View Answer

D

39. Ten days into his course of pancreatitis, this patient is found to have a fluid collection measuring 4 cm in diameter near the tail of his pancreas. He had a recurrence of his abdominal pain when he was restarted on a diet 2 days prior but is otherwise asymptomatic. He remains on total parenteral nutrition. Appropriate management of this collection would include which of the following?

A CT-guided aspiration to assess for infection

B Endoscopic drainage via an ultrasound-guided cystogastrostomy

C Operative debridement and external drainage

D CT-guided percutaneous drainage

E Observation alone

View Answer

E

40. A 59-year-old patient undergoes exploration for a 4-cm mass in the head of the pancreas that has caused obstructive jaundice. The patient had a biliary stent endoscopically placed prior to the procedure with complete resolution of jaundice. At the time of surgery, two small liver metastases are noted. Which of the following is not part of appropriate management at this point?

A Transduodenal pancreatic biopsy

B Hepaticojejunostomy

C Gastrojejunostomy

D Cholecystectomy

E Celiac ganglion nerve block

View Answer

A

41. A 65-year-old patient presents with a history significant for obstructive jaundice and weight loss. A workup reveals a 2.5-cm mass in the head of the pancreas; needle aspiration reveals adenocarcinoma. Which of the following findings on preoperative CT scan would preclude operative exploration for curative resection?

A Presence of replaced right hepatic artery

B Loss of fat plane between tumor and portal vein

C Loss of fat plane between tumor and superior mesenteric artery

D Occlusion of gastroduodenal artery

E Occlusion of superior mesenteric vein

View Answer

E

Directions: The group of items in this section consists of lettered options followed by a set of numbered items. For each item, select the lettered option(s) that is(are) most closely associated with it. Each lettered option may be selected once, more than once, or not at all.

Match the portion of the stomach, duodenum, or pancreas to the appropriate arterial supply.

42. Body and tail of pancreas

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

C

43. Duodenum and head of pancreas

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

E

44. Proximal lesser curvature of stomach

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

A

45. Distal greater curvature of stomach

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

B

46. Fundus of stomach

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

D

P.303

Answers and Explanations

• 1. The answer is B (Chapter 9, I C 6 b). The iliopsoas sign is pain in the lower abdomen and psoas region that is elicited when the thigh is flexed against resistance. It suggests an inflammatory process, such as appendicitis. Crepitus suggests a rapidly spreading gas-forming infection. Murphy sign is elicited by palpating the right upper quadrant during inspiration and suggests acute cholecystitis. Flank and periumbilical ecchymoses suggest retroperitoneal hemorrhage.

• 2. The answer is D (Chapter 9, IV C 2 b (1)). The most likely cause of massive lower gastrointestinal bleeding in the absence of diverticula is an angiodysplastic lesion of the colon, particularly the right colon. An upper gastrointestinal series and small bowel studies should be done only after an exhaustive colonic workup has failed to demonstrate the source of bleeding. Colonoscopy in the face of massive bleeding is unreliable and difficult and carries the risk of colonic perforation. In addition, it will not usually demonstrate an angiodysplastic lesion. A repeat barium enema is also unlikely to help. The most helpful study in this patient would be selective mesenteric angiography.

• 3. The answer is C (Chapter 9, I C 3 d (5)). The history described would be more typical for either testicular torsion or acute epididymitis, of which only torsion represents a surgical emergency. Torsion of the testicle is likely the result of an abnormal attachment of the tunica vaginalis around the cord that allows the testis to twist (bell-clapper deformity). Compromise of the blood supply causes exquisite pain and produces gangrene and atrophy of the testis unless the torsion is treated immediately. Torsion is usually seen in young males, most often occurring spontaneously and even during sleep. It is associated with an onset of severe pain and is accompanied by nausea, vomiting, and abdominal pain. Acute prostatitis may present with vague abdominal pain. A more typical presentation for appendicitis would be pain preceded by nausea or anorexia. This presentation is not typical for gastroenteritis (which is not a surgical emergency).

• 4. The answer is B (Chapter 10, II B). This patient is presenting with classic symptoms of achalasia. The dysphagia to both solids and liquids is classic, as is the bird-beak narrowing on radiographs. The underlying defect is failure of the lower esophageal sphincter to relax, causing increased pressure in the esophagus and dysfunctional swallowing. Disorganized, strong nonperistaltic contractions in the esophagus are characteristic of diffuse esophageal spasm. Strictures typically have dyspahgia to solids well before liquids cause symptoms.

• 5. The answer is B (Chapter 9, Table 9-1). Massive upper gastrointestinal bleeding is usually due to a bleeding source proximal to the ligament of Treitz. The cause is most likely to be a posterior duodenal ulcer that is eroding into the gastroduodenal artery. Gastritis, esophagitis, a Mallory-Weiss tear, and esophageal varices are less likely causes of massive upper gastrointestinal bleeding.

• 6. The answer is C (Chapter 9, IV B, C). Arteriography is most often used as the initial evaluation step for continued bleeding after anorectal bleeding sources have been eliminated by endoscopy. Arteriography allows identification of diverticular bleeding as well as an angiodysplastic lesion of the right colon. Surgery is generally not indicated until four to six units of blood have been shed. Coagulation products are of no use unless the patient has abnormal clotting studies. Saline lavage of the colon is not a routine procedure.

• 7. The answer are 7-C (Chapter 9, III E 1). Upper endoscopy is the most reliable method for precisely locating the site of upper gastrointestinal bleeding. Endoscopy can almost always be used unless bleeding is massive. Patients who are unstable or have blood losses requiring more than six units of blood within a 24-hour period require surgical intervention. Unstable patients should not typically be transported to interventional radiology. A Blakemore tube is only useful for bleeding esophageal varices. This patient, who does not have a history indicative of cirrhosis, is unlikely to have bleeding from varicies.

• 8. The answer are 8-d (Chapter 11, IV B). Upper endoscopy is the most reliable method for precisely locating the site of upper gastrointestinal bleeding. Endoscopy can almost always be used unless bleeding is massive. Patients who are unstable or have blood losses requiring more than six units of blood within a 24-hour period require surgical intervention. Unstable patients should not typically be transported to interventional radiology. A Blakemore tube is only useful for bleeding esophageal varices. This patient, who does not have a history indicative of cirrhosis, is unlikely to have bleeding from varicies.

• 9. The answer is C (Chapter 9, II A 3 a). Obstructing adhesive bands after abdominal surgery are the most common cause of intestinal obstruction. They may be diffuse or solitary. A partial small bowel obstruction often responds to conservative management with nasogastric decompression and hydration. Complete small bowel obstruction typically requires operative intervention.

• 10. The answer is E (Chapter 9, I F 1 c [1]). Free air within the peritoneal cavity signals perforation of a hollow viscus. It is present in about 80% of gastroduodenal perforations. Because free peritoneal air is rarely secondary to other causes, additional studies in this patient would not be necessary before laparotomy.

• 11. The answer is C (Chapter 10, II A 3–4). This patient's symptoms are consistent with a Zenker's diverticulum. A barium swallow would be diagnostic but not therapeutic. Endoscopy is contraindicated secondary to the risk of diverticular perforation by the endoscope. Surgical myotomy of the cricopharyengeous muscle with resection or suspension of the diverticulum is the treatment of choice. Computed tomography (CT) scan of the chest is not necessary. Changing the diet would not alter the underlying pathology.

• 12. The answer is A (Chapter 10, II D 4). Development of esophageal strictures is an indication for surgical antireflux procedures. Uncomplicated Barrett's esophagus is a controversial indication for an antireflux procedure, as available studies do not agree as to whether or not surgery reverses the mucosal changes associated with Barrett's esophagus. Confirmed severe dysplasia is an indication for esophagectomy, not antireflux surgery. Gastroesophageal reflux is associated with a lower esophageal sphincter pressure. Esophageal dysmotility is a contraindication to reflux surgery. Esophagitis should heal with appropriate medical management.

• 13. The answer is B (Chapter 10, V A, V B, V C). This patient's history, physical examination, and diagnostic studies are consistent with an acute esophageal perforation, and the situation represents a surgical emergency. Whenever possible, primary surgical repair is indicated regardless of the time since perforation. If sepsis and regional inflammation preclude primary repair, resection with cervical esophagostomy and gastrostomy and jejunostomy tube insertion should be performed. Restoration of alimentary continuity with stomach or colon can then be performed in 2–3 months.

• 14. The answers are 14-C (Chapter 11, IV A 4–5). Benign gastric ulcers should heal in 8–12 weeks with maximal medical therapy. If the ulcer does not heal completely during this time period, repeat endoscopy should be performed with biopsy. If gastric adenocarcinoma is diagnosed in this location, the optimal surgical therapy for this condition would be a distal gastrectomy with D1 (regional) lymph node dissection. More extensive surgery, such as total gastrectomy or splenectomy, would be reserved for more proximal gastric lesions. Neither radiation therapy followed by chemotherapy alone without surgery or limited surgery followed by radiotherapy is a treatment plan with curative intent.

• 15. The answers are 15-B (Chapter 11, V C 2 h [1] [c]). Benign gastric ulcers should heal in 8–12 weeks with maximal medical therapy. If the ulcer does not heal completely during this time period, repeat endoscopy should be performed with biopsy. If gastric adenocarcinoma is diagnosed in this location, the optimal surgical therapy for this condition would be a distal gastrectomy with D1 (regional) lymph node dissection. More extensive surgery, such as total gastrectomy or splenectomy, would be reserved for more proximal gastric lesions. Neither radiation therapy followed by chemotherapy alone without surgery or limited surgery followed by radiotherapy is a treatment plan with curative intent.

• 16. The answer is B (Chapter 11, IV B 5 c). Parietal cell vagotomy, also termed highly selective vagotomy, maintains the nerves of Laterjet that innervate the pylorus. By dividing only the branches that innervate the parietal cells, pyloric function is preserved and outflow of the stomach is maintained. It is a technically demanding operation, in that failure to adequately sever the appropriate nerves will result in recurrences of more than 10%. However, parietal cell vagotomy can be performed for bleeding or perforated ulcers.

• 17. The answer is B (Chapter 11, I B 5). The vagal nerves are one of the principal stimulants of gastric acid secretion through direct stimulation of the parietal cells and via gastrin release from antral cells. Although the splanchnic and celiac ganglions are important in gastric motility and sensation, they do not stimulate acid secretion. The T4 root and phrenic nerve are not involved in gastric nervous supply.

• 18. The answer is C (Chapter 12, I B 2). Both parathormone and vitamin D increase intestinal absorption of dietary calcium. Bile salts are essential for absorption of fats and fat-soluble vitamins. Vitamin B₁₂ is a water-soluble vitamin that complexes with intrinsic factor, which is a protein produced by the

stomach, and the protein–vitamin B₁₂ complex is absorbed in the terminal ileum. The range of iron absorption is only 10%–26% of dietary iron. Triglycerides are not absorbed intact but must first be broken down into free fatty acids and monoglycerides. Once absorbed, they are resynthesized into triglycerides, but they are not released into the portal circulation. Rather, the triglycerides are packaged as chylomicrons and released into the lymphatic circulation.

• 19. The answer is E (Chapter 12, II B). The diagnosis of Crohn's disease is supported by the enterovesical fistula, the presence of “fat wrapping” of the bowel, inflammation, and the clinical history. To prevent ongoing contamination of the urinary tract, the fistula must be closed, and resection of the involved segment of bowel would be the standard approach. Regarding the extent of resection, the 50% risk of recurrence is not decreased by more extensive resections, thus the less bowel removed the better. In this case, with three widely separated segments of ileum involved, removal of all involved bowel could result in loss of more than half of the ileum and would not be advisable. Crohn's disease does not directly involve the bladder and thus resection of the bladder wall is unnecessary except when needed to close the opening of the fistula. Meckel's diverticulum occurs proximal to the terminal ileum; it would not affect multiple bowel segments and does not cause “fat wrapping.”

• 20. The answer is B (Chapter 12, II B). This patient presents with recurrent Crohn's disease in the form of an obstruction from stricture, which is the most common manifestation that requires surgery. After surgery, the risk of recurrent manifestations of Crohn's disease requiring reoperation is 50%, and the risk remains 50% after each surgical procedure. Strictures, unlike fistulas and perforations, can be treated via bypass of the involved segment of bowel, although resection is preferred except when the risk is too great. The risk of cancer is related to the chronicity of the disease and would almost never require extensive small bowel resection, which may leave the patient with short bowel syndrome (a difficult disorder to treat in this population). Postoperative anastomotic strictures cause symptoms very early postoperatively, not years later. If this patient had previously had a resection of the terminal ileum, he would develop a deficiency of vitamin B₁₂, not folate.

• 21–23. The answers are 21-E (Chapter 12, II B 5), 22-D (Chapter 12, II B 3, 5), 23-C (Chapter 12, I B 2 f–g; II B 4–6). When surgery is necessary to treat complications of Crohn's disease, the operations are “conservative,” as defined by the length of the resection. Therefore, when an obstructive lesion is present, only a short length of bowel needs to be resected. In the case described, the distal ileum and cecum should be removed. Radical resections are not necessary, as they do not reduce the risk of recurrence and may ultimately contribute to short bowel syndrome if several resections are required over long periods. In addition, resection of mesentery and lymph nodes (e.g., for a cancer operation) is unnecessary. Bypass procedures without resection are reserved for only the most difficult cases where resection cannot be undertaken safely. A stricturoplasty is appropriate occasionally for short symptomatic strictures in the small bowel only.

The second postoperative week is the usual time for the development of serious complications, such as abdominal wound dehiscence, intestinal anastomotic breakdown, and intraperitoneal abscess. Blind loop syndrome occurs rarely; and although it does cause pain and diarrhea, it does not cause fever and ileus. Pyelonephritis usually causes flank pain and pyuria. Crohn's disease does not recur immediately or cause the signs unless complications have occurred. Pseudomembranous enterocolitis causes tenderness over the transverse colon and occasionally over the descending colon, with diarrhea. Of the choices listed, an intra-abdominal abscess is the most likely diagnosis.

The prognosis of Crohn's disease, which requires surgery, is not good because 50% of patients require additional surgical procedures within 5 years of the first operation. Therefore, the chance of cure is less than 50%. Medical therapy (including anti-inflammatory agents and antibiotic drugs) has not proved effective for preventing recurrence of the disease. Removal of the terminal ileum has no effect on disease recurrence or iron absorption; however, the absorption of vitamin B₁₂ is significantly impaired.

• 24–25. The answers are 24-C (Chapter 13, VIII A 6; XIV B 3), 25-C (Chapter 13, XV A 3 a). Flat plate and erect radiographs of the abdomen should be performed first. Further studies may be needed based on the results of this initial survey. As with all bowel obstructions, the initial treatment involves nasogastric suction, intravenous fluids, and resuscitation with careful attention to correcting metabolic and

electrolyte abnormalities. Once a patient has been adequately resuscitated, the decision to either observe carefully or intervene operatively can be made.

• 26–27. The answers are 26-D (Chapter 13, VIII C 1), 27-A (Chapter 13, VIII D 2). Crampy abdominal pain and diarrhea after a course of antibiotic therapy is highly suggestive of antibiotic-associated or pseudomembranous colitis. Diagnosis can be made either by proctoscopy, which demonstrates pseudomembranes, or by stool titer for Clostridium difficile toxin. Proctoscopy establishes the diagnosis immediately. Barium enema is contraindicated. The antibiotics should be stopped, and the patient should be started on metronidazole. Oral vancomycin is also effective, but it is more expensive. Colectomy is rarely required only in severe cases.

• 28. The answer is A (Chapter 12, II C). Meckel's diverticulum is the most common diverticulum of the gastrointestinal tract and goes by the rule of 2's: 2 ft from ileocecal valce, 2% incidence, 2 cm long, 2:1 male to female ratio. They can cause bleeding due to heterotropic gastric mucosa as well as intussusception and obstruction. An asymptomatic Meckel's diverticulum should not be resected.

• 29. The answer is C (Chapter 13, IV D 5 a–b). CT scan of the abdomen and pelvis is the most helpful test to confirm the suspected diagnosis of diverticulitis. Free air is detected on the chest radiograph in less than 3% of patients with diverticulitis. Contrast enema should generally be avoided in the initial stages of diverticulitis. Colonoscopy to exclude a sigmoid cancer may be of value after the condition of the patient has stabilized.

• 30. The answer is C (Chapter 13, XII C 1 f (1)). This patient presents with a classic history and physical findings of perirectal abscess. Antibiotic therapy will not cure an abscess. Definitive drainage is required. This therapy will be curative in approximately 50% of the patients, and the remainder will develop a fistula. However, the physician should deal with the abscess itself at the initial presentation. Attempts to definitely address any fistula tract at initial presentation is not recommended due to potential complications such as injury to the sphincter muscles and difficulties with continence.

• 31–32. The answers are 31-D (Chapter 14, I C 2 a, d), 32-D (Chapter 14, I C 2 a, d). Although many liver tumors undergo spontaneous hemorrhage, this condition occurs most frequently with hepatic cell adenomas. Up to 30% of patients present with spontaneous rupture into the peritoneal cavity as their initial finding.

The patient continues to bleed. Emergency liver resection after an acute rupture would be associated with high morbidity and mortality. While hepatic artery ligation may control the bleeding, this can probably be accomplished less invasively by radiologic embolization. Once the bleeding is controlled and the patient recovers, elective resection should be undertaken to avoid future hemorrhage.

• 33. The answer is E (Chapter 13, V D). Cases of diverticulitis complicated by perforation and abscess formation are best managed by percutaneous drainage in the absence of evidence of diffuse peritonitis. Young patients (typically considered as being less than 50 years of age) with a single severe case such as this should be considered for an interval resection of the diseased section of bowel because of the very high risk of subsequent severe episodes. Older patients are often referred after a second episode. Colonoscopy should not be routinely performed during the acute phase of an episode of diverticulitis but should be performed prior on an interval basis. Operative intervention during the acute phase is reserved for cases that either present with diffuse peritonitis, perforation or continued worsening of the clinical picture in spite of appropriate non-operative therapy. Primary anastomosis is typically avoided in the setting of severe infection and contamination.

• 34–36. The answers are 34-C (Chapter 14, II E 3 a), 35-D (Chapter 14, II B 3), 36-A (Chapter 14, II H 3 a–b, 4). Acute variceal bleeding commonly occurs because of portal hypertension from underlying cirrhosis. Other causes of upper gastrointestinal bleeding that must also be considered in these patients include gastritis and peptic ulcer disease. Upper gastrointestinal endoscopy is the most rapid way of making the diagnosis of the site and identifying the cause of upper gastrointestinal bleeding. Once the diagnosis has been made, sclerotherapy is the preferred method of managing acute variceal bleeding. It is successful in 90% of patients.

Portacaval shunt, mesocaval shunt, sclerotherapy, transjugular intrahepatic portosystemic shunt, and selective Warren shunt for recurrent bleeding would potentially be successful in preventing long-term hemorrhage. However, portacaval shunt would make a subsequent liver transplant extremely difficult and hazardous.

• 37. The answer is D (Chapter 14, III F). Cholangitis is a potentially life-threatening disease. This patient is present with Charcot's triad of pain, fever, and jaundice.

• 38–39. The answers are 38-D (Chapter 15, II C), 39-E (Chapter 15, II C). Uncomplicated acute pancreatitis is best managed conservatively with nasogastric decompression, intravenous hydration, bowel rest, and pain medicine. Imaging with ultrasound, CT scan, magnetic resonance imaging, or magnetic resonance cholangiopancreatography can be useful in establishing a possible etiology (gallstones) or detecting complications. Endoscopic retrograde cholangiopancreatography (ERCP) should not be used routinely during the acute presentation due to the risk of ERCP-associated pancreatitis complicating the acute situation. ERCP should be reserved for specific cases where there is evidence of biliary obstruction. Evaluation of pancreatic duct anatomy can be helpful on an interval basis to help assess causes of chronic or recurrent pancreatitis.

• 40. The answer is A (Chapter 15, III A). When patients are unresectable due to distant metastases at the time of surgery, a surgeon must accomplish several things. A biliary bypass (hepaticojejunostomy) palliates the obstructive jaundice, and a cholecystectomy is performed in conjunction with this. A gastric bypass (gastrojejunostomy) prevents the gastric outlet obstruction observed in 19% of unresected periampullary cancer patients. A celiac axis nerve block has been shown to significantly reduce cancer-related pain. A surgeon must also make a tissue diagnosis, in this case by taking a biopsy of one of the liver metastases. An additional pancreatic biopsy is unnecessary and adds additional risks.

• 41. The answer is E (Chapter 15, III A). Findings that determine unresectability on preoperative CT scan include encasement of the superior mesenteric artery or proximal celiac axis and occlusion of the superiormesenteric vein or portal vein. Tumor abutting these vessels but not encasing or occluding them is not a contraindication to resection. The gastroduodenal artery is ligated during a pancreaticoduodenectomy, thus its occlusion does not preclude resection. A replaced right hepatic artery is not uncommon and must be preserved. This does not, however, preclude resection.

• 42–46. The answers are 42-C, 43-E, 44-A, 45-B, and 46-D (Chapter 11, I B 3; Chapter 11, II B 1). The blood supply of the viscera is important in gastrointestinal surgery. Three of the four main arteries can be sacrificed, and blood flow to the stomach will still be preserved through collateral circulation. The proximal lesser curvature is supplied by the left gastric artery (arising from the celiac axis). The right gastric artery (arising from the common hepatic artery) supplies the distal lesser curvature. The left and right gastroepiploic arteries supply the proximal and distal greater curvature, respectively. The duodenum and head of the pancreas are supplied by the superior and inferior pancreaticoduodenal arteries that arise from the gastroduodenal and superior mesenteric arteries, respectively. The body and tail of the pancreas are supplied by branches of the splenic artery.

Study Questions for Part V(endocrine)

Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.

1. A 40-year-old man has a subtotal thyroidectomy performed for Graves' disease. Several hours later, he complains of difficulty breathing. On examination, he has stridor and a markedly swollen, tense neck wound. What should be one of the first steps in the management of this patient?

A Intubate with an endotracheal tube

B Perform a tracheostomy

C Control the bleeding site in the operating room

D Open the wound to evacuate the hematoma

E Aspirate the hematoma