
the infrarenal cava or iliac veins. A synthetic 
graft is likely to thrombose. An intracaval shunt 
generally requires a thoracotomy to gain prox- 
imal control and is reserved for retrohepatic 
injuries to the vena cava. 

68. (D) Exploratory laparotomy with evacuation 
of the uterus and closure of the uterus disrup- 
tion is the procedure of choice despite contin- 
ued hypotension. Blood administration should 
be instituted but is not as critical as gaining 
surgical hemostasis. A PASG may have a lim- 
ited temporizing effect but should not be used 
as an alternative to exploratory laparotomy. 
Any patient with abdominal trauma who is 
hypotensive should not be sent for a CT scan. 

69. (C) Plantar fasciitis may occur either with or 
without a calcaneal spur. Plantar fasciitis is more 
likely when footwear is inappropriate or there is 
excessive exercise (e.g., in athletes). There is pain 
either after exercise (in a patient who has had a 
period of rest) or at the end of prolonged activ- 
ity. Tenderness is over the medial aspect of the 
plantar fascia close to the calcaneum. X-ray may 
reveal a tear in the periosteum or a calcaneal 
spur. 



/Answers: 62-87 



289 



70. (A) The proximal wrist crease corresponds with 
the wrist joint, and the distal crease of the wrist 
corresponds with the proximal portion of the 
flexor retinaculum. The hypothenar muscles 
are on the ulnar side, and the thenar muscles 
are on the thumb side of the hand. The ulnar 
artery contributes predominantly to the super- 
ficial and the radial artery to the deep palmar 
arches in the hand. 

71. (B) It is important to recognize congenital dis- 
location of the newborn soon after birth. Delay 
in initiating appropriate treatment may lead 
to permanent hip joint disease. There may be 
apparent shortening of the thigh, although with 
the hip and knee flexed. 

72. (B) The mechanism of injury (abduction and 
external rotation) combined with the charac- 
teristic observable deformity of deltoid con- 
tour loss makes anterior dislocation the best 
choice. The common site of shoulder joint dis- 
location is inferior, because the rotator cuff 
muscles are absent there. 

73. (D) Ischemia contracture may result in defor- 
mity and disability of the hand, which impairs 
function of the entire upper extremity, not only 
of the elbow area. 

74. (D) Restriction of motion ("locking"), effusion 
("swelling"), and medial joint-line tenderness 
are the hallmarks of meniscal tears. Stability-to- 
stress testing eliminates collateral ligament rup- 
ture, and the ability to elevate the straight leg 
eliminates patella dislocation and quadriceps 
tendon ruptures. In addition, patella disloca- 
tion would also be characterized by gross 
patella deformity laterally. 

75. (C) Of all the conditions listed, only an Achilles 
tendon rupture will result in positive findings on 
the "squeeze" test (Thompson's sign), whereby 
a squeezing of the gastrocnemius muscle fails to 
cause plantar flexion of the foot. 

76. (B) Tenderness in the anatomic snuffbox (the 
interval between the extensor pollicis longus 
and the extensor pollicis brevis and abductor 



pollicis longus tendons) may signify a fracture 
of the carpal scaphoid (navicular) bone. Initial 
x-ray findings are often negative, but the frac- 
ture line often shows up in a repeat x-ray taken 
after 10-14 days. 

77. (C) The act of wringing rags results in repeated 
and forceful wrist dorsiflexion, causing increased 
pressure on the wrist extensor muscles, which 
have their tendinous origins from the lateral 
humeral epicondyle. This results in an inflam- 
matory condition at the bone tendon junc- 
tion, lateral epicondylitis, or "tennis elbow." 
Although this condition is common in tennis 
players, it occurs more frequently in the general 
population. 

78. (C) Although rest, anti-inflammatory agents, 
and crutches adequately treat the symptoms, 
the diagnosis of a stress fracture can be made 
only with a bone scan if the initial x-ray find- 
ings are negative for fracture. 

79. (A) In the absence of bladder or bowel dis- 
turbance, or sciatic symptoms, a neurological 
defect caused by a herniated disk is unlikely. 
A short period of rest, along with heat, anti- 
inflammatory agents, and analgesics, is the best 
treatment for a soft -tissue inflammatory lesion 
of the lumbar region. 

80. (C) Postmenopausal osteoporosis is the common 
denominator in all fractures involving elderly 
women. In this particular fracture, it is the twist- 
ing effect on an osteoporotic femur that causes 
the fracture rather than the impact of the fall 
itself. 

81. (B) Acute synovial reactions of weight-bearing 
joints with underlying arthritis are a common 
occurrence. It is usually related to minor trau- 
matic events. Complete immobilization may 
increase joint stiffness secondary to arthritis, but 
partial reduction of stressful motions (avoiding 
kneeling and squatting) and continued muscle 
activity would be beneficial. These will allow 
the synovial reaction to subside while decreas- 
ing the weakening and stiffness caused by the 
underlying arthritis. 



290 



12: Trauma 



82. (E) Where possible, a single-lumen cannula 
should be inserted into the vein to avoid re- 
peated attempts. The tincture of iodine should 
remain in contact with the skin for 30 seconds 
before venipuncture. Unsterile adhesive must 
not be placed over the entry site. 

83. (D) Skull fractures should be explored only if 
they are compound, if a depressed fracture is 
present, or if an intracranial lesion requires 
exploration. Compound fracture implies that 
the fracture site communicates with the exte- 
rior. Rhinorrhoea is caused by leakage of CSF 
through a fractured cribriform plate. 

84. (B) Subhepatic space infection usually occurs 
after surgery or peritonitis in the supracolic 
compartment. It is an unlikely complication of 
biliary pancreatitis. Infections in the subhepatic 
space may extend to the infracolic compartment 
via the paracolic gutter (of Morrison). This 
implies a perforation of the stomach. 

85. (D) In addition to necrosis of the superficial and 
deep fascia, thrombosis of the microcirculation 
of the subcutaneous tissue occurs. Mortality 
rates have been reduced from 80% in the past to 
less than 12% in recent series. Polymicrobial 
infection is more commonly encountered, and 
gram-positive and gram-negative organisms are 
found in 70% of cases. Treatment is based on 
adequate debridement and use of appropriate 
broad-spectrum antibiotics. 

86. (D) The patient needs a urinary diversion for 
the uretheral injury and a colostomy for the 
rectal injury. 

87. (E) The modern treatment of civilian injuries of 
the colon emphasizes primary repair in the vast 
majority. The results are excellent in terms of 
suture line complications. Colocolostomy is 
reserved for a select few patients with the most 
optimal circumstances. Exteriorization after 
repair is no longer advised. 

88. (G) All gunshot wounds clearly entering the 
abdominal cavity should be treated by emer- 
gency exploratory laparotomy. Over 80% of the 
time, injuries requiring repair will be found. 



89. (E) A CT scan with intravenous and oral con- 
trast can best rule out possible retroperitoneal 
injury caused by a stab wound. 

90. (B) Wound exploration that convincingly doc- 
uments failure of penetration through the pos- 
terior rectus fascia will most likely exclude 
abdominal injury from a tangential gunshot 
wound. A patient with negative findings on 
wound exploration can be discharged and fol- 
lowed as an outpatient. Peritoneal lavage 
would also rule out an intra-abdominal injury; 
however, it would require a subsequent period 
of hospital observation. A laparotomy would 
provide the most definitive evidence that an 
intra-abdominal injury did not occur, but a neg- 
ative finding on laparotomy has a definitive 
associated complication rate. 

91. (C) In a patient with significant bleeding, peri- 
toneal contamination, and multiple injuries, 
splenectomy is indicated. Prompt packing of 
the liver injury and splenectomy are the first 
considerations at laparotomy. 

92. (I) Postsplenectomy sepsis presents with sudden 
onset of nausea, vomiting, headache, confusion, 
and sometimes coma. Abdominal findings may 
be essentially normal following splenectomy. 
Inhibition of opsonization of leukocytes is evi- 
dent with increased susceptibility to pneumo- 
coccal infection. 

93. (K) Colon perforation is likely to show free 
air under the left hemidiaphragm. A sub- 
phrenic abscess presents with fever, leukocy- 
tosis, and a left pleural effusion. Gastric wall 
necrosis may likewise result in perforation 
with free air. There is air below the diaphragm 
following laparotomy, but it usually manifests 
symptoms clearly within the first week after 
operation. 

94. (A) Flail chest should be suspected in multiple 
rib fractures where the individual rib is divided 
in two places. Paradoxical movement results in 
lung compression as the flail segment moves 
inward during inspiration. 



Answers: 82-101 



291 



95. (C) Both subcapital and intertrochanteric frac- 
tures present with external rotation of the lower 
extremity. The lateral rotators are attached to 
the bone distal to the fracture line to cause this 
typical clinical sign. Trochanteric fractures have 
a better prognosis, because the blood supply to 

the proximal segment remains intact. 99. 

96. (C) The history is typical of spontaneous pneu- 
mothorax. Physical examination will reveal 
diminished breath sounds on the side of col- 100. 
lapse and x-ray will confirm the diagnosis. A 
tension pneumothorax will cause hypotesios. 

97. (E) Lateral impact may cause fracture ribs caus- 
ing pain, difficulty in breathing, and may be 
associated with significant hemorrhage from 
intercostal vessels. The physical signs described 101. 
are those of a massive hemothorax. 

98. (A) Precordial stab wound, distended jugular 
veins, and hypotension should suggest a cardiac 
tamponade. It must be kept in mind that the 



same signs are those of a tension pneumothorax. 
Dyspnea and deviation of trachea to the opposite 
side, absent breath sounds, and hyperresonant 
percussion note should suggest the correct 
diagnosis. 

(B) A temporal skull fracture crossing the middle 
meningeal artery grove with lucid interval are 
pathognomonic of an extradural hemorrhage. 

(F) Head-on collision and bent steering wheel 
should raise suspicion for head injuries, facial 
fractures, and deceleration injuries. The impact 
of knee against the dash-board forces the head 
of the femur posteriorly in the acetabular 
socket and may cause acetabular fracture. 

(E) Multiple rib fracture with often multiple 
fractures in the same segment of a rib may cause 
flail chest and contribute to pain and hypoxia. 
It is the underlying pulmonary contusion that 
will determine the extent of respiratory failure. 



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CHAPTER 13 



Pediatric Surgery 

Tyr Ohling Wilbanks and Meno Leuders 



Questions 



DIRECTIONS (Questions 1 through 34): Each of 
the numbered items in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 



1. A full term neonate is found to have a swollen 
right scrotom. Gentle persistent pressure easily 
reduces an air filled structure back into the 
abdomen. The condition recurs promptly as 
the infant begins to cry. This 

(A) Mandates immediate surgical repair 

(B) Is the same defect as a communicating 
hydrocoele 

(C) Should have a tension-free mesh repair 

(D) Should prompt exploration of the left 
groin 

(E) Is generally irreducible in children 

2. A 1-month-old infant presents to your office 
with an umbilical hernia. It is reducible but 
prolapses again almost immediately. It is TRUE 
that this defect 

(A) Is present in all children at birth 

(B) Will not close spontaneously 

(C) Should be repaired if still present at 
3 months of age 

(D) Should be repaired at this time if it is 
>1 cm in diameter 

(E) Is likely to become incarcerated 

3. You are called to the emergency room to see a 
5-year-old child who has been vomiting for 



two days. She is thin, pale, lethargic, and febrile 
to 102.4°F. She has a respiratory rate of 39 beats 
per minute (bpm) and a diffusely tender, rigid 
abdomen without localizing signs. You should 

(A) Order an abdominal/pelvic CT scan with 
oral contrast to clarify the diagnosis. 

(B) Realize that her omentum is likely to 
"wall off" and contain the infection. 

(C) Order a barium enema to rule out 
intussusception. 

(D) Start fluid resuscitation and observe on 
broad-spectrum IV antibiotics. 

(E) Take her immediately to the operating 
room for abdominal exploration. 

4. A 7-week-old girl is referred by her pediatrician 
for projectile vomiting over the past week. Her 
weight has remained stable, her fontanelles are 
not sunken and she sucks avidly. Her abdomen 
is soft with visible peristalsis in the epigastrium 
without evidence of a mass. A diagnosis of 
pyloric stenosis, in this case (Fig. 13-1) 

(A) Should lead to immediate surgical 
pyloromyotomy 

(B) Should not require any laboratory testing 

(C) Should prompt an order for an 
abdominal ultrasound 

(D) Should not be entertained until she has 
been tried on a new formula 

(E) Would be unlikely in the absence of an 
"olive" 



293 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



294 



1 3: Pediatric Surgery 




Figure 13-1. 

Hypertrophic pyloric stenosis. Note that the distal end 
of the hypertrophic muscle protrudes into the duode- 
num (arrow), accounting for the ease of perforation into 
the duodenum during pyloromyotomy. (Reproduced, with 
permission, from Doherty GM: Current Surgical Diagno- 
sis and Treatment, 12th ed. 1315. McGraw-Hill, 2006.) 

5. A previously healthy 2 V^-y ear-old is admitted by 
the pediatrician for bilious vomiting and severe 
abdominal pain. Despite reports of the child 
being inconsolable you find him sleeping very 
soundly in his mother's arms. His abdomen is 
soft with a suggestion of right upper quadrant 
fullness. He has heme-negative, soft stool in the 
rectum. He is afebrile and his white blood cell 
(WBC) is 7800. Abdominal x-ray shows dilated 
loops of small bowel. You consider a diagnosis of 
intussusception 

(A) To be unlikely in the absence of "current 
jelly" stools 

(B) And arrange prompt surgical exploration 
and reduction 

(C) And order an ultrasound 

(D) And order an air contrast enema 

(E) And order a CT scan with rectal contrast 

6. An 8-year-old presented with a 1-day-history of 
vomiting without diarrhea progressing to severe 
right lower quadrant. You make the diagnosis of 
early appendicitis and take her to the operating 
room. Upon delivering the cecum, you find a 
normal appearing appendix immediately adja- 
cent to multiple large lymph nodes in the 
mesentery of the appendix and terminal ileum. 
The tissues appear "boggy" and indurated. The 
most likely diagnosis is 

(A) Acute lymphoma 

(B) An intussesception, which was reduced 
as you delivered the cecum 



(C) Mesenteric adenitis 

(D) Subclinical appendicitis with reactive 
adenopathy 

(E) Campylobacter enterocolitis 

7. A 2-year-old toddler weighing 11 kg is admitted 
for observation of abdominal pain. There has 
been vomiting or diarrhea and the child had been 
eating normally 7 hours previously. Electrolytes 
are as follows: Na, 135 mEq/L; K, 3.9 mEq/L; 
HC0 3 , 19 mEq/L; CL 110 mEq/L. The most 
appropriate IV fluid orders would be 

(A) D5 y 4 NS @ 22 mL/hour 

(B) D5 y 2 NS @ 22 mL/hour 

(C) D5 NS @ 22 mL/hour 

(D) D5 y 4 NS @ 44 mL/hour 

(E) D5 y 2 NS @ 44 mL/hour 

8. A frustrated young mother calls emergency 
medical services (EMS) to report hearing a 
series of thumps down the staircase before 
finding her 15-month-old son lying at the foot 
of the stairs crying. He is brought to the emer- 
gency department boarded and collared. He is 
still crying, moving all extremities, has a heart 
rate of 135 bpm and a blood pressure of 80/95 
mm Hg. Which test should be done first? 

(A) Cervical spine films to rule out cervical 
spine injury 

(B) Skull films to rule out skull fracture 

(C) Head CT to rule out intracranial 
hemorrhage 

(D) Abdominal CT to rule out ruptured 
spleen 

(E) Skeletal survey to rule out child abuse 

9. A 15 kg, 7-year-old girl is in the emergency 
room with dramatic blood loss from a scalp 
laceration after blunt trauma. Suturing the lac- 
eration has achieved hemostasis but she is 
lethargic and clammy with digital and perioral 
cyanosis. Her heart rate is 110 bpm and blood 
pressure is 80/40 mm Hg. The most appropri- 
ate initial fluid order is 

(A) 450 mL of type specific blood over 
y 2 hour 

(B) 150 mL of D5 l h NS over l / 2 hour 



Questions: 5-13 



295 



(C) 150 mL of type specific blood over 
x li hour 

(D) 300 mL of D5 l k NS over l h hour. 

(E) 300 mL of type specific blood over 
V2 hour 

10. You are called to see a 4-hour-old neonate in the 
well-baby nursery who has developed bilious 
vomiting after taking his first feeding. He was 
born at 39-week gestation, has not yet passed 
meconium and has an unremarkable examina- 
tion. An upper gastrointestinal (GI) series 
would be the study of choice to rule out which 
of the following clinical conditions? 

(A) Ileal atresia 

(B) Meconium ileus 

(C) Duodenal web 

(D) Malrotation 

(E) Tracheoesophageal fistula 

11. A 2-month-old former preemie presents to your 
office with an easily reducible right inguinal 
hernia. He was born at 30-week gestation, was 
on continuous positive airway pressure (CPAP) 
for 4 days, was treated for hyperbilirubinemia, 
and was discharged home after 24 days. Since 
going home he has been thriving, eating avidly, 
and now weighs 3.6 kg. His parents are well 
informed and although they want the hernia 
repaired as quickly as possible; they are con- 
cerned about the risks of general anesthesia. 
You tell them that 

(A) They should wait another 5 V2 months 
until he is 60 weeks of gestational age. 

(B) They should wait until he weighs 5 kg. 

(C) They should wait another 3 months 
until he is 50 weeks of gestational age. 

(D) They can schedule him as soon as 
possible because he weighs >2.5 kg. 

(E) They can schedule him in 2 weeks 
because at that point he will have 
reached gestational term age of 40 weeks. 



12. A 12-year-old boy crashes his bicycle and 
drives one of the handle bars into his left upper 
quadrant. He complains of abdominal and left 
shoulder pain. He weighs 41 kg. On exam his 
heart rate is 111 bpm, his blood pressure is 
95/50 mm Hg ,and he is tender in the left 
upper quadrant. After a 450 mL bolus of 
Ringer's lactate he is calmer, his heart rate is 
85 bpm and his blood pressure is 105/55 mm 
Hg. You order an abdominal computerized 
axial tomography (CAT) scan. Nonoperative 
management in the intensive care unit (ICU) 
would be justified if 

(A) You find a grade I splenic laceration on 
the CAT scan with some active 
extravasation of IV contrast 

(B) If he becomes restless, recurrently 
tachycardic, and hypotensive while on 
the way to CAT scan 

(C) He requires 2 U of packed red blood cells 
(PRBCs) to maintain his vital signs in the 
3 hours after the CAT scan demonstrates 
a grade I splenic laceration 

(D) FAST exam before the CAT scan 
demonstrates free fluid around the spleen 

(E) It fails to increase his blood pressure 

13. A 9 y2-year-old girl presents to your office with 
an approximately 1 V-i-cm nodule in her neck, 
just to the left of the midline and below her 
cricoid cartilage. It is nontender and moves 
when she swallows. It has been enlarging over 
the last several months and was not seen by the 
pediatrician at her 9-year-old check up. There 
is no family history of endocrine disorders. The 
most likely diagnosis is 

(A) Reactive viral lymphadenopathy 

(B) Papillary thyroid cancer 

(C) A brachial cleft cyst 

(D) A follicular adenoma of the thyroid 

(E) A thyroglossal duct cyst 



296 



1 3: Pediatric Surgery 



14. A 3-year-old, recently adopted Romanian boy 
is referred after his initial pediatrician's assess- 
ment for an undescended testicle. On exam his 
left testicle is normal and in place. He has no 
evidence of hernias. However, his right hemis- 
crotum is empty and there is a testicule sized 
mass plapable at the pubic tubercle. The most 
appropriate next step is 

(A) Observation until age 5 

(B) Right orchiopexy 

(C) Right orchiopexy and right inguinal 
hernia repair 

(D) Right orchiopexy and right testicle biopsy 

(E) An abdominal ultrasound 

15. A 6-year-old girl presents with a left breast mass. 
Her mother first noticed it a day before and is 
very concerned because both the child's mater- 
nal grandmother and maternal aunt have had 
breast cancer. It is firm, smoothly circumscribed, 
and slightly eccentric under the left areola. The 
right breast is unremarkable. You suggest 

(A) Immediate excisional biopsy 

(B) A mammogram 

(C) Repeat examination in 1 month 

(D) Genetic testing for breast cancer (BRCA) 
1 and 2 mutations 

(E) Sterotactic needle biopsy 

16. A 9-month-old is brought in by EMS after 
falling from his changing table. He is poorly 
responsive and being mask ventilated. You opt 
to intubate him prior to sending him to CAT 
scan. Compared to an adult an important con- 
sideration in his intubation is 

(A) Selecting an cuffed tube, the size of his 
little finger 

(B) The relatively large size of the infant 
cricoid compared to the thyroid cartilages 

(C) Decreased forward flexion of the neck 
and trachea while supine 

(D) More rapid desaturation after cessation 
of bag /mask ventilation 

(E) It takes a shorter time to intubate an 
infant 



17. You are called to see a 7-day-old girl in the 
neonatal ICU who is having bilious aspirates 
from her feeding tube. She was born at 32-week 
gestation with Apgars of 8/10 and has been 
doing well after requiring CPA for only 18 hours. 
She has been afebrile, her WBC has been stable 
-18,000, but she has been having increased 
numbers of apneic and bradycardic episodes. 
Abdominal x-ray suggests traces of pneumoto- 
sis. The most appropriate next step is: 

(A) Initiate CPAP for her respiratory 
difficulties leading to air aspiration 

(B) Hold feedings and start antibiotics 

(C) Send stool for P. intestinalis and start 
antibiotics 

(D) Check her liver function tests 

(E) Exploratomy laparotomy 

18. You are called to the emergency room to see a 
7-week-old boy with blood in his bowel move- 
ments (BMs). On examination the child is active, 
responsive, and appears well perfused. His 
heart rate is 124 bpm and his blood pressure is 
80/45 mm Hg. The most likely diagnosis is 

(A) Meckel's diverticulum 

(B) Juvenile polyposis 

(C) Allergy to his formula 

(D) Peptic ulcer disease 

(E) Anal fissure 

19. A 4-year-old girl is referred to your office by the 
pediatrician for the finding of an abdominal 
mass on her 4-year-old well child visit. She had 
been consistently in the seventy-fifth pecentile 
for height and weight and although she is still in 
the seventy-fifth pecentile for height she is only 
in the fortieth percentile for weight. She has been 
eating normally and having normal daily BMs. 
On examination you palpate an 8-cm right 
midabdominal mass. It is firm, nontender, and 
poorly mobile. The most likely diagnosis is 

(A) Constipation with a distended cecum 

(B) Wilms' tumor 

(C) Neuroblastoma 

(D) Lymphoma 

(E) Hempatoblastoma 



Questions: 14-26 



297 



20. A 12-year-old girl presents to the emergency 
department following a skiing crash in which 
the left side of her midtorso hit a tree. She pres- 
ents with left side lower chest and upper 
abdominal pain. She also complains of left 
shoulder pain. The most likely diagnosis is 
which of the following? 

(A) Rib fractures 

(B) Liver injury 

(C) Ruptured diaphragm 

(D) Splenic injury 

(E) Ruptured stomach 

Questions 21 and 22 

A mentally retarded 7-year-old child with cerebral 
palsy is admitted for repair of a left indirect inguinal 
hernia. Clinical palpation reveals a large left retroperi- 
toneal abdominal mass. 

21. What is the most common presentation for a 
patient with a Wilm's tumor? 

(A) Unilateral flank mass 

(B) Back pain 

(C) Hematuria 

(D) Urinary tract infection (UTI) 

(E) Weight loss 

22. Before radiologic investigation, which is the 
best method to distinguish a Wilm's tumor 
from a neuroblastoma? 

(A) Shifting dullness 

(B) Physical examination of the abdomen 

(C) Catecholamine levels 

(D) Auscultation for bowel sounds 

(E) Cortisol administration 

23. A mother brings her 3-year-old daughter to the 
pediatric emergency room with a complaint of 
a tender and firm lump in her right labia. 
According to the mother the lump has been 
there for 3 months but now it cannot be 
"pushed back in". The girl is apprehensive and 
tender in the right lower quadrant for several 
hours. A likely diagnosis is: 



(A) Appendicitis 

(B) Direct inguinal hernia 

(C) Inguinal lymphadenopathy 

(D) Indirect incarcerated hernia containing 
an ovary 

(E) Indirect incarcerated hernia containing 
bowel 

24. An otherwise healthy 3-week-old baby boy 
comes to the emergency room with this mother. 
The baby has been vomiting for 1-day initially 
formula then more and more bilious material. 
He appears dehydrated, last diaper was changed 
16 hours ago. There is now some blood stool 
from his anus. His fontanelle is depressed. His 
SMA7 shows a moderate metabolic acidosis 
and his WBC is 17,000. After initial fluid resus- 
citation what diagnostic test is useful to make 
the diagnosis here? 

(A) CT scan of chest and abdomen 

(B) Barium enema 

(C) Upper GI series 

(D) Serial abdominal exams 

(E) Right upper quadrant ultrasonography 
(USG) 

25. Clinical symptoms and presentations of mal- 
rotation least likely include 

(A) Volvulus 

(B) Chronic abdominal pain 

(C) Failure to thrive 

(D) Intestinal atresia 

(E) Diarrhea 

26. A newborn full-term baby boy with diagnosis 
of imperforate anus (Fig. 13-2) is also at risk to 
have a 

(A) Dextrocardia 

(B) Rib cage anomaly 

(C) Tracheoesophageal fistula 

(D) Ulnar skeletal deformity 

(E) Proximal limb malformation 



298 



1 3: Pediatric Surgery 




Figure 13-2. 

Malrotation of the midgut with volvulus. Note 
cecum at the origin of the superior mesenteric 
vessels. Fibrous bands cross and obstruct the 
duodenum as they adhere to the cecum. Volvulus 
is untwisted in a counterclockwise direction. 
(Reproduced, with permission, from Doherty 
GM: Current Surgical Diagnosis and Treatment, 
12th ed. 1297. McGraw-Hill, 2006.) 



27. The most common pathogen in neonatal 
sepsis is 

(A) Haemophilus influenzae 

(B) Pneumococcus 

(C) Klebsiella pneumoniae 

(D) Escherichia coli 

(E) Staphylococcus epidermidis 

28. A 3.3 kg, 36-week baby girl was born prema- 
turely after labor caused by ruptured mem- 
branes. The prenatal ultrasound revealed a 
polyhydramnion at 26 weeks. Fetal echocar- 
diogram was normal and amniocentesis was 
without genetic aberrance. On examination 
there was a normal anus, an nasogastric tube 
(NGT) drained bile stained fluid. The baby 
passed some mucus from below but no typical 



dark meconium. A chest and abdominal x-ray 
showed a "double bubble sign". What is the 
most likely diagnosis? 

(A) Acute pancreatitis 

(B) Neonatal Hirschsprung's disease 

(C) Duodenal atresia 

(D) Malrotation of midgut 

(E) Duodenal duplication 

29. A 6-year-old girl is referred to you by her pedia- 
trician complaining of a pain in her throat and 
presenting with an anterior cervical midline 
mass for several weeks. After a course of antibi- 
otics the inflammation and erythema resolved 
but the mass still persisted. The mother is 
concerned. She remembers a time when the 
child was 3-years-old complaining of similar 
symptoms, but then it spontaneously resolved. 
Physical chest exam is normal but the mass 
appears to rise upward when the girl sticks out 
her tongue. What is the most common diagnosis? 

(A) Lingual thyroid 

(B) Branchial cleft remnant 

(C) Thyroglossal duct cyst 

(D) Uncomplicated cervical neck abscess 

(E) Thyroiditis 

30. A 7-year-old boy was involved in a motorcycle 
crash while seated in the back of a minivan 
without restraints. His vital signs in the emer- 
gency room are stable but he is complaining of 
left upper quadrant abdominal pain. The FAST 
scan shows scanty fluid around in the left colic 
gutter. An abdominal and pelvic CT scan with 
iv and po contrast is performed and the radi- 
ologist suggests a "blush" (arterial extravasa- 
tion) in the splenic parenchyma. The spleen 
itself sustained a deep parenchymal tear and 
is classified as a grade III injury. The child 
remains hemo dynamically stable. What is rec- 
ommended next? 

(A) Continuous hemodynamic monitoring, 
celiac angiogram, and angio embolisation 
of splenic artery. 

(B) Immediate exploration in the operation 
room 



Questions: 27-34 



299 



(C) If hemodynamic instability develops, 
aggressive fluid resuscitation including 
a repeated bolus of 20 mL/kg lactated 
Ringer's solution followed by a liver 
spleen scan 

(D) Monitoring only 

(E) Pneumovax and elective splenectomy 
in 6 weeks 

31. In the emergency room department a 2-year-old 
girl is brought after she is passing three episodes 
of maroon colored stools. A similar episode 
occurred the night before. She is afebrile and has 
no abdominal pain. Dark clotted blood mixed 
with fresh blood is seen in her diaper. Her heart 
rate is 116 bpm and a blood pressure measured 
at 76/42 mm Hg. Appropriate fluid resuscita- 
tion with infusion of 20cc/kg of normal saline 
ensues. Vital signs normalize. Coagulation stud- 
ies, crossmatch, complete blood count (CBC) are 
ordered and an insertion of a nasogastric tube is 
performed. There is no blood in the NGT and 
golden bile is aspirated. What is the differential 
diagnosis in this GI bleed? 

(A) Anal fissure 

(B) Meckel's diverticulum 

(C) Colon polps 

(D) Intussusception 

(E) Bleeding gastric ulcer 

32. Which is not a long-term complication of a 
1 -year-old baby boy having undergone correc- 
tive hepatoportoenterostomy (Kasai proce- 
dure) for biliary atresia? 

(A) Recurrent episodes of cholangitis 

(B) Hepatic cirrhosis and portal hypertension 
despite adequate bile drainage 

(C) Upper GI bleeding episodes from 
esophageal varices 

(D) Need for hepatic transplantation after 
initial Kasai procedure has failed 

(E) Anastomotic leakage of portoenterostomy 

33. Shortly after an uncomplicated birth a full-term 
baby boy develops respiratory distress and 
excessively spits after an unsuccessful feeding 
trial, requiring endotracheal intubation. A chest 



x-ray is performed and shows signs of aspira- 
tion in the right basilar and apical lung fields. 
There is air in the stomach, which appears 
hyperinflated. A trial of NGT placement is 
unsuccessful. What diagnosis is suspected? 

(A) Duodenal atresia 

(B) Hypertrophic pyloric stenosis 

(C) Tracheoesophageal fistula without 
esophageal atresia 

(D) Distal tracheoesophageal fistula with 
proximal esophageal atresia 

(E) Achalasia 

34. A 11-year-old boy with past medical history of 
sickle cell disease (homozygote form) comes to 
the pediatric emergency room with left upper 
abdominal pain, fever, and episodes of vomit- 
ing. He is complaining of previous episodes in 
the past that occurred after heavy meals. A chest 
x-ray shows the normal heart silhouette in the 
right chest. A routine abdominal ultrasound 
shows absence of a gallbladder in the right 
upper quadrant. The liver parenchyma is seen 
on the opposite side. Also, the radiologist calls 
you confused, indicating a thick-walled, fluid- 
filled cystic structure with echodense particles 
on the left side, which appears tender on pal- 
pation. A liver function test is normal except 
for an alkaline phospatase of 187. WBC is 17.6. 
What is the most likely diagnosis? 

(A) The patient has constipation and should 
get an enema to clear out his fecal 
impaction from the left colon. 

(B) Preventing a sickle cell crisis, the patient 
should be placed on additional nasal 
oxygen, copious hydration, pain 
medication, and maintaining a 
hematocrit of >28%. 

(C) In addition to preventing a sickle cell 
crisis, the patient seems to have acute 
cholecystitis and needs IV antibiotics 
followed by cholecystectomy. 

(D) The patient has situs inversus totalis 
and cholecystectomy is contraindicated. 

(E) Cholelithiasis requiring delay in 
cholecystectomy until symptoms are 
totally resolved. 



Answers and Explanations 



1. (B) Congenital inguinal hernias are more 
common in premature infants, in males, and on 
the right side. The defect involves the failure of 
the processus vaginalis to fuse leaving an open 
communication from the abdomen to the tunica 
albuginea. The semantic difference between a 
scrotal hernia and a communicating hydrocele is 
that the hernia contains abdominal contents 
while the hydrocoele contains only fluid. The 
abdominal musculature is normal and no repair 
is required beyond high ligation of the sac. 
Previously the historically high risk of anesthe- 
sia prompted contralateral exploration to avoid 
a second anesthetic. With modern anesthesia 
the risk of ischemic injury to the spermatic cord 
out weighs the risk of anesthesia. That risk, how- 
ever, increases below 50 weeks of gestational 
age (i.e., from conception). Although some 
authorities would repair this child promptly, 
many would wait until he has passed the 
50-week mark. At that time, some would per- 
form flexible fiber-optic peritoneoscopy through 
the open right sac during the repair to evaluate 
the contralateral side, while others would elect 
to simply observe that side for the clinical 
appearance of a hernia. 

2. (A) The umbilical hernia is the only hernia uni- 
versally present at birth due to the need for 
umbilical cord patency up to that instant. After 
birth, the vast majority of umbilical hernias 
close by age 3-5 years. The risk of incarceration 
is low and repair is usually reserved for chil- 
dren older than 3-5 years of age or those with 
a fascial defect >l-2 cm in diameter. 

3. (E) Conditions other than appendicitis, such as 
mesenteric adenitis, could possibly present like 



this; but this child's pale countenance and 
tachypnea suggest impending septic shock. 
While a 10-20-mL/kg fluid bolus and antibiotics 
should be rapidly administered; this child clearly 
has a acute surgical abdomen and requires 
urgent exploration. The thicker adult omentum 
will frequently contain a perforated appendix, 
creating an abscess. A young child's omentum is 
typically thin and flimsy and perforation usually 
leads rapidly to diffuse peritonitis. Barium 
enema to rule out intussusscepting, which would 
be unlikely in a child this old, is contraindicated 
in the presence of peritoneal signs. If further 
imaging were desired, USG is fast, generally well 
tolerated, and can be quite revealing in thin, 
young children. CAT scanning would involve 
radiation exposure, can be difficult to read in 
which this child would likely vomit up. 

(C) Although pyloric stenosis is typically seen 
in 4-week-old male infants, it can certainly be 
seen in females and in those older and younger. 
The hypertrophied pylorus, which presents as 
an olive-sized mass in the epigastrium, is fre- 
quently "hiding" below the liver or the dis- 
tended stomach and can only be appreciated in 
-50% of patients. Electrolyte distrubances and 
volume depletion are more common in infants 
who have been vomiting for several weeks and 
can lead to cardiovascular collapse on the 
induction of anesthesia. Although this expected 
weight and the diagnosis should prompt a 
check of her electrolytes and surgery should 
be delayed until any deficits are gradually cor- 
rected. Formula intolerance and pylorospasm 
are also causes of chronic vomiting and the 
diagnosis of hypertrophic pyloric stenosis 
should be confirmed by an ultrasonogram 



300 



/Answers: 1-10 



301 



showing a pyloric wall thickness of >3 mm and 
channel length of >16 mm. 

5. (D) This is a typical presentation for intussus- 
ception. Between episodes of colicy pain, the 
exhausted child may rest comfortably. Although 
USG can be used to screen for intussusception 
a negative study with such a compelling clini- 
cal scenario would not be definitive. An air 
contrast (or barium) enema with no more than 
120 mm Hg pressure would provide a defini- 
tive diagnosis and possibly be therapeutic. This 
should certainly be tried before subjecting the 
child to laparotomy. A CAT scan would involve 
as much radiation without being as definitive 
and without any hope of therapeutic benefit. 
Peritoneal signs, fever, leukocytosis, and bloody 
stools are all late signs suggesting intestinal 
necrosis and would be contraindications to 
rectal studies. In those cases prompt explo- 
ration is indicated. 

6. (C) Had you observed the USG yourself, you 
might have noted that the noncompressable 
structure (s) appeared more spherical than 
tubular. Lymphoma is unlikely in this age 
group, especially with this acute presentation. 
You would expect a bacterial enterocolitis to 
produce more fever, leukocytosis, and diar- 
rhea. While both subclinical appendicitis and a 
reduced intussusception are theoretically pos- 
sible, streptococcal infection is another possi- 
bility but also tends to produce more fever and 
leukocytosis and less adenopathy. It would be 
a strong second choice and the child should 
also have had a rapid strep test. 

7. (D) Children's kidneys do not acquire signifi- 
cant ability to concentrate sodium until well 
after the age of 2 years. D5 % NS is the most 
appropriate maintenance fluid for young chil- 
dren with normal electrolytes. The baseline 
fluid requirement for children is 100 mL/kgd 
for the first 10 kg, 50 mL/kgd for the second 
10 kg, and 25 mL/kgd for each kg thereafter, 
(nb: Premature infants will require significantly 
more.) This child's requirement can be calcu- 
lated as follows: 10 kg x 100 mL/kgd + 1 kg x 
10 mL/kgd = 1050 mL/d = 44 mL/h. 



8. (C) Due to the ligamentous flexability and 
platicity of the cartilaginous infant skeleton, 
both bony spinal injuries and skull fracutre are 
uncommon. However, because of the easy 
deformability of the skull, brain injury can 
easily occur, especially since infants are "top 
heavy". Their heads are relatively large com- 
pared to their bodies and they tend to fall head- 
first. His vital signs are not surprising for a 
crying infant and while splenic injury should 
be considered, it is less likely than the possible 
brain injury. Likewise, one should always con- 
sider child abuse, but the mother's agitation and 
story are not unreasonable and unless further 
history in uncovered skeletal survey is proba- 
bly not warranted at this time. 

9. (E) This child is in the early stages of profound 
shock as manifested by the signs of vasocon- 
striction. Her blood pressure is not that abnor- 
mal for her age but hypotension may be a late or 
even preterminal symptom of hypovolemic 
shock in young children. Given the apparent 
severity of the blood loss, type-specific blood is 
probably more appropriate volume replacement 
than crystalloid. A standard bolus for volume 
replacement should be 10-20 mL/kg. Once 
again, given the apparent severity of volume 
depletion, the 20-mL /kg bolus (300 mL) would 
be more appropriate. 

10. (E) Upper GI series in the obvious study for tra- 
cheoesophageal fistulae and duodenal webs. It 
would also diagnosis an ileal atresia. Although 
a distal ileal lesion might be difficult to delineate 
it would still be the best test. Because of its util- 
ity in diagnosing these other conditions it is also 
the test of choice for malrotation, which can be 
diagnosed by demonstrating the sweep of the 
duodenum and ligament of Treitz to be to the 
right rather than the left of the spine. It would 
also more readily rule in or out a midgut volvu- 
lus, which is the complication of malrotation, 
about which we are most concerned in this 
patient. Only the meconium ileus (which con- 
sists of inspissated nuggets of hard meconium 
obstructing the distal colon) would be better 
diagnosed (and possibly treated) with a water- 
soluble rectal contrast study. 



302 



1 3: Pediatric Surgery 



11. (A) Because of the immaturity of their reticular 
activating systems, infants of less than 50-week 
gestatonal age are at increased risk for apneic 
episodes in the first 24 hours after general anes- 
thesia. Although herniorrhaphy would usually 
be performed as day surgery infants of less than 
50-week gestational age or weighing <2.5 kg 
should be admitted for 24 hours of postopera- 
tive monitoring or have their elective opera- 
tions delayed until they have achieved those 
landmarks. However, former preemies are at 
increased risk and apneic complications have 
been seen up to 55 weeks of gestional age. The 
conservative recommendation for these infants is 
to wait until they are of 60-week gestational age. 

12. (D) Nonoperative management of splenic 
trauma is usually successful in grade I lacera- 
tions and would be the standard of care in a 
hemodyamically stable patient. This boy 
responded well to a modest fluid bolus but if 
he becomes unstable on the way to CAT scan 
it would be hazardous to allow him to go 
into full-blown shock while in the scanner. 
Likewise, he should be explored (or embolized, 
depending on the resources available) for other 
signs of active bleeding including requiring 
>20 mL/kg PRBC to maintain his vital signs or 
seeing active extravasation on contrast on the 
CAT scan. Seeing fluid around the spleen on 
the FAST exam simply supports the clinical 
diagnosis of ruptured spleen but not an indi- 
cation for intervention in the absence of hemo- 
dynamic instability. 

13. (B) While reactive lymphadenopathy is by far 
the most common cause of neck masses in chil- 
dren; a lymph node should not move with deg- 
lutition and is more likely to be tender. A 
branchial cleft syst should be more lateral and 
the thyroglossal duct cyst should be higher and 
in the midline (although they can sometimes 
present off the midline). One might also have 
expected some prior evidence of both of these 
congenital cysts, although that is not always the 
case. The location and characteristics strongly 
suggest a thyroid nodule. While follicular ade- 
nomas are much more common in adults than 
cancers they are rarer in children and a rapidly 



growing solitary nodule is likely to be a papillary 
carcinoma, the most common thyroid cancer in 
children. 

14. (C) Although waiting until age 1 is acceptable, 
there should be little further delay. Waiting 
until puberty would subject the child to a 
high probability of abnormal development. 
Abdominal USG can be useful to search for an 
intra-abdominal testicle but this child's testicle 
was palpable. Since all cryptorchid testicles are 
accompanied by an inguinal hernia; heniorra- 
phy should always accompany an orchiopexy 
for cryptorchism. Testicular biopsy is unnec- 
essary and may be injurious. The risk of malig- 
nancy, although increased 20-fold, does not 
manifest itself until at least the early twenties. 

15. (C) Breast cancer is vanishingly rare in chil- 
dren with on -60 cases reported in the English 
literature even in patients with the BRC A muta- 
tions. Therefore, needle biopsy and mammo- 
gram are unlikely to be helpful. The most likely 
tumor in this case is a benign fibroadenoma. 
Removal of breast masses in prepubescent girls 
carries a strong possibility of damage to the 
involved breast bud with subsequent hypopla- 
sia of the adult breast. In this case, it would be 
better to defer excision until after puberty 
unless the mass continues to enlarge or becomes 
symptomatic. 

16. (E) When spine, an infant's relatively large 
occiput, large tongue, and small mandible 
resulted in an obstructed airway due to for- 
ward flexion of the neck. Padding should be 
placed beneath the infants shoulder and back 
to allow the head to fall back into the physio- 
logic "sniffing" position. The infant cricoid car- 
tilage is also smaller than the thyroid, making 
the subglottic space funnel shaped rather than 
tubular. Pediatric endotracheal (ET) tubes are 
therefore uncuffed and size is detemined by 
measuring the child with the Braslow tape or 
comparing the tube to the patient's little finger. 
Due to their higher cardiac indices and more 
rapid medabolisms, children require a more 
rapid respiratory rate and will desaturate more 
quickly once respirations are held. 



/Answers: 11-25 



303 



17. (B) Necrotizing enterocolitis (NEC) is primarily 
a disease of preemies occurring in anywhere 
from 3% to 10% of the population. It is believed 
to be initiated by an unfavorable combination 
of mucosal injury, bacterial overgrowth, and 
ready nutrients (in the form of infant formula). 
Early manifestations are bilious nasogastric/ 
orogastric (NG/OG) aspirates and early signs 
of infection. Later gas may be seen in the walls 
of the intestines (pneumotosis intestinalis or 
pneumotosiscoli) on abdominal x-ray. The 
final, preterminal stages would be free air and 
peritonitis. Initial treatment is to be withhold 
enteral nutrients and start broad-spectrum 
antibiotics aimed at the typical GI pathogens. 
Surgical exploration is reserved for more severe 
symptoms such as clinical deterioration, free 
air, or abdominal wall erythema. 

18. (C) An allergic colitis due to milk or soy protein 
allergy is the most common cause of GI bleed- 
ing in the neonate. Anal fissures (easily diag- 
nosed by examination) are the next most 
common in neonates and probably the most 
common in infants. Juvenile polyps (which are 
solitary in 80% of the cases) are a more 
common cause in older children. 

19. (C) While constipation with a distended cecum 
is probably the most common cause of an 
abdominal mass, this child has a history of 
normal BMs and a relatively fixed mass. Lym- 
phoma is the most common solid tumor of 
childhood after brain tumors; but it is more 
common in older ages and does not typically 
present in the abdomen. Neuroblastoma is the 
most common abdominal tumor and would 
lead to the differential. Wilm's tumor (or 
nephroblastoma) would be the next most 
common abdominal tumor occurring about 
75% as frequently as neuroblastoma. Hepato- 
blastomas are far less comon than either of 
these two tumors. 

20. (D) The spleen is the most common solid organ 
injured by blunt trauma. Though gastric rupture 
could cause the clinical presentation described, it 
is very rare. Rib fracture in the midtorso alone 
generally does not cause the referred shoulder 



pain, because blood does not collect under the 
left diaphragm, as seen in splenic injuries. 

21. (A) The most common presentation for a patient 
with a Wilm's tumor is a unilateral flank mass. 

22. (B) Wilm's tumor is usually diagnosed in well- 
appearing children between the ages of 6-10. 
The initial complaint is unilateral flank mass 
usually palpated during bathing or dressing of 
child. Neuroblastoma, a tumor of adrenal gland 
origin, tends to secret dopamine. These children 
appear emaciated and are typically 2-3 years 
younger in age group. CT scan is essential in 
both cases prior to any surgery. Although large 
Wilm's tumors push the intra-abdominal con- 
tent to the contralateral side, the tumor itself 
rarely crosses the midline. On the contrary, 
neruoblastoma typically crosses the midline. 
Lymphomas in general involve the nodal tissue 
surrounding the great vessels and push the 
abdominal viscera anteriorly and laterally. 

23. (D) Most inguinal incarcerated hernias contain 
bowel but a nonreducible mass involving the 
labia speaks for an incarcerated ovary. 

24. (C) This is a true pediatric surgery emergency; 
malrotation, bilious vomiting with severe meta- 
bolic acidosis, lethargy and dehydration is a 
hallmark of this serious condition. Initially 
vomiting of the baby could first result in a 
masked metabolic alkalosis caused by loss of 
chloride and potassium. Later, however, meta- 
bolic acidosis caused by hypoperfusion, shock, 
and lactic acidosis prevails. The treatment is 
fluid and electrolyte resuscitation and prompt 
operative exploration, detorsion with bowel 
resection if necrotic bowel is present. Time is of 
the essence! Thirty percent of patients with 
malrotation present within the first week of 
life, 55% in the first month, and nearly all of 
them in the first year. 

25. (D) All of the above can be seen in malrotation. 
In the case of this 3-week-old baby boy the 
presence of intestinal atresia is less likely since 
symptoms of obstruction would have occurred 
much earlier. 



304 



1 3: Pediatric Surgery 



26. (C) It is also commonly known as VATER asso- 
ciation, (vertebral, anorectal malformations, tra- 
cheoesophageal fistula, renal and distal limb 
malformations) The most common abnormalities 
are cardiac in origin and involve ventriculosep- 
tal defect (VSD) and atrial septal defect (ASD). 

27. (E) Staph. Epi is the most common pathogen on 
neonatal ICUs and wards and also associated 
as a pathogen for necrotizing enterocolitis. 
Indwelling catheters or a break in the fragile 
neonatal skin is often responsible. Often there 
is a rash, with peeling of hand and feet due to 
a staphylococcal toxin. Candida is a pathogen 
in babies who undergo prolonged courses of 
antibiotics. Enteral bacteria are second in line 
after staphylococci. 

28. (C) The most common form of duodenal atresia 
is where the obstruction occurs below the 
ampulla of Vater. Hence bilious NGT output is 
reported in the scenario. Also the most common 
variant is characterized by a membranous intra- 
luminal atresia (type I). Nearly 35% of babies 
with congenital duodenal obstruction have syn- 
drome and of those a majority have associated 
cardiac defects. If the duodenal obstruction is 
incomplete, we call this a duodenal stenosis. 
Clinically this manifests much later in life and 
is characterized by failure to thrive, chronic 
vomiting, electroyte anomalities and is called a 
duodenal windscok variant. Here a membra- 
nous web in the most often second and third 
part of the duodenum is causing clinical symp- 
toms of high, incomplete bowel obstruction. 
The treatment is resection of the web and a side- 
to-side duodenoduodenostomy. 

29. (C) Embryologically the thyroglossal duct cyst 
(Fig. 13-3) runs from the pyramidal lobe of the 
thyroid to the foramen cecum at the base of 
the tongue. It needs complete excision includ- 
ing part of the hyoid bone to avoid recurrence. 
An ectopic lingual thyroid is located at the base 
of the tongue and virtually never seen in the 
above described anterior midline location. 
Cervical lymphadenitis needs to be ruled out 
and a several microbial stains performed if an 
abscess develops. Masses caused by atypical 
mycorbacterial do not respond to antibiotic 




Figure 13-3. 

Thyroglossal cyst and 
duct course through the 
hyoid bone to the fora- 
men cecum of the 
tongue. (Reproduced, 
with permission, from 
Doherty GM: Current 
Surgical Diagnosis and 
Treatment, 12th ed. 
1281. McGraw-Hill, 
2006.) 

therapy and need to be excised. Brachial cleft 
remnants are almost always seen in the alter 
neck and divided in several types depending 
on their branch origin. They, however, can also 
get infected in manifest sometimes in form of a 
lateral neck abscess. 

30. (A) While all blunt abdominal trauma patients 
developing hemodynamic instability should go 
to the operating room without delay; in this 
case it would be more beneficial to perform 
angioembolisation in a hemodynamically stable 
child. Plain films are of little value unless there 
is free air, prompting urgent colostomy. If there 
is no homodynamic instability in this child, 
every attempt should be made to preserve the 
spleen and avoid appendectomy. Pneumovax 
should be given in the perioperative period of 
a life saving splenectomy or when significant 
splenic tissue loss occurred. There is no role for 
an elective splenectomy in this trauma setting. 

31. (E) Most common cause of lower GI bleed in 
this 2-year-old girl is a juvenile polyp. Anal 
fissures are also very common offenders of 
lower GI bleed, but perianal pain is a hallmark 
and not present in this case scenario. Meckel's 



/Answers: 26-33 



305 



diverticulum is the second most common cause 
in this age group involving a large amount of 
blood. Intussusception has to be excluded but in 
the absence of abdominal pain highly unlikely. 
Every attempt should be made to exclude an 
upper GI bleeding source, that is peptic ulcer 
disease or sequela of portal hypertension man- 
ifesting in esophageal varices (as seen in biliary 
atresia or chronic active viral hepatitis). Meckel's 
diverticula are true diverticula and derive their 
blood supply directly from the aorta as a rem- 
nant of a right vitelline artery. GI bleeding occurs 
as a result of heterotopic gastric mucosa. 



duct system. The gallbladder is shrunken to a 
small strand of fibrous tissue including common 
bile duct and common hepatic duct. After the 
patient's first 3 months of life the success rate of 
operative hepatoportoenterotomy (Kasai proce- 
dure) falls significatly Thirty-three percent dete- 
riorate despite surgery. The Kasai operation 
remains the initial surgical treatment of biliary 
atresia. Long-term complications of hepatic cir- 
rhosis, portal hypertension, bleeding esophageal 
varices, and recurrent bouts of cholangitis often 
force the patient to be scheduled for a hepatic 
liver transplant later in life. 



32. (E) The etiology of biliary atresia remains 
unknown, but recent studies have linked into a 
prenatal rheo virus infection. An initial ultra- 
sound is helpful to delineate extrahepatic bile 
anatomy in cases of unexplained nonphysiolog- 
ical hyperbilirubinemia. An magnetic resonance 
cholangiopancreatography (MRCP) is also help- 
ful. If a hepatic HIDA scan shows uptake into the 
hepatocytes but fails to show a normal extra- 
hepatic excretion pattern, a percutaneous liver 
biopsy is indicated. Typically there is a lympho- 
cytic infiltration of the periportal field and 
absence of paucity of bile ducts. The most 
common type of biliary atresia (85%) is charac- 
terized by the atresia of the entire extrahepatic 



33. (D) This case presentation is typical for a type C 
tracheoesophageal fistula with a proximal atre- 
sia of (Fig. 13^1) the esophageus. All the clinical 
symptoms can be explained. It is essential to 
hemodynamicaly stabilized the baby initially 
followed by an urgent corrective surgery. Often 
the tracheal fistula causes a big problem for 
anesthesia in terms of overinflation of the stom- 
ach and decrease in pulmonary compliance. 
Concomitantly a gastrotomy is performed 
alongside a right lateral thoracotomy. After 
extrapleural dissection and exposure of the right 
posterior mediastinum a ligation of right azygos 
vein and tracheoesophageal fistula is under- 
taken. The proximal esophageal pouch is gently 






Figure 13-4. 

A: Pure (long-gap) esophageal atresia. B: Esophageal atresia with proximal tracheoesophageal fistula. C: Esophageal atresia with 
distal tracheoesophageal fistula. D: Esophageal atresia with proximal and distal fistulae. E: Tracheoesophageal fistula without 
esophageal atresia. (Reproduced, with permission, from Sabiston DC: Textbook of Surgery. Saunders, 1991.) 



306 



1 3: Pediatric Surgery 



34. 



mobilized and a primary esophageal anasto- 
mosis is often successful. In case of long-gap 
esophageal atresia, a transverse colon interpo- 
sition is also used to bridge the gap. Type C is 
most common followed by a singular proximal 
esophageal without fistula. The H-type occurs in 
1% of all cases and is difficult to diagnose, since 
these babies often develop chronic pulmonary 
infections without typical GI symptoms. 

(C) This patient has situs inversus totalis and 
acute cholecystitis. After ensuring proper 



treatment of his sickle cell disease, he should 
receive IV antibiotics and be prepared for 
laparoscopic cholecystectomy. The surgical 
instrumentarium is to be placed in a mirror 
image but essentially the same rules and stan- 
dards apply The gallstones here probably con- 
tain bilirubin stones from frequent hemolytic 
episodes. It is also important to maintain a HCT 
of >28% and if necessary transfusions with 
Hb-A blood are carried out preoperatively 



CHAPTER 14 



Practice Test 

James E. Barone and C. Gene Cayten 

Questions 



DIRECTIONS (Questions 1 through 48): Each of 
the numbered item in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 



A 25-year-old woman complains of intermittent 
vague right upper quadrant (RUQ) pain. She 
has been on oral contraceptive tablets for 6 years. 
A CT scan of her abdomen shows multiple low- 
density solid masses occupying the entire right 
lobe of her liver as well as most of the left lobe. 
What is the best treatment for this patient? 



(A) 
(B) 



(C) 



(D) 



(E) 



Hepatic embolization 
Discontinuation of oral contraceptives 
and a repeated CT scan of her abdomen 
in 3-6 months 

CT-guided percutaneous needle biopsy 
of several liver masses 

Laparoscopic biopsy of the liver masses 
and cholecystectomy 
Gold therapy parenterally 



2. A 76-year-old woman undergoes successful 
endoscopic stenting of the common bile duct 
(CBD) for obstructive jaundice secondary to an 
inoperable cholangiocarcinoma. Two weeks later, 
she consults her physician because of a fever of 
102°F, general malaise, nausea, and RUQ dis- 
comfort. On physical examination, icteric sclera 
and RUQ tenderness are noted. Laboratory test 
results show leukocytosis, anemia, and an ele- 
vated serum bilirubin level. Chest x-ray shows 
no acute infiltrate, but the right diaphragm is 
elevated. What is the most likely diagnosis? 



(A) Cholangitis 

(B) Liver abscess 

(C) Acute calculous cholecystitis 

(D) Liver metastasis 

(E) Pneumonia 

A 78-year-old woman develops a liver abscess 
following stent drainage of jaundice. What is 
the preferred therapy? 

(A) Oral administration of antibiotics 

(B) Aspiration of abscess 

(C) CT-guided percutaneous drainage alone 

(D) Administration of antibiotics and 
CT-guided percutaneous drainage 

(E) Surgical drainage 

A 35-year-old man presents with a bleeding 
duodenal ulcer documented by endoscopy. The 
patient is somewhat unstable, and bleeding 
does not stop despite transfusing 8 U of blood. 
What is the most appropriate surgical therapy? 

(A) Further blood transfusion alone 

(B) Oversewing the ulcer alone 

(C) Oversewing the ulcer and performing a 
gastroj ej uno stomy 

(D) Oversewing the ulcer and performing a 
vagotomy and pyloroplasty 

(E) Oversewing the ulcer and performing a 
proximal gastrectomy 



307 



Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 



308 



14: Practice Test 



5. After undergoing a gynecologic operation, a 
36-year-old patient developed /3-streptococcal 
septicemia. Which is true of /^-streptococcal 
infection? 

(A) It does not spread rapidly along 
lymphatic channels. 

(B) It is mainly resistant to penicillin. 

(C) It may spread rapidly through tissue 
planes. 

(D) It is unlikely to cause overwhelming 
infection from an intravenous site. 

(E) It commonly causes urinary tract 
infection (UTI). 

6. A 44-year-old man develops intra-abdominal 
sepsis after undergoing difficult bowel resec- 
tion and anastomosis. He is initially given 
ceftizoxime sodium (Cefizox), which is in effec- 
tive because of overgrowth of which of the 
following? 

(A) Pseiidomontzs 

(B) Staphylococcus aureus 

(C) Neisseria gonorrhoeae 

(D) Bacteroides fragilis 

(E) Haemophilus influenzae 

7. A 64-year-old man is noted on CT scan to have 
a liver abscess. He is diagnosed as more likely 
to have a pyogenic than amebic liver abscess. 
Why? 

(A) He emigrated from Mexico. 

(B) Jaundice is absent. 

(C) He has associated diarrhea. 

(D) He has a history of biliary tract disease. 

(E) There is a rapid response to 
metronidazole. 

8. What is true of Candida sepsis? 

(A) It carries a relatively low mortality risk. 

(B) It is treated with actinomycin. 

(C) It can be partly prevented by 
ketoconazole. 

(D) It is caused by spore-forming organisms. 

(E) It is seen usually in conditions not 
requiring antibiotics. 



9. A 43-year-old man had a previous injury to his 
wrist. The ulnar nerve was severed, as indi- 
cated by which of the following? 

(A) Claw hand involving the ring and little 
fingers 

(B) Claw hand involving the index and 
middle fingers 

(C) Atrophy of the thenar muscles 

(D) Absent sensation in the index finger 

(E) Inability to flex the distal phalanx of the 
index finger 

10. After falling on the pavement, a 72-year-old 
woman is found to have a fracture of the radius 
and ulna (Colles' fracture). What is true of this 
fracture? 

(A) The fall occurs on the dorsum of the 
wrist. 

(B) Open reduction is most commonly 
indicated. 

(C) Younger men are generally affected. 

(D) The distal radial metaphysis is displaced 
dorsally. 

(E) The ulnar shaft is fractured proximally. 

11. An 83-year-old retired navy general is sched- 
uled to undergo aortoiliac bypass surgery for 
intermittent claudication. The factor(s) that 
would most likely cause concern because of 
the potential for development of cardiac com- 
plications is (are): 

(A) Signs of left ventricular failure 

(B) The patient's advanced age (>80 years) 
and jugular venous distention 

(C) History of angina and myocardial 
infarction (MI) 6 months previously 

(D) Left ejection fraction of over 50% 

(E) Aortic stenosis 

Questions 12 and 13 

A 24-year-old bank clerk is admitted to the hospital 
with left-sided blindness. She had emigrated from 
Africa and had been treated for sickle-cell disease. 
Examination reveals bleeding into the posterior (vit- 
reous) chamber of the eye. Funduscopy cannot be 
done because of the presence of blood inside the eye. 



Questions: 5-18 



309 



12. What should be the next step in management? 

(A) Needle aspiration of the anterior chamber 
of the eye 

(B) Exploration of the posterior chamber 

(C) Administration of cortisone 

(D) Administration of steroids 

(E) Observation 

13. The patient should be advised that repeated 
crisis may occur with which of the following? 

(A) Alkalosis 

(B) Moderate warmth 

(C) Pregnancy 

(D) Anemia 

(E) Oxygen administration 



14. 



15. 



A 62-year-old woman underwent a modified 
mastectomy operation 5 years ago. One month 
before hospital admission, she undergoes 
repeated paracentesis of her left pleural 
cavity for a malignant effusion. The effusion 
recurred, as seen on x-ray, and she complains 
of dyspnea. What would appropriate therapy 
include? 

(A) Diuretic therapy 

(B) A salt-free diet 

(C) A low -albumin diet 

(D) Thoracoscopy, removal of fluid, and 
injection of talc into the left pleural cavity 

(E) Thoracotomy and pneumonectomy 

A 43-year-old man sustains a fracture of the 
tibia. There are no neurologic or muscular 
lesions noted on careful examination. An 
above-knee cast is applied. After 6 weeks, the 
plaster is removed. It is noted that he has a 
foot drop and is unable to extend his ankle 
because of pressure injury to which of the 
following? 

(A) Posterior tibial nerve 

(B) Saphenous nerve 



(C) Femoral nerve 

(D) Deep fibula (peroneal) nerve 

(E) Nerve to the soleus muscle 

16. A 62-year-old woman with multiple myeloma 
is given pamidronate calcium biphosphonate. 
This treatment has been shown to do what? 

(A) Increase survival 

(B) Improve quality of life and protect 
against skeletal fractures 

(C) Stimulate osteoclast 

(D) Increase hypercalcemia 

(E) Replace chemotherapy 



17. 



18. 



A recently arrived 62-year-old emigrant from 
Greece complains of upper abdominal pain and 
fever. Ultrasound reveals a large liver cyst that, 
on serological testing, is shown to be hydatid 
disease. What should he undergo? 

(A) Cortisone therapy 

(B) Percutaneous drainage 

(C) Laparotomy and open drainage 

(D) Laparotomy and needle aspiration 

(E) Laparotomy and excision of cyst and 
perioperative albedazole 

A 34-year-old woman with Crohn's disease has 
undergone her fifth operation with small- 
bowel resection. She has hemoglobin of 7 g/dL. 
An upper gastrointestinal (GI) series shows an 
apple-core lesion due to adenocarcinoma of the 
small bowel (Fig. 14-1). What is the most likely 
cause of her anemia? 

(A) Erythropoietin deficiency 

(B) Thyroid overactivity 

(C) Megaloblastic anemia 

(D) Aplastic anemia 

(E) Inability to absorb fat soluble vitamins 



310 



14: Practice Test 




21. 



22. 



Figure 14-1. 

Upper Gl series shows apple-core lesion of mid-small bowel. 



19. A 42-year-old man who has consumed several 
bottles of whiskey weekly for the past 20 years 
presents with hematemesis due to gastric 
varices. After appropriate resuscitation surgery 
is undertaken, what should he undergo? 

(A) Total gastrectomy 

(B) Splenectomy 

(C) Portal vein ligation 

(D) Hepatic vein ligation 

(E) Placement of an emergency portacaval 
shunt 

20. A 12-year-old boy is admitted to the hospital 
with severe abdominal pain. He is noted to 
have slight jaundice. His hematocrit is 30, and 
reticulocytes are evident in a peripheral smear. 
His father underwent a splenectomy at age 
25. Which test would clarify the cause of 
anemia? 

(A) Barium enema 

(B) Hemoglobin electrophoresis 

(C) Serum iron 



23. 



24. 



(D) Coombs' test 

(E) Red blood cell (RBC) osmotic fragility 
test 

A 58-year-old woman has a gastric ulcer, 
achlorhydria, and vibration sense loss in the 
lower extremities. She has a megaloblastic 
anemia. What test would help support a diag- 
nosis of pernicious anemia? 

(A) Response to injection of radioactive B 12 

(B) Endoscopic retrograde 
cholangiopancreatography (ERCP) 

(C) Prothrombin time (PT) 

(D) Radiolabeled B 12 given orally 

(E) Response to trial of folic acid 

A black ambulance driver presents with upper 
extremity pain, abdominal pain, jaundice, and 
splenomegaly. He appears cyanotic and gives 
a history of chronic obstructive pulmonary 
disease (COPD). X-rays show osteomyelitis, 
which, on needle aspiration, grows Salmonella. 
He has mild jaundice and a nonhealing ulcer 
on the left leg. His mother had anemia and 
died after suffering a stroke. His hematocrit is 
28, and his blood shows sickle cells. What 
should the treatment do and not do? 

(A) Not include antibiotic treatment of 
osteomyelitis 

(B) Always include blood transfusion when 
his hematocrit is <30 

(C) Include administration of folic acid 

(D) Avoid the use of nasal oxygen 

(E) Include intravenous iron 

Laparoscopy in abdominal trauma may be 
indicated in which of the following? 

(A) To exclude diaphragmatic injury 

(B) In patients with multiple previous 
abdominal operations 

(C) If there is limited cardiovascular reserve 

(D) If severe diffuse peritonitis exists 

(E) In hemodynamically unstable patients 

A 42-year-old woman presents with a 3-cm 
breast mass of 3-month duration. Mammo- 
graphy shows microcalcification and features 



Questions: 19-28 



311 



suggestive of malignancy.The diagnosis is 
confirmed by which of the following? 

(A) Needle biopsy 

(B) Open biopsy from the edge 

(C) Mammography 

(D) Lymph node biopsy 

(E) Thermography 

25. A 45-year-old male is admitted to the emergency 
department subsequent to a high-speed motor 
vehicle accident. He was reportedly driving 
while intoxicated with alcohol and hit the 
embankment of an overpass. Examination 
reveals an unconscious male with a swollen 
neck and inspiratory stridor. Oxygen saturation 
is rapidly decreasing. What is the first concern? 

(A) Immobilize the neck to avoid further 
neurologic injury. 

(B) Obtain a whole body CT scan to assess 
full extent of injury. 

(C) Call an otolaryngologist to evaluate the 
airway further. 

(D) Perform a cricothyrotomy. 

(E) Locate family members to obtain consent 
for any possible surgical intervention. 

26. A 28-year-old woman has new onset hyper- 
tension and a bruit on abdominal examination. 
An arteriogram shows fibromuscular dysplasia 
(FMD) of the right renal artery. What is the best 
treatment option? 

(A) Aortorenal saphenous vein bypass 

(B) Patch angioplasty of the renal artery 

(C) Percutaneous transluminal angioplasty 

(D) Transaortic renal endarterectomy 

(E) Hepatorenal bypass 

27. A 42-year-old woman undergoes hysterectomy 
under spinal anesthesia. She develops severe 
respiratory distress after completion of the 
procedure. 

What is the most common cause of respira- 
tory arrest during administration of spinal 
anesthesia? 



(A) Paralysis of the intercostal muscle 

(B) Paralysis of the diaphragm (phrenic 
nerves) 

(C) Centrally induced mechanism second- 
ary to decreased cardiac output 

(D) Diffusion of anesthetic to the level of the 
pons 

(E) Diffusion of anesthetic to the level of the 
medulla 

Questions 28 through 29 

A 35-year-old man is brought to the emergency 
department after having been assaulted. A witness 
claims that he was hit on the head with a baseball 
bat and after the blow he was unconscious for 
approximately 10 minutes. The patient has a large 
bruise behind the left ear (Battle's sign) the site of 
impact being just a few centimeters above that. He 
is a little somnolesent but responds to questions 
and follows commands appropriately and accu- 
rately. He has no neurologic deficit other than mild 
weakness throughout the entire left half of the face. 
Inspection reveals dripping of a blood-tinged fluid 
coming from the patient's nose, which occurs par- 
ticularly after attempts to rise from the recumbent 
position. A CT scan of the brain with bone windows 
shows no injury to the brain itself. There is a linear, 
nondepressed fracture transversely on the left 
petrous bone. There is opacification of the ipsilateral 
mastoid air cells, and there is a small amount of air 
intracranially at the tip of the left temporal fossa. 
The diagnosis of a traumatic cerebrospinal fluid 
(CSF) leak is obvious. 

28. The most likely site of injury leading to cere- 
brospinal fluid rhinorrhea is an occult frac- 
ture in the frontal basal skull of which of the 
following? 

(A) Semicircular canal 

(B) Cavernous sinus 

(C) Eustachian auditory tube 

(D) Odontoid process 

(E) Superior orbital fissure 



312 



14: Practice Test 



29. 



Weakness of the left side of the face is due to an 
injury of the left facial nerve as it courses 
through the petrous temporal bone. The patient 
will manifest which of the following? 



(A) 


Absent gag reflex 


(B) 


Dilated pupil (mydriasis) 


(C) 


A bad taste sensation over the posterior 




third of the tongue 


(D) 


Deafness 


(E) 


Dryness of the cornea 



30. Which of following treatments should be 
recommended? 

(A) Trendelenberg's position (lowering the 
head of the bed) 

(B) Urgent craniotomy to repair leakage of 
the CSF 

(C) Lumbar spinal drainage if the leakage 
persists 

(D) Encourage mobilization 

(E) Insertion of a nasopharyngeal ribbon 

31. A young couple has been unsuccessful in con- 
ceiving a child over a 4-month period. The 
28-year-old wife had been extensively investi- 
gated by a female reproductive specialist, and 
no abnormalities were detected. The husband, 
who initially refused to undergo semen analy- 
sis now agreed to this investigation, which 
revealed a low volume and azotemia. Follicle- 
stimulating hormone (FSH) level is normal. 
What is the most likely diagnosis? 

(A) Bilateral testicular atrophy 

(B) Congenital absence of the vas deferens 

(C) Hydrocele 

(D) Varicocele 

(E) Emotional disturbance 

32. In evaluating a breast lesion in a female athlete, 
the surgeon notes that the tumor is in the ante- 
rior axillary line. To which site does the lateral 
edge of normal breast tissue extend? 

(A) The lateral edge of the pectoralis major 
muscle 

(B) The medial edge of the pectoralis minor 
muscle 



(C) Cover the medial third of the serratus 
anterior muscle 

(D) The semispinalis capitis 

(E) The posterior axillary fold 

33. A 45 year old woman presents with a bloody 
nipple discharge. The most likely cause of this 
problem is: 

(A) Fibrocystic breast disease 

(B) Intraductal papilloma 

(C) Pituitary tumor 

(D) Invasive ductal carcinoma 

(E) Lobular carcinoma 

34. A 74-year-old man presents with severe con- 
stant pain in the lower extremities associated 
with numbness and paresthesia of the plantar 
and lateral aspect of both feet. It is aggravated 
by walking or prolonged standing and occa- 
sionally made better by lying down. A mag- 
netic resonance image (MRI) shows lumbar 
stenosis. He will have which of the following? 

(A) Spasticity 

(B) Hyperreflexia 

(C) Vertebral artery occlusion 

(D) Multiple roots involved bilaterally 

(E) Cancer is inevitably found 

35. A 9-year-old boy has a 70% body surface area 
(BSA) burn that requires daily debridement in 
the Hubbard tank. To ease the pain of this 
debridement, what is the best selection? 

(A) Diazepam (Valium) and morphine 

(B) Innovar 

(C) Thiopental (Pentothal) 

(D) Nitrous oxide 

(E) Ketamine (Ketalar) 

36. An 83-year-old retired scientist has inoperable 
prostatic cancer. His prostate specific antigen 
(PSA) levels begin to increase, and x-rays of his 
pelvis reveal metastatic bone disease. What is 
the characteristic feature of prostatic metastasis? 

(A) "Bossing" of the frontal and parietal 
lobes 

(B) Osteoblastic lesions 



Questions: 29-44 



313 



(C) Osteopetrosis and vascular necrosis of 
the head of the femur 

(D) Fracture 

(E) Onion peel lesion 

37. A 62-year-old man develops abdominal pain 
after eating. An arteriogram reveals absence 
of blood flow in the celiac artery. Collateral 
branches supply the stomach through which of 
the following? 

(A) Intercostal arteries 

(B) Right renal artery 

(C) Superior mesenteric artery 

(D) Inferior epigastric artery 

(E) Left colic artery 

38. A 33-year-old man is involved in a motor vehi- 
cle accident. At operation, hepatic laceration 
and severe bleeding are noted. Which of the 
following would be relatively well tolerated 
by the patient? 

(A) Persistent hepatic bleeding 

(B) Portacaval shunt 

(C) Portal vein ligation 

(D) Hepatic arterial ligation 

(E) Esophageal variceal bleeding 

39. In evaluation of a patient who had previous 
surgery acid secretion studies are performed. In 
the normal individual, what does gastrin do? 

(A) It decreases basal (baseline) acid. 

(B) It causes basal acid to remain constant. 

(C) It causes basal acid to rise substantially 
within 1 hour. 

(D) It causes a rise in basal acid after a 
latent period of 6 hours. 

(E) It causes a fall and then a rise in basal 
acid. 

40. In fluid replacement following a 20% BSAburn, 
the fluid requirement for the initial 24-hour 
period is dependent on which of the following? 

(A) Patient's weight 

(B) Serum Na 

(C) CO level 



41. 



42. 



(D) Acid base status 

(E) Lactate level 

A 20-year-old man with a duodenal ulcer com- 
plains of pain when eating food as well as 
during the early hours of the morning. During 
the cephalic phase of digestion, the stomach is 
stimulated by which of the following? 

(A) Olfactory nerve 

(B) Right glossopharyngeal nerve 

(C) Sympathetic chain 

(D) Left splanchnic nerve 

(E) Vagus nerve 

A 42-year-old construction worker noted a 
swelling in the right submandibuler region. 
Biopsy reveals malignancy and surgical excision 
is advised. The patient is informed that one of the 
risks of this operation is which of the following? 

(A) Horner syndrome 

(B) Excessive sweating in the temporal 
region 

(C) Deformity of the angle of the mouth 

(D) Submandibular duct calculus 

(E) Trismus 



43. A 33-year-old man treated for lymphoma has 
increased levels of uric acid. This finding is 
usually caused by: 

(A) Increased secretion of uric acid by the 
kidneys 

(B) Increased production of uric acid 

(C) Hypercalcemia 

(D) Severe disease in the proximal 
interphalangeal (PIP) joints 

(E) Side effects of chemotherapy 

44. In osteoarthritis, there is which of the following? 

(A) Degeneration of cartilage 

(B) Slipped epiphysis 

(C) Symmetrical polyarthritis and marked 
inflammatory synovitis 

(D) Always a history of trauma 

(E) Usually a prescription for colchicine 



314 



14: Practice Test 



45. A 12-year-old boy is admitted to the hospital 
with a tentative diagnosis of osteomyelitis of the 
distal radius. What is found in this condition? 

(A) Tenderness is characteristically minimal. 

(B) There is an abscess in the soft tissue 
over the radius. 

(C) Hematogenous penicillin resistant S. 
aureus infection is likely to be present. 

(D) Fracture of the bone is always present. 

(E) There is tenosynovitis of the flexor 
tendons. 

46. A student develops Bell's palsy of the facial 
nerve. During examination, she may also be 
found to have which of the following? 

(A) Loss of sensation in the skin over the 
cheek 

(B) Loss of sensation in the skin over the 
upper lip 

(C) Loss of cornea sensation 

(D) Dryness and damage to the cornea 

(E) Absent pupil reflex 

47. A fracture of the femur occurs through the dia- 
physis of the femur. This injury involves which 
of the following? 

(A) Head of the femur 

(B) Acetabulum 

(C) Midshaft 

(D) Medial condyle 

(E) Anterior cruciate ligament 

48. A 14-year-old boy is seen by his physician 
because of pain in the right hip. He is noted to 
have a limp on walking. His symptoms gradu- 
ally developed over the past 3 months. The 
most likely cause of his symptoms is which of 
the following? 

(A) Volkmann's ischemia 

(B) Congenital dislocation of the hip 

(C) Slipped capital femoral epiphysis 

(D) Fracture of the proximal end of the fibula 

(E) Referred from a prostate lesion 



DIRECTIONS (Questions 49 through 51): Each set 
of matching questions in this section consists of a 
list of lettered options followed by several num- 
bered items. For each numbered item, select the 
appropriate lettered option. 

Question 49 

(A) Pituitary ablation by surgery 

(B) Pituitary suppression with luteninizing 
hormone (LH) agonists 

(C) Prostatectomy 

(D) Cyclophosphamide (Endoxana) 

(E) Methotrexate 

(F) Thyroidectomy 

(G) Toxoids 

(H) Aromatase inhibitors (Anastrazol) 
(I) Parathyroidectomy 

49. A 45-year-old man with abdominal pain, 
kidney stones, and peptic ulcer disease may 
very likely require which? 

Question 50 

(A) Mucinous cystadenocarcinoma 

(B) Serous cystadenocarcinoma 

(C) Corpus luteum cyst 

(D) Dermoid cyst 

(E) Benign serous cyst 

(F) Pseudocyst 

(G) Endometriosis cyst 
(H) Hydatid cyst 

50. The most common cyst in the ovary in a pre- 
menopausal patient is which? 

Question 51 

(A) Is a condition in which it is safe to leave 
microscopic disease at the cut edges 

(B) Shows favorable response to 
radiotherapy 

(C) Has a 5-year survival rate of about 12% 

(D) Rates are increased in patients with 
duodenal ulcer 



Questions: 45-56 



315 



(E) Is a condition in which extensive 
removal of drainage lymph nodes 
should not be done 

(F) Is associated with hyperchlorhydria 
(H) Is associated with diverticulitis 

51. What is true of pepsinogen? 

DIRECTIONS (Questions 52 through 92): Each of 
the numbered item in this section is followed by 
five answers. Select the ONE lettered answer that 
is BEST in each case. 



52. 



53. 



A 43-year-old woman presents with (RUQ) 
abdominal pain, and vomiting. She has had 
three children. The white blood cell (WBC) 
count is 14.3 x 109/L and liver function tests are 
normal. To establish the diagnosis in this 
patient, the test of choice is: 

(A) Computerized axial tomography (CAT) 
scan 

(B) Ultrasound 

(C) Hydroxy iminodiacetic acid (HID A) scan 

(D) MRI 

(E) Endoscopic retrograde 
cholangiopancreatography (ERCP) 

A 51-year-old woman underwent a Billroth II 
subtotal gastrectomy for carcinoma of the 
stomach 6 days ago. She had been recovering 
well except for persistent ileus. On morning 
rounds, you notice a large amount of serosan- 
guinous drainage on her gown. The most likely 
diagnosis is: 

(A) Wound dehiscence 

(B) Wound infection 

(C) Leak at the gastrojejunostomy 
anastomosis 

(D) Leak from the duodenal stump 

(E) Ascites 



54. A 67-year-old, 60-kg homeless man has been in 
the intensive care unit (ICU) for a week after an 



emergency laparotomy and sigmoid resection 
for perforated diverticulitis. His serum albu- 
min is 1.1 g/dL. He was just weaned from 
mechanical ventilation. His colostomy is not 
functioning. You start total parenteral nutrition 
(TPN) to deliver 1800 kcal/24 h. Two days later, 
the patient is in respiratory distress and requires 
reintubation and mechanical ventilation. You 
should check the level of serum 

(A) Phosphate 

(B) Magnesium 

(C) Calcium 

(D) Selenium 

(E) Glucose 

55. A 65-year-old man is 30 hours post-op sigmoid 
colon resection for diverticulitis. He says he 
feels well and he has a heart rate of 85 bpm, a 
blood pressure (BP) of 115/80 mm Hg, and a 
fever of 101. 6°F. The most likely cause of the 
fever is: 

(A) Clostridial myonecrosis 

(B) Wound infection 

(C) UTI 

(D) Pneumonia 

(E) Noninfectious 

56. A 28-year-old, 70-kg man who was shot in the 
abdomen underwent a resection of his pancreas 
and duodenum for a shattered head of the pan- 
creas. He required 14 U of packed RBCs and 
25 L of crystalloid for resuscitation. Two days 
later he has hypoxemia and bilateral fluffy infil- 
trates on chest x-ray. The diagnosis of ARDS is 
made. Mechanical ventilation is begun via an 
endotracheal tube. Which of the following orders 
for ventilator settings is most appropriate? 

(A) Tidal volume 650 mL, PEEP 8 

(B) Tidal volume 450 mL, PEEP 5 

(C) Tidal volume 800 mL, PEEP 

(D) Tidal volume 650 mL, PEEP 

(E) Tidal volume 450 mL, PEEP 



316 



14: Practice Test 



57. A 38-year-old woman underwent an open 
cholecystectomy a week ago. She is found to 
have a subhepatic abscess and bacteremia. The 
preliminary blood culture report states that the 
organism cultured is an aerobic gram-negative 
rod. Of the antibiotics listed below, which 
would be the best choice? 

(A) Aztreonam 

(B) Clindamycin 

(C) Metronidazole 

(D) Vancomycin 

(E) Methicillin 

58. A patient in the surgical ICU is in septic shock 
after surgery for perforated diverticulitis. His 
temperature is 102. 3°F and his heart rate is 
120 bpm. He is requiring dopamine for BP 
support. Which of the following drugs would 
be appropriate for use in this situation? 

(A) Recombinant activated protein C 

(B) Antitumor necrosis factor(TNF)antibody 

(C) Interleukin-1 (IL-1) receptor antagonist 

(D) Antiendotoxin antibody 

(E) Sodium nitroprusside 

59. A patient is recovering from acute respiratory 
distress syndrome (ARDS). The patient no 
longer requires sedation and is being consid- 
ered for weaning from the ventilator and pos- 
sible removal of the endotracheal tube. Which 
of the following parameters is an indicator of 
potentially successful weaning? 

(A) Pa0 2 /Fi0 2 ratio of 230 

(B) Rapid shallow breathing index of 125 

(C) Minute ventilation of 8.6 L/min 

(D) Mean airway pressure of 27 cm H 2 

(E) Negative inspiratory force of 14 

60. A 19-year-old male is admitted with a 2-cm 
stab wound of the sigmoid colon on the 
antimesenteric border. A small amount of solid 
feces is noted. No other injuries are present. 
Vital signs are stable throughout the case. The 
correct procedure is: 

(A) Repair the wound in two layers 

(B) Exteriorize the wound as a colostomy 



(C) Repair the wound in two layers with 
transverse colostomy 

(D) Resect the segment of sigmoid and per- 
form a primary anastomosis 

(E) Resect the wound and perform a 
Hartmann procedure 

61. An elderly woman underwent a radical mas- 
tectomy with radiation to the axilla 20 years 
ago. For 25 years, she has had an open wound 
that has never healed. It is not a recurrence of 
breast cancer. It is most likely: 

(A) Basal cell carcinoma 

(B) Squamous cell carcinoma 

(C) Hypertrophic granulation tissue 

(D) Malignant melanoma 

(E) Pyoderma gangrenosum 

62. A 63-year-old man is admitted for an elective 
colon resection for recurrent attacks of sigmoid 
diverticulitis. You want to administer prophy- 
lactic antibiotics. In choosing a regimen you 
should be aware that the most common organ- 
ism found in the colon of normal individuals is: 

(A) Escherichia coli 

(B) Clostridium difficile 

(C) Pseudomonas species 

(D) Bacteroides species 

(E) Enterobacter cloacae 

63. A mountain climber arrives in your emergency 
department with frostbite of the left hand. The 
best method of rewarming the extremity is: 

(A) Forced warm air convection 

(B) To administer IV fluids warmed to 37°C 

(C) Radiant heat 

(D) Vigorous massage 

(E) Immersion in water warmed to 40°C 

64. Two weeks after birth, a baby has persistent 
tachypnea, tachycardia, diaphoresis, and cya- 
nosis. Workup reveals a patent ductus arterio- 
sus. This can be closed with the use of: 

(A) Indomethacin 

(B) Acetaminophen 



Questions: 57-68 



317 



(C) Aspirin 

(D) Cyclosporine 

(E) Prostaglandin El 

65. A 65-year-old man presents with squamous cell 
carcinoma of the anus. He is in good health 
other wise. Metastatic workup is negative. The 
treatment of choice for this cancer is: 

(A) Radiation 

(B) Chemotherapy 

(C) A&B 

(D) Abdominoperineal resection 

(E) Wide local excision 

66. The most likely cause of the finding pictured in 
Fig. 14-2 in a patient who has undergone no 
procedures is: 



67. 



Optimal treatment for the patient whose chest 
x-ray is (Fig. 14-3) depicted below would be: 




Figure 14-2. 

Barium enema x-ray. Note the long segment of narrowing, 
the spasm, and the deformity (arrow) produced by an 
intramural abcess. (Reproduced, with permission, from 
Doherty GM: Current Surgical Diagnosis and Treatment, 
12th ed. 715. McGraw-Hill, 2006.) 



(A) Renal stone 

(B) Bladder tumor 

(C) Motion artifact 

(D) Sigmoid diverticulitis 

(E) Ventral hernia 




Figure 14-3. 

Spontaneous pneumothorax on right side. (Repro- 
duced, with permission, from Doherty GM: Current 
Surgical Diagnosis and Treatment, 12th ed. 36. 
McGraw-Hill, 2006.) 



(A) Endotracheal intubation, mechanical 
ventilation, and PEEP 

(B) Diuretics 

(C) Metered dose inhalers using bata agonist 
drugs 

(D) IV antibiotics 

(E) Needle decompression 

68. A 45-year-old woman who smokes is found to 
have a splenic artery aneurysm. It was most 
likely caused by: 

(A) Atherosclerosis 

(B) Trauma 

(C) Medial dysplasia 

(D) Pancreatitis 

(E) Protal hypertension 



318 



14: Practice Test 



69. A patient receiving total parenteral nutrition 
for a month is noted to have elevated aspartat 
aminotransferase (AST), alanine aminotrans- 
ferase (ALT), and alkaline phosphatase levels. 
A percutaneous liver biopsy shows fat vac- 
uoles. This finding is most commonly second- 
ary to excess administration of: 

(A) Glucose 

(B) Fat 

(C) Protein 

(D) Selenium 

(E) Insulin 

70. A 73-year-old man has ischemic rest pain of 
the left calf. Workup reveals occulsion of the 
left superficial femoral artery. He is scheduled 
for an elective femoral-popliteal bypass. A 
good way to reduce the risk of infection would 
be to: 

(A) Irrigate the wound with bacitracin during 
the operation 

(B) Start cefazlin 1 gIV 4 hours before the 
surgery 

(C) Use a plastic adherent drape 

(D) Not shave the leg 

(E) Finish the case in under 5 hours 

71. A 44-year-old woman is found to have an ele- 
vated serum calcium of 11.3 mg/dL during a 
routine physical examination. It remains ele- 
vated after 3 months and serum parathyroid 
hormone (PTH) levels are also high. You sus- 
pect a parathyroid adenoma. The best test to 
localize the lesion preoperatively is: 

(A) Ultrasound of the neck 

(B) Sestamibi scan 

(C) I 131 scan 

(D) CAT scan of the neck 

(E) MRI of the neck 

72. A 75-year-old man is admitted with epigastric 
pain, anemia, and weight loss. On upper gas- 
trointestinal endoscopy, a large ulcer is found 
in the distal antrum. The biopsy report shows 
adenocarcinoma of the stomach. CAT scan 
of the liver shows no metastasis. You would 
recommend: 



(A) Whipple procedure 
(pancreaticoduodenectomy) 

(B) Vagotomy and antrectomy 

(C) Subtotal gastrectomy 

(D) Vagotomy and pyloroplasty with wedge 
resection of the ulcer 

(E) Total gastrectomy 

73. A 12-year-old perpubertal female has a painless 
2.5-cm firm mass in the left subareolar area 
upon examination in the clinic. The right side 
has no palpable masses. The patient's mother is 
quite concerned. You recommend: 

(A) Excisional biopsy 

(B) Ultrasound 

(C) Fine needle aspiration 

(D) Incisional biopsy 

(E) Observation 

74. A 30-year-old alcoholic is admitted with severe 
epigastric pain. He has hypoxemia, dehydra- 
tion, and an elevated amylase and lipase. CAT 
scan shows probable hemorrhagic pancreatitis. 
An antibiotic shown to reduce the incidence of 
pancreatic sepsis in this type of pancreatitis is: 

(A) Ampicillin/ sulbactam 

(B) Aztreonam 

(C) Imipenem/cilastatin 

(D) Cefotaxime 

(E) Gentamicin 

75. A 51-year-old man presents with recent onset of 
what appears to be a large left varicocele. He 
should be investigated for possible: 

(A) Infertility 

(B) Testicular tumor 

(C) Renal tumor 

(D) Portal hypertension 

(E) Torsion of the appendix testis 

76. A 23-year-old baseball player falls on his out- 
stretched hand while attempting to catch a ball. 
He complains of persistent wrist pain. Although 
the initial wrist x-rays are read as normal, pain 
on palpation of the anatomic snuffbox suggests 
fracture of the: 



Questions: 69-82 



319 



77. 



78. 



79. 



(A) First metacarpal 

(B) Hook of the hamate 

(C) Pisiform 

(D) Proximal phalanx of the thumb 

(E) Scaphoid 

A 12-year-old boy with sickle cell disease pres- 
ents with pain and swelling of the right lower 
extremity. A bone scan reveals osteomyelitis of 
the tibial diaphysis. An organism found more 
commonly than in the general population in 
these cases is: 

(A) H. influenzae 

(B) Salmonella species 

(C) Klebsiella species 

(D) Bacteroides species 

(E) Aspergillus 

A 57-year-old woman presents with vague 
abdominal pain. After a course of treatment 
with H 2 -blockers failed and abdominal ultra- 
sound was negative, she underwent a CAT 
scan of the abdomen. The scan was negative 
except for the presence of a 3-cm mass in the 
left adrenal gland. Her pain disappeared. Urine 
and serum biochemical studies for a function- 
ing adrenal tumor are negative. Her past med- 
ical history is negative. The next step should be: 

(A) Adrenalectomy 

(B) CT-guided percutaneous core needle 
biopsy 

(C) Arteriography 

(D) MRI 

(E) Repeat CAT scan in 6 months 

A 79-year-old man had a chest x-ray because of 
a history of smoking. However, a calcified gall- 
bladder was noted. This was confirmed by 
CAT scan. The patient is asymptomatic and 
has no medical illnesses. The next step in the 
management of this patient should be: 

(A) Cholecystectomy 

(B) CT-guided percutaneous core needle 
biopsy 



(C) Cholecystectomy with 
pancreaticoduodenectomy 

(D) Cholecystostomy 

(E) Repeat CAT scan in 6 months 

80. A 62-year-old man presents with epigastric 
pain for 3 weeks. He had undergone a vago- 
tomy and antrectomy 18 years ago for a bleed- 
ing duodenal ulcer. On examination, he does 
not appear ill and has no significant physical 
findings. The patient should now be: 

(A) Treated with a proton pump inhibitor 

(B) Endoscoped 

(C) Treated with a prostaglandin El analog 

(D) Prepared for an exploratory laparotomy 

(E) Worked up with a CAT scan of the 
abdomen 

81. A 42-year-old woman presents with a swollen, 
painful, erythematous left breast which does 
not repond to a 10 day course of oxacillin. 
Ultrasound reveals no abscess. The next step in 
management should be: 

(A) Begin a 10-day course of vancomycin 

(B) Workup the patient for an 
immunosuppressive disease 

(C) Incise and drain the area 

(D) Biopsy the skin and parenchyma of the 
breast 

(E) Begin a 5-day course of prednisone in 
decreasing doses 

82. An aid in the prevention of aspiration of gastric 
contents prior to endotracheal intubation in 
patients about to undergo general anesthesia is: 

(A) Insertion of a nasogastric tube 

(B) Administration of an emetic agent 
30 minutes before intubation 

(C) External pressure on the cricoid cartilage 

(D) Placement of a Blakemore tube 

(E) Administration of ondansetron 
15 minutes before intubation 



320 



14: Practice Test 



83. 



84. 



85. 



A 68-year-old woman is admitted with an acute 
surgical abdomen. After resuscitation with crys- 
talloids IV fluids and administration of antibi- 
otics, she is taken for an immediate laparotomy. 
Perforated diverticulitis of the sigmoid colon is 
found. The sigmoid colon is inflamed but mobile 
and the mesentery contains a perforated abscess. 
The best operation for this patient would be: 

(A) Insertion of a sump drain in the abscess 
and a transverse loop colostomy 

(B) Sigmoid resection including the abscess 
and colon-to-colon anastomosis 

(C) Sigmoid loop colostomy 

(D) Abdominoperineal resection 

(E) Sigmoid resection and end sigmoid 
colostomy and oversew the rectum 
(Hartmann procedure) 

Five days after a craniotomy for a brain tumor, 
a patient in the ICU suffers a massive upper 
gastrointestinal bleed. On arrival to the unit, 
you note bright red blood in the nansogastric 
tube. The patient has a BP off 85/50 mm Hg 
and a heart rate of 126 bpm. Laboratory tests 
and type and crossmatch were sent, but the 
results are still pending. The first therapeutic 
option you would choose is to: 

(A) Lavage the nasogastric tube with cold 
saline. 

(B) Give norepinephrine starting at 

0.5 mcg/kg/min and titrate to BP of 
120/80 mm Hg. 

(C) Infuse 2 L of Ringer's lactate IV as fast 
as possible. 

(D) Call for a gastoenterology consult and 
request upper gastrointestinal 
endoscopy. 

(E) Give recombinant protein C. 

The most commonly used drug in the immuno- 
suppression of renal transplant patients is 
cyclosporine. A major side effect of this drug is: 

(A) Pancytopenia 

(B) Constipation 

(C) Nephotoxicity 

(D) Amenorrhea 

(E) Peripheral neuropathy 



86. 



87. 



A 40-year-old man was admitted with severe 
acute pancreatitis. He was noted to have a pH 
of 7.29, PaCO z of 65, and HC0 3 of 16. He was 
intubated and placed on mechanical ventila- 
tion. After aggressive fluid resuscitation, peak 
airway pressure was 55 cm H 2 and abdomi- 
nal pressure measured via the bladder was 
32 mm Hg. The best therapeutic option at this 
point is: 

(A) Apply PEEP 

(B) Tracheostomy 

(C) Use inverse ratio ventilation 

(D) Decompressive laparotomy 

(E) Insert bilateral chest tubes 

A 10-month-old boy has recently been weaned 
and placed on solid food. He develops colicky 
abdominal pain with vomiting. Examination 
of the abdomen shows emptiness in the right 
iliac fossa and a mass in the epigatrium. 
Intussusception is suspected. Following ade- 
quate hydration, this condition should be 
treated by which of the following? 



(A) 
(B) 
(C) 
(D) 



(E) 



Laxatives 

Gastrojejunostomy 

Laparotomy and manual reduction 

Radiologic reduction by barium with 

measured pressure control of column of 

barium 

Right hemicolectomy 



Question 88 and 89 

A premature infant is noted at birth to have mild 
abdominal distention. There are no abnormal pul- 
monary findings on auscultation. 

88. A plain x-ray of the abdomen shows intramu- 
ral air (Fig. 14^), which is attributed to which 
of the following? 

(A) Choledochojejunal fistula 

(B) Perforation of bowel caused by colon 
cancer 

(C) Perforated gastric ulcer 

(D) Gangrene of the small bowel 

(E) Pneumatosis cystoides intestinalis 



Questions: 83-92 



321 




Abdominal x-ray of premature infant. Intramural air is evident. 



Figure 14-4. 



89. What is the most appropriate treatment? 

(A) Urgent laparotomy 

(B) Treatment for E. coli species 

(C) Treatment for intestinal gangrene 

(D) Reassurance and no intervention, in 
most cases 

(E) Charcoal 

90. With regard to the injured pregnant patient, 
which of the following is true? 

(A) Hematocrit, blood volume, and BP all 
decrease with advancing pregnancy. 

(B) CT scan is the diagnostic test of choice 
in pregnancy. 

(C) Amniotic fluid analysis has a very low 
sensitivity in detecting viability of the 
fetus. 

(D) The ideal position of transport of a 
pregnant patient is on her right side. 

(E) Pregnant patients who are injured are at 
high risk for the development of 
disseminated intravascular coagulapathy 
(DIC). 



91. Which of the following is a contraindication to 
nonoperative management of splenic injury? 

(A) Prior hematologic disorder 

(B) HIV-positive patient 

(C) Hemodynamic instability 

(D) Multiple other solid-organ injuries 

(E) Pediatric patient 

92. A 60-year-old man with no significant past 
medical history is scheduled for elective chole- 
cystectomy. He has been taking aspirin daily. 
Preoperative recommendations should include 
which of the following? 

(A) Determination of prothrombin time (PT) 

(B) Estimation of platelet count 

(C) Discontinuation of aspirin 2 days before 
surgery 

(D) Discontinuation of aspirin at least 1 week 
before surgery 

(E) Determination of bleeding time 



322 



14: Practice Test 



The responses for questions 93-95 are the same, 
you will be required to select one answer for each 
item in the set. 

(a) Glucagonoma 

(b) Insulinoma 

(c) Zollinger-EUison syndrome (ZES) 

(d) Watery diarrhea, hypokalemia, and 
achlorhydria (WDHA) syndrome 

(e) Somatostatinoma 

(f) Multiple endocrine neoplasia type-1 
(MEN)-l 

(g) MEN-2A 
(h) MEN-2B 

For each patient below, select the most likely 
diagnosis. 

93. A 50-year-old woman complains of weakness, 
profuse watery diarrhea and crampy abdomi- 
nal pain. She reports a 10-lb weight loss. Her 
serum potassium is 2.8 mEq/L. 

94. A 45-year-old man presents with an upper gas- 
trointestinal bleed. An upper endoscopy reveals 
multiple duodenal ulcers and an enlarged 
stomach. 

95. A 35-year-old woman with epigastric pain, 
which did not improve on ranitidine, is found 
to have a nonhealing pyloric channel ulcer on 
upper endoscopy. Her serum calcium level is 
12 mg/dL. 

The response options for items 96-98 are the same, 
you will be required to select one answer for each 
item in the set. 

(a) Thalassemia 

(b) Hereditary spherocytosis 

(c) Sickle cell disease 

(d) Idiopathic autoimmune hemolytic 
anemia 

(e) Thrombotic thrombocytopenic purpura 

(f) Idiopathic thrombocytopenic pupura 

(g) Systemic lupus erythematosus 



(h) Myeloid metaplasia 
(i) Non-Hodgkin's lymphoma 
(j) Felty's syndrome 

96. A 30-year-old man is noted to be anemic, with 
clinical jaundice and a palpable spleen on 
abdominal exam. Splenectomy is the only 
treatment for this patient's automsomal domi- 
nant disorder. 

97. The peripheral smear of a child with anemia 
shows hypochromic microcytic anemia with 
target cells. What is the child's diagnosis? 

98. A woman with longstanding rheumatoid 
arthritis has neutropenia on routine labs and 
splenomegaly is noted on physical examina- 
tion. Which is the most likely diagnosis? 

The response options for items 99-100 are the 
same, you will be required to select one answer for 
each item in the set. 

(a) Nonparasitic cyst 

(b) Hydatid cyst 

(c) Hamartoma 

(d) Adenoma 

(e) Focal nodular hyperplasia 

(f) Hemangioma 

(g) Hepatocellular carcinoma 
(h) Metastatic carcinoma 

Select the most likely diagnosis for the patients below. 

99. A 50-year-old woman underwent wide exci- 
sion of a 2.5-cm infiltrating ductal carcinoma of 
the breast with axillary lymph node dissection 
followed by radiation and chemotherapy 
2 years ago. The patient now complains of RUQ 
abdominal pain. A CAT scan reveals two 
masses in the right lobe of the liver. 

100. A 35-year-old woman complains of RUQ pain 
after meals with nausea and vomiting. An 
ultrasound reveals cholelitiasis and an anechoic 
3-cm mass on the inferior surface of the right 
lobe of the liver. 



Answers and Explanations 



1. (B) The CT scan findings of this patient plus the 
history of prolonged use of oral contraceptives 
are characteristic in hepatocellular adenoma. 
Because the tumor extensively involves both the 
right and left lobes of the liver, oral contraceptive 
use must be discontinued, and the patient must 
be observed for 3-6 months. Significant reduc- 
tion in size of the adenoma has been noted in 
many cases after cessation of oral contraceptive 
use. If there is no regression of lesions, then liver 
transplantation should be recommended. 

2. (B) Fever, jaundice, RUQ pain with tenderness, 
and leukocytosis are symptoms common to 
both cholangitis and liver abscess. Elevation of 
the right diaphragm on chest x-ray favors a 
diagnosis of a liver abscess. Because of the pop- 
ularity of treating patients with cholangiocar- 
cinoma with long-term indwelling stents, the 
incidence of complications due to pyogenic 
abscess has also increased. 

3. (D) Administration of antibiotics and CT- 
guided percutaneous drainage of a liver abscess 
(consequent to biliary stenting) can be achieved 
with lower morbidity and mortality. Most pyo- 
genic liver abscesses harbor multiple organisms 
(E. coli, Klebsiella, Proteus, Streptococcus, and 
anaerobes). Broad-spectrum antibiotics should 
be empirically started before the specific organ- 
ism has been identified and before sensitivities 
are known. Closed aspiration of a liver abscess 
without drainage is inadequate in providing a 
more rapid resolution of the condition. 



plasty and performing a vagotomy is the pro- 
cedure of choice because of its low operative 
mortality. However, this procedure carries a 
higher-recurrence rate. Major resections, such 
as antrectomy and subtotal gastrectomy are con- 
traindicated in the unstable patient. At endo- 
scopy biopsies for H. pylori should be taken 
and, if positive, treatment designed to eradi- 
cate H. pylori should be started. Eradication of 
H. pylori reduces the recurrence rate of bleeding. 

5. (C) It is unclear why patients develop over- 
whelming infection at certain times. A surgical 
wound must be examined if a high fever occurs. 

6. (A) Ceftizoxime (Cefizox) is not effective 
against many strains of Pseudomonas. If the 
drug is used, a higher dosage may be indicated, 
and the antibiotic should be changed if a quick 
response does not occur. Complications may 
occur in patients who are allergic to penicillin. 

7. (D) He has a history of biliary tract disease. 
Pyogenic abscess occurs after abdominal sepsis, 
biliary tract surgery, and septicemia. Amebic 
liver abscess is not commonly encountered in 
the United States. Amebic liver abscess should be 
considered, however, if the patient has recently 
visited a tropical country or if abdominal pain 
and diarrhea are present. Metronidazole (Flagyl) 
is most effective in treating amebic abscess, and 
laparotomy should be avoided when possible 
unless complications specifically indicating inter- 
vention are present. 



4. (D) For the patient who is unstable and has a 
pyloric or duodenal ulcer, oversewing the ulcer 
and closing the pyloric incision as a pyloro- 



8. (C) Candida sepsis is an important clinical prob- 
lem in burn units and ICUs and in patients 
with immunosuppression. Candida albicans is 



323 



324 



14: Practice Test 



dimorphic, and both yeast and mycelial forms 
are seen in infected tissues. Ketoconazole is 
given by mouth; it cannot be given in liver dis- 
ease or in a nonacid environment. The main 
treatment of Candida sepsis is administration of 
amphotericin B. Actinomycin is an antibiotic 
that has antineoplastic action. 

9. (A) The lumbrical muscles arise from the flexor 
digitorum profundus tendons at a level distal 
to the small bones in the hand. The hypothenar 
muscles are on the ulnar side, and the thenar 
muscles are on the thumb side of the hand. 
The medial two lumbrical muscles are para- 
lyzed, and this leads to the typical deformity. 

10. (D) The distal radial metaphysis is displaced 
dorsally. This fracture was described by Colles 
over 150 years ago. The impact is caused by a 
fall on the flexor surface of the wrist. The distal 
segment is displaced dorsally. The reverse 
injury, involving a fall on the extensor surface 
of the wrist and flexor deformity, is a Smith 
fracture. Colles's fracture occurs more com- 
monly in older women. The styloid of the 
ulna — not the shaft of this bone — is fractured. 

11. (A) The single most serious prognostic sign for 
adverse changes after vascular surgery is the 
presence of congestive cardiac failure. Every 
effort must be made to correct pulmonary con- 
gestion and improve left ventricular function 
before undertaking elective procedures. MI 
occurring within 3 months before operation 
carries a high mortality rate. 

12. (E) Sickle-cell disease typically affects small 
arterioles and causes acute and chronic clinical 
manifestations. After an interval of a few days, 
an ophthalmologist should reexamine the 
patient to determine the next step in treatment. 

13. (A) Treatment of sickle-cell disease is aimed 
at minimizing the precipitating factors, such 
as hypoxemia and alkalosis. Analgesics are 
required to treat the acute attack. 

14. (D) If this method is unsuccessful, then fluid 
drained into the peritoneal cavity by a shunt 
could be considered. 



15. (D) The common fibula (peroneal) nerve divides 
into the superficial fibula (peroneal) nerve, 
which supplies the fibula (peroneal) compart- 
ment, and the deep fibula (peroneal) nerve, 
which supplies the extensor compartment of the 
leg. This injury may occur because of a fracture 
of the proximal fibula or because of compression 
of the nerve by a tightly applied plaster cast in 
this region. 

16. (B) In multiple myeloma, pamidronate calcium 
biphosphonate has been found to be useful as 
an adjunctive treatment, reducing the incidence 
of skeletal fractures. 

17. (E) During the operative procedure, care must 
be taken to avoid spilling fluid from the cyst, 
which contains daughter scoleces. Perioperative 
treatment with albendazole should be started 
to help protect against any operative spillage 
of cyst contents. Recommended course is 
albendazole (10 mg/kg) for 1 week. If spillage 
occurs, treatment should continue for 1 month 
postoperatively. 

18. (C) The distal ileum is the site of absorption of 
vitamin B 12 following release of intrinsic factor 
from the gastric mucosa. 

19. (B) The most common causes of gastric varices 
in patients with splenic vein thrombosis occur 
following pancreatitis and malignancy. 

20. (E) The clinical finding of a positive family his- 
tory suggests autosomal dominant hereditary 
spherocytosis. The diagnosis is confirmed by 
the presence of spherocytes in the peripheral 
blood and the abnormal osmotic fragility of 
their RBCs in dilute saline. In childhood, pig- 
mented biliary tract stones and hemolytic 
anemia may be present. 

21. (D) The Schilling test is performed by giving 
radiolabeled B J9 orally (after saturating the B 12 
stores by intramuscular B 12 ). In pernicious 
anemia, less than 3% of the label is found in the 
24-hour urine collection (N >7%). Hemoglobin 
electrophoresis will detect defects in a- or 
/3-globin chain synthesis, as seen in thalassemia 
(Mediterranean anemia). 



/Answers: 9-30 



325 



22. (C) Eight percent of American blacks have the 
HbS gene and 1 in 400 have the disease. 
Symptoms may appear in the first year of life if 
associated infection or hypersensitive drugs 
are administered. 

23. (A) Laparoscopy in abdominal trauma is indi- 
cated in the management of select patients with 
intra-abdominal injuries. It may minimize 
intraoperative intervention in select patients 
with penetrating wounds to the abdomen. 

24. (A) In general, a needle biopsy or needle aspi- 
ration cytology is performed as an out-patient 
procedure. Establishment of the diagnosis 
before hospital admission enables the surgeon 
to discuss surgical options before anesthesia is 
given. Excision biopsy is performed if the 
biopsy fails to confirm the diagnosis of a suspi- 
cious lesion. 

25. (D) Blunt trauma to the neck is the most fre- 
quent cause of injury to the larynx. Rapid accu- 
mulation of blood, usually in supraglottic 
portions, can produce rapid laryngeal obstruc- 
tion. A tear in the mucosal lining of the larynx 
and pharynx causes subcutaneous emphysema. 
The initial treatment is establishment of an ade- 
quate airway. Physicians should familiarize 
themselves with this technique. All clinics and 
doctor's offices should have the essential equip- 
ment required to perform this procedure when 
such an emergency arises. 

26. (C) Among all causes of renovascular hyper- 
tension, FMD responds best to angioplasty. 
Results of PTA for FMD are similar to those of 
bypass. PTA has lower morbidity, causes less 
discomfort, and is less expensive. Recurrence 
can be treated by repeated PTA. 

27. (C) Spinal anesthesia induces venous vasodila- 
tion because of sympathetic blockade. Venous 
pooling can seriously impair venous return. It is 
the sympathetic blockade and not somatic nerve 
blockade that is responsible for the vasomotor 
and respiratory changes. It is important to ensure 
that volume depletion is corrected before induc- 
tion of spinal anesthesia, because venous return 
and, hence, cardiac output are diminished. These 



changes are aggravated by keeping the head 
raised. 

28. (C) This is paradoxical rhinorrhea. CSF leaks 
through a fracture in the temporal bone (with 
a local dural laceration) into the mastoid air 
cells and middle ear. Because of the commu- 
nication of the middle ear with the nasophar- 
ynx through the eustachian tube, CSF enters 
the nasopharynx and may exit through the 
nose. In the case of a small leak, there may be 
no more than the complaint of a postnasal 
drip or an unusual salty taste in the back of 
the mouth. In more severe cases, one can expe- 
rience a frank constant drip of CSF through 
the nose. In this case, the evidence for the site 
of the leak being the temporal fracture is com- 
pelling — the presence of a petrous fracture, 
the opacification of the normally aereated 
mastoid air cells, and the presence of air in 
the middle fossa. 

29. (E) After the facial nerve leaves the brainstem, it 
exits the skull through the internal acoustic 
meatus. Subsequently, it has a long and tortuous 
intraosseous pathway through the petrous bone 
that makes it particularly vulnerable to injury 
when the petrous bone itself had undergone a 
fracture. Nondisplaced fractures can result in a 
contusion of the nerve; whereas, displaced frac- 
tures can result in a complete transection of the 
nerve before it exits the skull through the stylo- 
mastoid foramen. Hyperacustism occurs if the 
hyperacustism facial nerve lesion is proximal to 
innervation of the stapes muscle. Severance of 
the accompanying chorda tympany nerve will 
result in loss of taste sensation in the anterior 
two-thirds of the tongue. 

30. (C) Upward of 95% of CSF leaks that are caused 
by nonpenetrating trauma will heal without 
the need for surgery. Optimal conservative 
management in these cases consists of head 
elevation geared toward reducing the pressure 
of CSF and, thus, its tendency to leak out of the 
head. In the case of more persistent leaks, serial 
spinal taps or a lumbar drain can be employed. 
A lumbar drain places a small silicone tube into 
the lumbar subarachnoid space through a 
spinal needle. CSF can be drained through it in 



326 



14: Practice Test 



a controlled fashion. Only a minority of patients 
with nonpenetrating CSF leaks will develop 
meningitis or eventually need surgery to repair 
the leak. 

31. (B) In congenital absence of the vas deferens, 
mutation of the cystic fibrosis transmembrane 
receptor gene (CFTg) occurs. The epididymis 
vas deferens, seminal vesicle, membranous ure- 
thra, part of the trigone of the bladder, and 
ureter arise from the mesonephric duct. In the 
presence of a normal FSH level, testicular 
biopsy would most likely confirm normal 
sperm formation. In the presence of a Sertoli 
cell tumor, spermatozoa are unlikely to form, 
and the FSH level is elevated. 

32. (C) The breast tissue extends over the medial 
margin of the serratus anterior muscle. The 
nerve to the serratus anterior lies on the lateral 
aspect of this muscle and may be accidentally 
injured during breast surgery. 

33. (E) Secretions drain from the nipple by multi- 
ple openings. The most common cause of a 
bloody nipple discharge is intraductal papil- 
loma (approx. 45%), but malignancy must be 
excluded. In about 10% of cases, an underlying 
carcinoma is detected. Prolactinoma of the pitu- 
itary gland may be responsible for clear or 
milky discharge (frequently bilateral). This may 
be diagnosed by an elevated prolactin level. 
Fibrocystic disease is not associated with 
bloody nipple discharge. 

34. (D) Symptoms, although not always perfectly 
symmetric, are almost invariably bilateral. 
Symptoms are usually accompanied by dimin- 
ished tone and reflexes and the absence of upper 
motor neuron features of spasticity, hyper- 
reflexia, and upgoing toes. 

35. (E) Ketamine is a neuroleptic agent (it sup- 
presses psychomotor activity). It often provides 
adequate analgesia without respiratory or car- 
diorespiratory depression. It may increase laryn- 
gospasm and raise intracranial pressure (ICP). 
In adults, its main disadvantage is that it may 
induce hallucinations (emergence reactions), 
which occur in 12% of patients, manifesting as 



dreamlike states, confusion, excitement, and 
possible irrational behavior. 

36. (B) Patients with metastatic bone disease from 
prostatic cancer may survive for several years 
after diagnosis is established. 

37. (C) The superior mesenteric artery will supply 
the inferior pancreaticoduodenal branch, which 
will form collateral branches with the superior 
pancreaticoduodenal branch from the celiac 
axis branch (gastroduodenal). 

38. (D) Hepatic arterial ligation is often well toler- 
ated. It reduces hepatic blood flow and, thus, 
decreases portal pressure. As in many other 
sites, the effect of proximal ligation is less dras- 
tic than that of distal ligation, because collater- 
als beyond the obstruction supply the definitive 
organ. Hepatic artery ligation should be avoided 
in the presence of obstructive jaundice or portal 
vein obstruction. 

39. (C) After gastrin or histamine administration, 
there is an increase in acid secretion to between 
20 and 60 mEq/h, with a mean value in this 
group significantly higher than in normal indi- 
viduals or gastric ulcer patients. The rise in 
acid secretion after injection of gastrin is known 
as the augmented value. Basal acid output is 
usually 0.5-15 mEq/h. 

40. (A) In burns, the Parkland formula is used to 
calculate initial fluid management. Fluid 
requirement = 4 x weight (kg) x % second and 
third degree BSA. Half this volume is given 
over the first 8 hours from time of the burn 
and the other half over the next 16 hours. After 
the initial 24-hour period, clinical parameters 
are used to guide fluid management. 

41. (E) Both the right and left vagi contribute to the 
cephalic, gastric, and intestinal phase of acid 
secretion. The left vagus contributes predomi- 
nantly to the anterior and the right to the pos- 
terior vagus nerve as they enter the abdominal 
cavity. 

42. (C) The mandibular branch of the facial nerve 
may pass below the margin of the mandible 



/Answers: 31-55 



327 



(15% of cases). Injury to the nerve will result in 
considerable deformity of the lower facial mus- 
cles including paralysis of those acting on the 
angle of the mouth and lower lip. 

43. (B) The numerous causes of gout can conve- 
niently be divided into overproduction of uric 
acid and undersecretion of uric acid by the kid- 
neys. Hyperuricemia results from increased 
cellular turnover in patients with lymphoma. 

44. (A) Osteoarthritis is characteristically a nonin- 
flammatory condition with normal WBC count 
in joint fluid; rheumatoid arthritis causes a 
symmetrical polyarthritis and marked inflam- 
matory synovitis with an increase in the fluid 
WBC count. 

45. (C) S. aureus infection is likely to be present. 
Osteomyelitis may also be caused by com- 
pound fractures and infection of the soft tis- 
sues surrounding the periosteum. 

46. (D) The palpebral portion of the orbicularis oculi 
muscle closes the eye. Damage to the facial nerve 
causes inability to close the eye, and serious dry- 
ness of the conjunctiva may cause blindness. 

47. (C) The physis is the growing cartilaginous 
portion of the bone. The diaphysis is toward 
the center and the epiphysis toward the ends of 
the bone. 

48. (C) It is important to recognize this entity on x- 
ray Treatment must be carried out to avoid fur- 
ther slipping of the joint epiphysis, because 
arthritis may result in neglected cases. Unlike 
fractures of the head of the femur occurring in 
older persons, the condition is unlikely to lead 
to necrosis of the femoral head. 

49. (I) The patient has typical features of hyper- 
parathyroidism. The other conditions do not 
have these three features. 

50. (C) A corpus luteum cyst is functional and usu- 
ally regresses within one menstrual cycle. If a 
cyst is smaller than 5-6 cm, reevaluate the 
patient in 4-6 weeks before suggesting laparo- 
tomy. Dermoid cysts are benign variations of 



teratomas. They usually are cured by simple 
excision, but the opposite ovary may be 
involved in 10% of cases. 

51. (C) Survival rates are increased in patients with 
gastric ulcer. The 5-year survival rate for all types 
of gastric carcinoma is about 12%, but it is 35% if 
the nodes are clear and 7% if the nodes are 
involved. It is important that the cut edges are 
clear of tumor to avoid almost certain recurrence. 

52. (B) The test of choice is ultrasound. It is quick, 
noninvasive, and accurate for the diagnosis of 
gallstones and acute cholecystitis. When pres- 
ent, signs of acute cholecystitis such as peric- 
holecystitic fluid and a thickened gallbladder 
wall can easily be seen on ultrasound. CAT 
scan often does not show gallstones if the den- 
sity of the stones is similar to that of bile. HIDA 
scan is usually reserved for patients in whom 
ultrasound is negative but suspicion of gall- 
bladder disease is high. MRI is expensive and 
not studied for the diagnosis of stones. ERCP is 
usally done to rule out common duct stones. 

53. (A) A large amount of seroanguinous drainage 
from the abdominal wound that occurs 5 to 7 
days post-op is usually the result of dehiscence 
of the abdominal wound closure. A wound 
infection is heralded by erythema, swelling, 
and thick pus. Leaks from either enteric suture 
line would probably be bilious. Ascites is not 
commonly blood tinged. 

54. (A) Rapid institution of full nutritional sup- 
port can cause "refeeding syndrome" in mal- 
nourished patients. The hall mark of this 
condition is hypophosphatemia. Phosphate is 
taken up by phosphate-depleted cells trying to 
metabolize the nutrition and levels of ATP fall 
precipitously. This leads to respiratory failure. 
Refeeding syndrome can be avoided by start- 
ing nutritional support at low levels and 
increasing slowly. The other substances listed 
are not associated with respiratory failure after 
starting nutritional support. 

55. (E) The patient almost certainly has a nonin- 
fectious reason for his early postoperative fever. 
There is no evidence that this is so. Most fevers 



328 



14: Practice Test 



of this type resolve without any specific cause 
being found. Clostridial myonecrosis is always 
accompanied by cardiovascular instability, 
obtundation, and severe pain. UTI, pneumonia, 
and wound infection are unlikely so early in 
the postopertive period. 

56. (B) In keeping with the current recommendation 
of lung protective ventilation with tidal volume 
of 5-7 mL/kg, answer B is correct. Low to mod- 
erate levels of PEEP should also be applied. This 
strateg of low tidal volume plus PEEP is thought 
to prevent overdistension of normal alveoli and 
limit secondary injury to the lung. 

57. (A) Aztreonam is effective against gram- 
negative aerobic organisms. Clindamycin and 
metronidazole cover gram-negative anaerobic 
bacteria. Vancomycin and methicillin are effec- 
tive drugs against gram-positive organisms. 

58. (A) Recombinant activated protein C (drotreco- 
gin) was shown to reduce mortality in severe 
septic shock, but not mild septic shock. The 
major side effect of recombinant activated pro- 
tein C is bleeding. Anti-TNF antibody, IL-1 
receptor antagonist, and antiendotoxin antibody 
have failed to change outcomes in randomized, 
prospective trials. Sodium nitroprusside is a 
vasodilator and would worsen septic shock. 

59. (C) Minute ventilation (abbreviated Ve and the 
product of tidal volume x rate) of <10L/min 
suggests the patient is ready for weaning. A 
PaO,/Fi0 2 ratio of >300 is normal and would 
be helpful inconfirming the patient's readiness 
for weaning. A rapid shallow breathing index 
(frequency /tidal volume) of <105 if favorable 
as is a negative insipatory force of >-20 cm of 
H 2 0. Mean airway pressure does not predict 
successful extubation. 

60. (A) In the absence of significant contamination 
or devitalized tissue in a stable patient, the 
wound should be repaired without having to 
resort to a colostomy or a resection. This repre- 
sents a change in the philosophy of managing 
colon injuries from 20 years ago. It is based on 
solid evidence-based medicine and experience 
with such patients. 



61. (B) First described by Marjolin in 1828 and 
known as Marjolin's ulcers, malignant degen- 
eration arising in a chronic wound is nearly 
always squamous cell carcinoma. These lesions 
are most commonly seen in burn scars but have 
been associated with osteomyelitis, radiation 
therapy, hidradenitis suppurativa, and diabetic 
ulcers. 

62. (D) The approximate ratio of anaerobic organ- 
isms to aerobic organisms in the colon is 300:1. 
Pseudomoncis and C. difficile are not normally 
found in large quanitites in the colon. 

63. (E) Warm water immersion is the preferred 
method of rew arming extremities suspected of 
suffering from frostbite. Vigorous massage is 
contraindicated as it may cause trauma to the 
tissues. IV fluids warmed to 37°C would take a 
very long time to have an impact even if the cir- 
culation to the skin of the hand was adequate, 
which is not likely in frostbite. The other two 
choices would not provide a consistent tem- 
perature. 

64. (A) The nonsteroidal anti-inflammatory drug, 
indomethacin, is the drug of choice for closure 
of a patient ductus arteriosus in a premature 
infant with an isolated patient ductus arterio- 
sus. For complex cardiac anomalies, which 
require a patient ductus arteriosus to sustain 
life until corrective surgery can be done, 
prostaglandin E 1 can be administered to keep 
the ductus arteriosus open. The other choices 
are not indicated in patient ductus arteriosus. 

65. (C) Radiation and chemotherapy are indicated 
for squamous cell carcinoma of the anus. Surgery 
is used only for biopsy and for selected cases of 
recurrence after radiation and chemotherapy. 

66. (D) The most likely cause of the finding 
depicted, which is air in the bladder, is a 
colovesical fistula secondary to acute sigmoid 
diverticulitis. A renal stone, if visible at all, 
would be a calcific density and would be in 
the dependent portion of the bladder. There is 
no motion visible. A bladder tumor would 
appear as a filling defect with the density of 
soft tissue. It is not a hernia. 



/Answers: 56-76 



329 



67. (E) The x-ray shows a tension pneumothorax. 
Insertion of a needle in the second intercostal 
space, midclavicular line can be a lifesaving 
procedure. The diagnosis of tension pneu- 
mothorax should be made on the basis of clin- 
ical findings such as decreased breath sounds 
and tympany to percussion on the affected 
side. Neck veins may be destended if the 
patient is not phyovolemic. The patient will be 
short of breath and hypotensive. The other 
answers are incorrect, especially A, which 
would exacerbate the problem by introducing 
positive pressure into the airways. 

68. (C) Splenic artery aneurysms in women are 
almost always caused by medial dysplasia of 
the artery. It may be the cause of rupture in 
pregnancy and can be life-threatening if not 
treated promptly by laparotomy. Aneurysms 
may be caused by atherosclerosis, trauma, and 
pancreatitis (when complicated by pseudocyst 
formation). Portal hypertension is not a cause 
of aneurysm. 

69. (A) Adminstration of excess glucose will lead to 
hepatic steatosis with 3-4 weeks. Liver function 
test will become abnormal and a liver biopsy 
will show fat vacuoles. Excess glucose admin- 
istration can also lead to overproduction of Co 2 
and difficulty in weaning patients from 
mechanical ventilation. Excess administration 
of intravenous fat may cause suppression of 
the immune system. Excess protein adminis- 
tration may lead to elevated levels of urea 
nitrogen in the blood. 

70. (D) Shaving is associated with an increased inci- 
dence of wound infection compared to the use of 
electric clippers or depilatories, as well as com- 
pared to no hair removal at all. Prophylatic 
antibiotics should be started within 60 minutes of 
the incision time. Plastic adherent drapes and 
antibiotic wound irrigation have not been proven 
to reduce wound infection rates. Wound infec- 
tion rates increase as duration of surgery 
increases beyond 2 hours due to the reemergence 
of skin flora. 

71. (B) The best study for localizing parathyroid 
adenomas is the sestamibi scan I 131 is used 



occasionally to work up thyroid disease. The 
other three test will often show the location of 
the parathyroid adenoma, especially if it is 
large. However, they are not as accurate as ses- 
tamibi for this problem. 

72. (C) A subtotal gastrectomy with negative mar- 
gins is appropriate treatment for gastric carci- 
noma. Vagotomy adds nothing as patients with 
gastric cancer are invariably achlorhydric. A 
Whipple procedure is done for panccreatic car- 
cinoma. Total gastrectomy is rarely indicated 
for a distal gastric carcinoma. 

73. (E) In a 12-year-old prepubertal female, the over- 
whelming likelihood is that the mass is budding 
breast tissue. The patient and her mother should 
be reassured and told to return in a few months 
if the other breast has not begun to develop. The 
other answers are incorrect because they will not 
help in the diagnosis and in the case of the two 
biopsies, they may actually cause harm in the 
breast may not develop normally. 

74. (C) Imipenem/cilastatin has been reported in 
several randomized, prospective studies to 
decrease the risk of infecious omplications in 
severe pancreatitis. The other antibiotics have 
not been subjected to such rigorous investi- 
gation. 

75. (C) Because of the fact that the left testicular 
vein empties into the left renal vein, a renal cell 
carcinoma of the left kidney, which occludes 
the renal vein, may also occlude the testicular 
vein. The right renal vein empties into the infe- 
rior vena cava. A variocoele will not occur in 
right renal cell carcinoma. 

76. (E) The scaphoid or carpal navicular bone can 
be palpated in the anatomic snuffbox, which is 
formed by the abductor pollicis longus and the 
extensor pollicis brevis tendons on the lateral or 
radial side and the pollicis longus tendon on 
the medial or ulnar side. Scaphoid fractures 
are not always clearly visible at the time of ini- 
tial injury. Pain in the anatomic snuffbox 
should heighten suspicion that a scaphoid frac- 
ture is present. The patient should be splinted 
and repeat x-rays should be taken a few days 



330 



14: Practice Test 



later. These fractures are prone to nonunion, 
especially if the diagnosis is delayed. 

77. (B) Although S. aureus is the most common 
organism found in osteomyelitis associated 
with sickle-cell disease, nontyphoid salmonella 
species are often found. Salmonella bacteria are 
thought to esc