LANGE small and large intestine

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

(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.

A 25-year-old man has recurrent, indolent fistula in anus. 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)

(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.

Management, following rehydration and electrolyte 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) 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 conservative 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.

Why is distal resection, as compared to proximal 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.

(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.

A patients CT scan reveals diverticulitis confined to the sigmoid colon. There is no associated pericolic 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

(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.

A 38-year-old male is admitted to hospital with symptoms suggestive of small-bowel obstruction. 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.

(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 of operation. The fistulas occurring after resection of the bowel in Crohn's disease are less likely to heal without surgical intervention. The small intestine is the most common site of intestinal fistula formation.

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

(B) In patients presenting with small-bowel obstruction, clinical examination can usually identify a groin swelling attributable to strangulated hernia. If external groin hernia is excluded, the presence of an abdominal scar would highly suggest that intestinal obstruction 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.

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

(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.

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 sigmoid 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

(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.

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 D) Ileostomy (E) Rigid sigmoidoscopy

(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.

A 25-year-old male develops diarrhea and colicky abdominal pain. Ulcertive colitus is diagnosed on colonoscopy. Which of the following findings is consistent with the diagnosis? (A) The rectum is not involved. (B) The disease is confluent, there are no skip areas in the colon and the rectum is involved. (C) The full thickness of the bowel wall is involved. (D) Microscopic examination of the mucosa reveals normal cells without evidence of dysplasia. (E) The incidence of colorectal cancer is equal to that of the general population.

(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.

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. The diagnosis is more likely to be Crohn's disease 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

(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 frequently 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.

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

(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.

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

(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 mesenteric papaverine administration may be adequate, and surgical intervention may be avoided. Von Willebrand's disease is characterized by a mild to moderate fall in factor VIII levels (pseudohemophilia) but with a much milder bleeding tendency than in true hemophilia. It affects males and females equally.

A 17-year-old female model presents to the emergency 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 laparoscopic appendectomy is offered. 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.

(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 similar. Wound complication and overall complication rates are the same. Procedure cost are higher owing to the use of additional equipment.

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 measures 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

(C) Intestinal obstruction due to a Meckel's diverticulum may result from a volvulus, band obstruction, or intussusception. Among children, bleeding and inflammation are seen more frequently. Meckel's diverticulum is a remnant of the vitellointestinal duct.

A 44-year-old man is stabbed in the abdomen. The injury penetrates the root of the small-bowel mesentery. At laparotomy, resection of 2 cm of ileum is removed. 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

(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 resection. Over a longer period of time (2-3 years), megaloblastic anemia occurs.

83-year-old man is diagnosed on colonscopy to have cancer of the colon. He refuses surgical intervention and after a 3-month follow- up period is admitted to the emergency department 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

(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%.

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 (B) There was evidence of fistula formation (C) The serosa appeared normal on inspection, but the colon mucosa was extensively involved (D) Skip lesions were noted (E) The preoperative GI series showed a narrowing string like stricture in the ileum (string sign)

(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 proximal 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 ulcerative colitis, but a "backwash" ileitis may be encountered.

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

(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.

A 64-year-old woman is admitted to the hospital with abdominal pain, vomiting, and abdominal distention. Bowel sounds are increased on auscultation, and a plain film shows marked distention of loops of bowel with nonspecific pattern. The most likely diagnosis is which of the following? (A) Sigmoid volvulus (B) Cecal volvulus (C) Jejunal obstruction (D) Ileal obstruction (E) Pyloric obstruction

(D) A plain film of the abdomen shows valvulae conniventes in jejunal (proximal) obstruction, a featureless bowel pattern in distal ileal obstruction, and haustra in colon obstruction.

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. 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

(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.

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

(D) In a Richter hernia, only part of the circumference 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.

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

(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.

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

(D) The man likely has diverticulitis. The differential includes irritable bowel, appendicitis, inflammatory bowel disease, pyelonephritis, 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.

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 secondary 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.

(E) Primary small-bowel volvulus is common in countries where the diet is high in bulk. Except for the neonatal variety (associated with malrotation), 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 resection is required, it is usually of a limited nature

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 but was never hospitalized. Examination reveals a pale but alert individual with no significant abdominal findings. Findings on rectal examination are positive for bright red rectal bleeding. Her vital signs are stable and her hemoglobin is 9.5 g. 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

(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.

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

(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.