1. A 2-cm gastric ulcer in the antrum of the stomach is associated with all of the following EXCEPT H. pylori infection Increased acid secretion Malignancy.

1.   A 2-cm gastric ulcer in the antrum of the stomach is associated with all of the following EXCEPT

• H. pylori infection• Increased acid secretion• Malignancy• NSAIDs• Atrophic gastritis

1.   Answer  BGastric ulcer classificationI (50%): body/antrum of stomach, along lesser curvature Low to normal acid levels

Tx with antrectomy

II (25%): type I + duodenal ulcerHigh acid levelsTx with vagotomy, antrectomy 

III (15%): prepyloric High acid levels

Tx with vagotomy, antrectomy 

IV: close to GE jxn Low to normal acid levels

V: anywhere in stomach, drug-associated

2. A generally healthy 35-year-old man has a 6-hour history of abdominal pain and nausea. He passes a stool containing mucous and blood. A CT scan is obtained and shown below.

The best therapeutic intervention would bea.      colonoscopyb.     IV neostigminec.      Barium enemad.     Bowel resection and anastamosise.      Nasogastric suction and antibiotics

3.     The most common cause of this condition in adults is

a.      Meckel’s diverticulumb.     Gallstonesc.      Ischemic bowel diseased.     Crohn’s diseasee.      Gastrointestinal tumor

2.   Answer D3.    Answer E

Intussusceptum: proximal portion that invaginates into distal bowel

Intussuscipiens: recipient, distal bowel into which proximal bowel invaginates into

Children: under 3 years old, preceded by nonspecific febrile illness (viral), hypertrophy of Peyer’s patches

Adults: malignancy (lymphoma)Dx: CT scanTx: resection

4. A 58-year-old woman has had no flatus or bowel movement for 2 days, and intermittent vomiting for the past 24 hours. She has had mid-epigastric pain for the past 3 years, but has never sought treatment. Diet modification helped decrease the frequency and severity of pain. She has never had a previous abdominal operation.

Exam demonstrates a distended abdomen with moderate tenderness to deep palpation but no rebound. No stool or masses are noted on rectal exam. An abdominal x-ray is shown.

 The most likely etiology is

a.   tuberculosis

b.  fungal

c.  inflammatory

d.  neoplastic

e. bacterial

5.    The patient is taken to the OR and exploration reveals the finding shown.

 The management of choice isa.      enterotomyb.     adhesiolysisc.      segmental resectiond.     peritoneal washingse.      intestinal bypass

4.  Answer C5.   Answer ARigler’s triad: abd xray -- SBO, pneumobilia, radioopaque stoneXray often non-diagnostic

• Etiology: recurrent cholecystitis with inflammtion and adhesion formation, stone erodes through gallbladder into adjacent viscus, usually duodenum

• Distal ileum common site of obstruction

• Tx: resuscitation, OR enterotomy proximal to stone

• Not necessary to deal with cholecystoenteric fistula at initial operation, spontaneously close in many

• Elective cholecystectomy

• Recurrence rate 5%

6.   A previously healthy 25-year-old woman has right lower quadrant pain and fever. CT confirms appendicitis. After an uneventful appendectomy, the patient is discharged. The final report on CT describes a 2.0 cm left adrenal mass.The patient is asymptomatic. Which of the following is NOT appropriate?

a.      dexamethasone suppression testb.     measurement of serum potassium and plasma aldosterone concentration/plasma renin activity ratioc.      fine-needle aspiration biopsyd.     adrenalectomy if the tumor is functionalfollow-up CT in 6 to 12 months

6. Answer  CAdrenalectomy for lesions > 6 cmNonfunctioning lesions < 4 cm interval CT or MRI at 6

months and 1 year4-6 cm adrenalectomy or close observation90% benign  r/o subclinical hypercortisolism  1-mg dexamethasone suppression test overnight  8 AM plasma cortisol > 3 mg/dL (failure to suppress)   chk 24-hour urinary free cortisol and plasma ACTH    Aldosteronoma least common    screened for only in patients with HTN or hypokalemia   serum potassium, plasma aldosterone/plasma renin (>20)   confirm with 24-hour urinary aldosterone levels

Pheochromocytoma     fractionated urinary and/or plasma catecholamines,

metanephrines, and urinary vanillylmandelic acid (VMA)    Preoperative α-adrenergic blockade with

phenoxybenzamine- administered for at least 1 week before operation- Side effects: reflex tachycardia, nasal congestion

    intravenous fluids    β-Adrenergic blockade for reflex tachycardia

- do not give until adequate α-blockade established

7.    A 43-year-old man with alcoholic cirrhosis has had two episodes of variceal hemorrhage treated acutely with sclerotherapy. Lab values are as follows: albumin 3.3 g/dL; total bilirubin 1.2 mg/dL, alkaline phosphatase 120units/mL, PT 12 sec (control 11.5 sec), PTT 36 sec, aspartate amino transferase 30 units/L, and alanine amino transferase 25 units/L. He has no ascites and has never been encephalopathic. Appropriate management at this time might include each of the following EXCEPT

a.      distal spleno-renal shuntb.     endoscopic rubber band ligationc.      transjugular intrahepatic portosystemic shuntd.     orthotopic liver transplantatione.      small diameter H portocaval shunt 

7. Answer DPt is Child’s class AChild’s-Pugh Classification (A BATH)

Score

Ascites (grade) Bilirubin

(mg/dl) Albumin (gm/dl)

PT (sec

prolonged)

Hepaticencephalopathy

1None

< 2 > 3.5 < 4 None

2Mild

2 - 3 2.8 - 3.5 4 - 6 1 - 2

3Severe

> 3 < 2.8 > 6 3 - 4

A 5 – 6 Life expectancy: 15 to 20 years, abdominal surgery peri-operative mortality: 10% B 7 – 9 Indicated for liver transplantation evaluation, abdominal surgery peri-operative mortality: 30% C > 9 Life expectancy: 1 to 3 years, abdominal surgery peri-operative mortality: 82%  

Management of variceal bleedings

Acute: Octreotide, endoscopic ligation, sclerotherapy, balloon tamponade, TIPS

Portosystemic shunts• Nonselective shunts: more encephalopathy End-to-side portacaval: all portal flow diverted into systemic circulation, ascites persistsSide-to-side portacaval, interposition (16 mm), splenorenal: better at controlling ascites b/c splanchnic venous and intrahepatic sinusoidal drainage still open • SelectiveDistal splenorenal shunt: Distal splenic vein to left renal vein, ligate collateral veins, can worsen ascites• Partial shunts Meso/Portacaval interposition with small-diameter (8 mm) graft, maintains hepatic portal perfusion