Preguntas y Respuestas 7

Ciruga General

A 23-year-old man is admitted to the hospital through the emergency

department with probable appendicitis. He has been having right lower
quadrant abdominal pain for several days, which has been becoming
increasingly worse. His temperature 39.2 C (102.6 F), blood pressure is
80/40 mm Hg, pulse is 120/min, and respirations are 35/min. The abdomen
is rigid with guarding. Multiple petechiae and purpura are present, and the
patient is oozing blood from his oral mucosa. According to the patient's
wife, he has not had bleeding problems in the past.

Question 1 of 5. The fact the abdomen is rigid with guarding suggests

which of the following?

/ A. Colon cancer

/ B. Diverticulitis

/ C. Liver failure

/ D. Peritonitis

/ E. Shock

The correct answer is D. The usual reason for a

patient to have a rigid abdomen is that peritonitis is
present, and is causing severe pain related to peritoneal
nerve fiber stimulation. The probable cause of the
peritonitis is a ruptured appendix. This patient is also
probably in shock (choice E), as indicated by the
hypotension with increased respirations and heart rate,
but this would not cause the abdominal guarding. The
other answers are distracters.

Question 2 of 5. Given this patient's presentation,

which of the following is the most likely cause of his
petechiae, purpura, and mucosal blood oozing?

A. Disseminated intravascular coagulation

B. Hemophilia A

/ C. Idiopathic thrombocytopenic purpura

/ D. Von Willebrand disease

/ E. Wiskott-AIdrich syndrome

The correct answer is A. You should suspect disseminated

intravascular coagulation (DIC) in patients who are seriously
ill with other disease who then develop evidence of a
coagulopathy. In this case, sepsis is the probable inciting event.

DIC is thought to occur in 30-50% of patients with sepsis, and

may, in many cases, be triggered by a reaction to gramnegative or staphylococcal cell wall material. Other
settings in which DIC can be a complication include major
trauma, obstetric complications, acute myelocytic leukemias,
disseminated carcinomas, burns, massive transfusions, acute
hepatic failure, myocardial infarction, and inflammatory
conditions (e.g., ulcerative colitis, rheumatoid arthritis, Crohn
disease, sarcoidosis).

Question 3 of 5. Which of the following findings on screening

laboratory tests would be most consistent with the probable diagnosis?

/ A. Decreased platelet count, increased prothrombin time, increased

activated partial thromboplastin time

/ B. Increased platelet count, increased prothrombin time, normal

activated partial thromboplastin time

/ C. Increased platelet count, normal prothrombin time, increased

activated partial thromboplastin time

/ D. Normal platelet count, increased prothrombin time, increased

activated partial thromboplastin time

/ E. Normal platelet count, normal prothrombin time, normal activated

partial thromboplastin time

The correct answer is A. Platelet count is

invariably decreased (and usually obvious on
peripheral smear) in DIC, and this is one of the more
reliable screening tests for the condition (although it
does not exclude many other diagnoses). Both
prothrombin time and activated partial thromboplastin
times are often prolonged, but you should be aware that
they might each be shortened or normal as well in DIC.
Thus, these two commonly performed tests are actually
not as useful as they might appear. The other choices
listed are wrong because the platelet counts are not
decreased.

Question 4 of 5. For confirmation of the probable

diagnosis, the emergency department physician orders a
D-dimer test. D-dimer is which of the following?

/ A. A clotting factor in the common coagulation pathway

/ B. A clotting factor in the extrinsic coagulation pathway

/ C. A clotting factor in the intrinsic coagulation pathway

/ D. A factor found in the complement pathway

/ E. A fibrin degradation product

The correct answer is E. One of the more available and

useful of these tests is the D-dimer tests, which measures
a fibrin degradation product that is made when a
cross-linked clot (indicating the presence of thrombin to
form the clots) is lysed by plasmin. One way to
understand disseminated intravascular coagulation is to
think of it as primarily a thrombotic problem, with
excessive clot formation and then lysis, which leads
secondarily to a hemorrhagic problem as platelets and
clotting factors are consumed. High D-dimer levels
indicate that clots are forming and then lysing at an
unusual rate in the body, and thus, together with a low
platelet count, suggest that DIC is present.

Question 5 of 5. Which of the following would be most

effective in diminishing the rate at which clot formation
is occurring?

/ A. Aminocaproic acid

/ B. Heparin

/ C. PIatelet transfusion

/ D. Red cell transfusion

/ E. Tranexamic acid

The correct answer is B. The patients are often

already critically ill, and the DIC they have developed
often contributes to major organ failure. The basic
problem in therapy is how to treat simultaneous
bleeding and clotting tendencies. Paradoxically, while
the bleeding tendency may be appearing to dominate
the clinical picture, treatment with the anticoagulant
heparin may actually help the patient by decreasing
the rate at which the clotting factors are being
consumed. This must, of course, be done very carefully,
since an "overshoot" may exacerbate the patient's
problems.

A 25-year-old woman consults a physician because she has developed

severe dysphagia and constipation that has led to a recent weight loss
of 15 pounds. She is referred to a gastroenterologist, to whom she
reports that she has a great deal of trouble swallowing solid foods, but
not Iiquids, and has also been having nearly constant gastroesophageal
reflux symptoms. She has awakened during the night several times
coughing and feeling as if she had aspirated acid stomach contents.
Esophagogastroduodenoscopy and colonoscopy are performed, and
demonstrate massive dilatation of the esophagus and colon.

Question 1 of 5. Which of the following parasitic diseases would most

likely produce megaesophagus and megacolon?

/ A. Chagas disease

/ B. Cysticercosis

/ C. Hydatid disease

/ D. Malaria

/ E. Threadworm infection

The correct answer is A. Megaesophagus and

megacolon are unusual pathologic changes, and should
bring Chagas disease to mind, which is also known as
American trypanosomiasis. Megacolon, but not
megaesophagus, can also be due to Hirschsprung
disease, but this is usually diagnosed in infants and
young children and is due to abnormal neural
development in the gut.

Question 2 of 5. The infecting species is which of the

following?

/ A. FIuke

/ B. Nematode

/ C. PIasmodia

/ D. Tapeworm

/ E. Trypanosome

The correct answer is E. Chagas disease is caused by

infection with Trypanosoma cruzi, which is an
intracellular protozoan parasite that takes a leishmanial
form within muscle cells.

Question 3 of 5. On further questioning, the woman reports

having lived for a year in Bolivia as a teenager. At one point, she
had had an automobile accident and had been transfused with
blood at a local hospital there. The person whose blood she
received had probably acquired the infection via a bite by which
of the following?

/ A. FIea

/ B. Mosquito

/ C. Reduviid bug

/ D. Tick

/ E. Tsetse fly

The correct answer is C. Reduviid bugs are insects that live in

poorly constructed adobe housing and feed on human or animal
blood. Trypanosomes they ingest during their feedings multiply in
the insect gut and are deposited in fecal material near the wound
when the insect bites another individual. Contamination through
the wound leads to invasion into, and reproduction within, host
cells. Release of the trypanosomes back into the blood stream
makes them available for transmission either via another bug bite
or via blood transfusion. While Chagas disease can persist for
decades, the period in which significant numbers of parasites are in
the blood is usually only during the comparatively short (and often
asymptomatic) acute phase of the illness.

Question 4 of 5. While this woman's gastrointestinal

tract disease brought her to medical attention,
involvement of which of the following is the principal
source of morbidity and mortality in this condition?

/ A. Heart

/ B. Kidneys

/ C. Liver

/ D. Lungs

/ E. Pancreas

The correct answer is A. Chagas disease is conventionally

divided into three stages. The short acute period may be
asymptomatic or may be characterized by fever, swelling of lymph
glands, hepatosplenomegaly, and local inflammation at the site of
the bite. This is followed by an asymptomatic period, which may
last years to the rest of the patient's life. In one-third of patients,
clinically evident disease becomes apparent 10-20 years after
infection. 27% of infected patients develop cardiac symptoms
(which may cause flaccid cardiomyopathy, cardiac aneurysm
formation, or sudden death); 6% develop digestive system
damage with megaviscera (thought to be related to neural
involvement rather than muscle involvement); and 3% develop
neural involvement. You should also be aware that coexisting AIDS
infection may predispose for an unusually rapid and severe course
of Chagas disease.

Question 5 of 5. While no drug therapy is useful in the

therapy of chronic cases, treatment can be used in newly
diagnosed acute cases. Which of the following medications
would be most useful in treating the acute infection?

/ A. Chloroquine

/ B. Doxycycline

/ C. Nifurtimox

/ D. Primaquine

/ E. Pyrimethamine-sulfadoxine

The correct answer is C. The diagnosis in suspected

acute cases can be established with review of thin or
thick blood smears. (The diagnosis in latent and chronic
cases usually requires special blood culture techniques
or PCR-amplified detection of parasite DNA in blood.)
The only effective drugs are nifurtimox and
benznidazole, which are given in courses up to 4
months because the organisms are difficult to eradicate.
The other choices listed are drugs used in malaria
prophylaxis or treatment.

A 65-year-old man presents to his physician because he has been having

increasing difficulty swallowing over the past 2 months. He is still able to swallow
liquids, but swallowing solid food now causes severe pain and a sense of fullness
behind his sternum. He has lost 18 pounds since his swallowing difficulties began.
The patient is referred to a gastroenterologist, who demonstrates a mass lesion of
the distal esophagus, which on biopsy is shown to contain cancer.

Question 1 of 6. Which of the following is most important in separating the

esophagus from the larynx, and must consequently be carefully passed behind
during endoscopy?

/ A. Arytenoids

/ B. Cricoid cartilage

/ C. Epiglottis

/ D. Pharynx

/ E. Vocal cords

The correct answer is C. Endoscopists are very

careful when guiding the endoscope past the
epiglottis, which is a pear-shaped portion of elastic
cartilage that can be moved during swallowing to close
the larynx, preventing swallowed material from
eventually entering the lungs.

Question 2 of 6. Which of the following nerves

provides the efferent impulses necessary for the
esophageal actions that occur during swallowing?

/ A. GIossopharyngeal

/ B. Hypoglossal

/ C. Spinal accessory

/ D. Trigeminal

/ E. Vagus

The correct answer is E. The vagus nerve supplies

the efferent input into the esophagus that is necessary
for swallowing.

Question 3 of 6. Which of the following approximately

represents the proportion of different esophageal cancer
types now being observed in the United States?

/ A. 1/10 adenocarcinoma and 9/10 squamous cell

carcinoma

/ B. 1/3 adenocarcinoma and 2/3 squamous cell carcinoma

/ C. 1/2 adenocarcinoma and 1/2 squamous cell carcinoma

/ D. 2/3 adenocarcinoma and 1/3 squamous cell carcinoma

/ E. 9/10 adenocarcinoma and 1/10 squamous cell

carcinoma

The correct answer is C. More recent statistics

indicate that the incidence of adenocarcinoma and
squamous cell carcinoma of the esophagus are now
roughly equal. Formerly, approximately 2/3 of the
esophageal cancers were squamous in origin (choice
B). Adenocarcinoma of the esophagus is often found in
the distal esophagus.

Question 4 of 6. Precancerous metaplasia of the

esophageal epithelium gives rise to a mucosa
resembling which of the following?

/ A. Mesothelium

/ B. Respiratory epithelium

/ C. Small intestine

/ D. Squamous epithelium

/ E. Stomach

The correct answer is C. This is an indirect question

about Barrett's esophagus, which is an important
precursor of adenocarcinoma of the esophagus. While
Barrett's esophagus was initially defined to be either
gastric-type or intestinal-type metaplasia of the
esophagus, more recent studies have shown that the
actual problem lesion is more likely to be intestinal
metaplasia (diagnosed when isolated goblet cells are
seen in the epithelium) rather than gastric metaplasia
(choice E).

Question 5 of 6. Frequent use of which of the following

has recently been found to probably have a protective
effect against development of esophageal cancer?

/ A. Acetaminophen

/ B. AIcohol

/ C. Aspirin

/ D. Cigarettes

/ E. Codeine

The correct answer is C. An interesting new research

observation that may be exploited in the future is that
the incidence of esophageal cancer appears to be much
lower in people who use aspirin frequently.

Question 6 of 6. Currently, esophageal cancer has

which of the following long-term survival rates?

/ A. Less than 5%

/ B. 30%

/ C. 50%

/ D. 70%

/ E. More than 95%

The correct answer is A. Esophageal cancer is one of

the very bad cancers, presently with poor long-term
survival. The underlying problem is that the esophagus
is only about 3 mm thick, and both metastatic disease
and direct spread (often unresectable) to mediastinal
structures is common. Active research is presently being
undertaken to modify this prognosis by using
chemotherapy and radiation therapy prior to surgery,
but these modalities have not yet come into widespread
use.