The Quizzes about Gastrointestinal Bleeding (17 test)

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Gastrointestinal Bleeding

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Question 1

A 51-year-old man is brought to the emergency department (ED) by emergency medical services (EMS) with a blood pressure (BP) of 90/60 mm Hg, heart rate (HR) of 110 beats per minute, respiratory rate (RR) of 18 breaths per minute, and oxygen saturation of 97% on room The patient tells you that he has a history of bleeding ulcers. On examination, his abdomen is tender in the epigastric area. He is guaiac positive, with black stool. He has a bout of hematemesis and you notice that his BP is now 80/50 mm Hg, HR is 114 beats per minute, as he is slowly starting to drift off. Which of the following is the most appropriate next step in therapy?

A	Assess airway, establish two large-bore intravenous (IV) lines, cross-match for two units of blood, administer 1 to 2 L of normal saline, and schedule an emer- gent endoscopy.
B	Assess airway, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor.
C	Place two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy.
D	Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy.
E	Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor.

Question 1 Explanation:

Emergency medicine always starts with an assessment of the patient’s airway. For patients suspected of having a significant GI bleed, two large-bore IV lines need to be established rapidly. Treating an undifferentiated upper GI bleed is like treating a gunshot wound to the abdomen—you should expect the worst. Immediate volume resuscitation should begin with 1 to 2 L of normal saline. If there is no improvement in the BP of a hypotensive patient, blood should be administered. Sending a cross-match early is advisable because it can take up to an hour to retrieve. Use type O, Rh-negative (if female) or type O, Rh-positive (if male) if type-specific blood is not ready. It is crucial to remember that the initial hematocrit of the patient is a poor indicator of the severity of acute bleeding because it takes 24 to 72 hours to equilibrate. (b) A proton pump inhibitor may be administered, but priority is to the airway, breathing, and circulation (ABCs) and this patient is hypotensive. (c) You must assess airway first. (d and e) The patient is maintaining his airway and does not need to be intubated emergently. However, if his BP worsens and he becomes altered or you anticipate his condition to worse, endotracheal intubation is appropriate.

Question 2

A 45-year-old woman presents to the ED with 1 day of painful rectal bleeding. Review of systems is negative for weight loss, abdominal pain, nausea, and On physical examination, you note an exquisitely tender swelling with engorgement and a bluish discoloration distal to the anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg, RR 18 breaths per minute, and temperature 99°F. Which of the following is the next best step in management?

A	Recommend warm sitz baths, topical analgesics, stool softeners, a high-fiber diet, and arrange for surgical follow-up.
B	Incision and drainage under local anesthesia or procedural sedation followed by packing and surgical follow-up.
C	Obtain a complete blood cell (CBC) count, clotting studies, type and cross, and arrange for emergent colonoscopy.
D	Excision under local anesthesia followed by sitz baths and analgesics.
E	Surgical consult for immediate operative management.

Question 2 Explanation:

Hemorrhoids are dilated venules of the hemorrhoidal plexuses. They are associated with constipation, straining, increased abdominal pressure, pregnancy, increased portal pressure, and a low-fiber diet. Hemorrhoids can be either internal or external. Those that arise above the dentate line are internal and painless. Those below the dentate line are external and painful. Individuals commonly present with thrombosed external hemorrhoids. On examination, there is a tender mass at the anal orifice that is typically bluish-purple in color. If pain is severe and the thrombosis is less than 48 hours, the physician should excise the thrombus under local anesthesia followed by a warm sitz baths. This patient is suffering from an acutely thrombosed externalGastrointestinal Bleeding Answers 277 hemorrhoid. If not excised, symptoms will most often resolve within several days when the hemorrhoid ulcerates and leaks the dark accumulated blood. Residual skin tags may persist. Excision provides both immediateand long-term relief and prevents the formation of skin tags. (a) The symptoms of nonthrombosed external and nonprolapsing internal hemorrhoids can be improved by the WASH regimen. Warm water, via sitz baths or by directing a shower stream at the affected area for several minutes, reduces anal pressures; mild oral analgesics relieve pain; stool softeners ease the passage of stool to avoid straining; and a high-fiber diet produces stool that passes more easily. (b) Incision of a hemorrhoid (as opposed to excision) leads to incomplete clot evacuation, subsequent rebleeding, and swelling of lacerated vessels. (c) This patient has a thrombosed external hemorrhoid. The need for further evaluation of the rectal bleeding has not been established. (e) Hemorrhoids rarely require immediate operative management, unless there is evidence of thrombus formation with progression to gangrene.

Question 3

A 20-year-old man presents to the ED with fever and severe right lower quadrant (RLQ) pain for 1 Prior to this episode, he reports 2 months of crampy abdominal pain, generalized malaise, a 10-lb weight loss, and occasional bloody diarrhea. On examination, his HR is 115 beats per minute, BP is 125/70 mm Hg, RR is 18 breaths per minute, and tem- perature is 100.8°F. His only significant past medical history is recurrent perirectal abscesses. On physical examination, the patient appears uncom- fortable and has a tender mass in the RLQ, without guarding or rebound. Rectal examination is positive for trace heme-positive stool. An abdominal computed tomographic (CT) scan reveals no periappendiceal fat stranding. There is inflammation of the distal ileum and several areas of the colon. There are no rectal inflammatory changes. Which of the following is the most likely diagnosis?

A	Crohn disease (CD)
B	Ulcerative colitis (UC)
C	Appendicitis
D	Pseudomembranous enterocolitis
E	Diverticulitis

Question 3 Explanation:

IBD is a chronic inflammatory disease of the GI tract. There are two major types: CD and UC. CD can involve any part of the GI tract, from mouth to anus, and is characterized by segmental involvement. The distal ileum is involved in the majority of cases; therefore, acute presentations can mimic appendicitis. CD spares the rectum in 50% of cases. There is a bimodal age distribution, with the first peak occurring in patients 15 to 22 years of age and a second in patients 55 to 60 years of age. Definitive diagnosis is by upper GI series, air-contrast barium enema, and colonoscopy. Segmental involvement of the colon with rectal sparing is the most characteristic feature. Other findings on colonoscopy include involvement of all bowel wall layers, skip lesions (ie, interspersed normal and diseased bowel), aphthous ulcers, and cobblestone appearance from submucosal thickening interspersed with mucosal ulceration. Extraintestinal manifestations are seen in 25% to 30% of patients with CD. (b) UC primarily involves the mucosa only with formation of crypt abscesses, epithelial necrosis, and mucosal ulceration. Rectal pain and bloody diarrhea are more common in UC than in CD. UC begins in the rectum, and fails to progress beyond this point in one-third of patients. Colonoscopy demonstrates inflammation of the mucosa only and continuous lesions of the GI tract. Although blood loss from sustained bleeding may be the most common complication, toxic megacolon must not be278 Emergency Medicine missed. (c) While appendicitis may be in the differential diagnosis, the acute on chronic nature of this disease and a normal-appearing appendix on abdominal CT rules it out. (d) Pseudomembranous enterocolitis is an inflammatory bowel disorder that results from toxin-producing Clostridium difficile, a spore-forming obligate anaerobic bacillus. The disease typically begins 7 to 10 days after the institution of antibiotic therapy, most often in hospitalized patients. However, incidence in the community is rising. (e) Diverticulitis is an acute inflammatory disease caused by bacterial proliferation within existing colonic diverticula. The most common presentation is pain, often in the left lower quadrant (LLQ). Abdominal CT demonstrates inflammation of pericolic fat, presence of diverticula, bowel wall thickening, or peridiverticular abscess.

Question 4

A 62-year-old man with a history of hypertension presents to the ED with severe constant mid-epigastric pain for the past Over the last sev- eral months, he has had intermittent pain shortly after eating, but never this severe. He states he now has generalized abdominal pain that began suddenly about 15 minutes ago. He has no history of trauma, has never had surgery, and takes no medications. His vitals include HR of 115 beats per minute lying supine, increasing to 135 when sitting up, BP of 170/105 mm Hg supine, falling to 145/85 mm Hg when sitting up. He appears pale. His abdomen is rigid and diffusely tender with guarding and rebound. Bowel sounds are absent and stool hemoccult is positive. The white blood cell (WBC) count is 8500/mL, hemoglobin 8.5 mg/dL, hematocrit 27%, and platelets 255/mL. Which of the following is the most likely diagnosis?

A	Boerhaave syndrome
B	Perforated gastric ulcer
C	Abdominal aortic aneurysm (AAA)
D	Inflammatory bowel disease (IBD)
E	Diverticulosis

Question 4 Explanation:

This patient had an untreated gastric ulcer that just perforated. The history of epigastric pain related to eating points to a gastric ulcer, whereas pain 2 to 3 hours after eating is more likely caused by a duodenal ulcer. The sudden onset of generalized abdominal pain associated with a rigid abdomen is concerning for a perforated viscus, in this case, a perforated gastric ulcer. This is a surgical emergency. An abdominal and upright chest radiograph can be performed quickly to look for free air, which will be seen under the diaphragm on the chest radiograph. This is useful for the majority of perforations, which are anterior, but may miss posterior perforations because the posterior duodenum is retroperitoneal. The treatment includes IV hydration, antibiotics, and immediate surgical correction. (a) Boerhaave syndrome is a full-thickness tear of the left posterolateral aspect of the distal esophagus. It is typically associated with epigastric and retrosternal chest pain that often radiates to the back, neck, left chest, or shoulders. Although it may present similar to a perforated ulcer, in general the pain is more focused in the chest. (c) While the history of untreated hypertension is concerning for a ruptured AAA the history clearly points to previously undiagnosed peptic ulcer disease. (d) IBD is a chronic condition affecting the GI tract. The abdominal pain is usually crampy, while GI bleeding is generally associated with bloody diarrhea. (e) Diverticula are saclike herniations of colonic mucosa that occur at weak points in the bowel wall. They may bleed (diverticulosis) or become filled with fecal matter and lead to inflammation (diverticulitis). Diverticulosis is most commonly associated with substantial painless rectal bleeding but not with significant abdominal pain.

Question 5

A 60-year-old man with a history of alcohol abuse presents to the ED with hematemesis for 1 He denies abdominal or chest pain. On physical examination, his eyes appear reddened which he attributes to hav- ing drunken heavily the night before (he also reveals vomiting several times after this recent binge). Vital signs are HR 115 beats per minute, BP 130/85 mm Hg, RR 18 breaths per minute, and temperature 99.5°F. Chest radio- graph is unremarkable. Laboratory results reveal a WBC 10,000/mL, hemo- globin 14 mg/dL, hematocrit 40%, and platelets 210/mL. Which diagnosis is endoscopic evaluation most likely to confirm?

A	Esophageal varices
B	Boerhaave syndrome
C	Curling ulcer
D	Perforated gastric ulcer
E	Mallory-Weiss tear

Question 5 Explanation:

A Mallory-Weiss tear usually follows a forceful bout of retching and vomiting and involves a 1- to 4-cm area of the mucosa or submucosa of the GI tract; 75% of cases occur in the stomach with the remainder near the gastroesophageal (GE) junction. Bleeding is usually mild and self-limited. However, 3% of deaths from upper GI bleeds result from Mallory-Weiss tears. (a) Esophageal varices are dilated submucosal veins found in 50% of patients with cirrhosis of the liver. They usually develop as a result of portal hypertension. Up to 30% of patients with esophageal varices develop upper GI bleeds, and the bleeding is usually massive. Patients are often asymptomatic until the varices rupture and bleed. Although this patient is certainly predisposed to varices secondary to his ethanol abuse, his acute presentation of pain after vomiting is more consistent with a Mallory-Weiss tear. (b) Boerhaave syndrome involves a spontaneous full thickness perforation of the esophagus—80% involving the posterolateral aspect of the distal esophagus—that usually results from violent retching. Alcohol ingestion is a risk factor. Because the overlying pleura is torn, esophageal contents can spill into the mediastinum and thorax, leading to severe epigastric and retrosternal chest pain, with radiations to the back, neck, or shoulders. Characteristic findings on chest radiograph include a left pneumothorax, a left pleural effusion, mediastinal emphysema, and a widened mediastinum, all of which the individual in the question does not exhibit. Boerhaave syndrome represents a surgical emergency, with mortality approaching 50% if surgery is not performed within 24 hours. (c) A Curling ulcer is an ulcer or erosion caused by stress gastritis because of patients with severe burn injuries. The most common finding is painless GI bleeding. There is no evidence of severe burn injury in this patient. (d) A perforated gastric ulcer is a complication of chronic gastritis, which is usually associated with severe, acute abdominal pain. Perforations occur when an ulcer erodes through the wall and leaks air and digestive contents into the peritoneal cavity. Often, pain initially begins in the epigastrium but becomes generalized shortly thereafter. Patients usually lie still and avoid movement that might disturb the peritoneal cavity. An upright chest radiograph may demonstrate air under the diaphragm.

Question 6

A 50-year-old man is brought to the ED by ambulance with significant hematemesis. In the ambulance, paramedics placed two large-bore IVs and began infusing normal In the ED, his HR is 127 beats per minute, BP is 79/45 mm Hg, temperature is 97.9°F, RR is 24 breaths per minute, and oxygen saturation is 96%. On physical examination, his abdomen is nontender, but you note spider angiomata, palmar erythema, and gyneco- mastia. Laboratory results reveal WBC 9000/mL, hematocrit 28%, platelets 40/mL, aspartate transaminase (AST) 675 U/L, alanine transaminase (ALT) 325 U/L, alkaline phosphatase 95 U/L, total bilirubin 14.4 mg/dL, conju- gated bilirubin 12.9 mg/dL, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen (BUN) 20 mg/dL, creatinine 1.1 mg/dL, and glucose 150 mg/dL. Which of the following is the most likely diagnosis?

A	Perforated gastric ulcer
B	Diverticulosis
C	Splenic laceration
D	Esophageal varices
E	Ruptured AAA

Question 6 Explanation:

Esophageal varices develop in patients with chronic liver disease in response to portal hypertension. Approximately 60% of patients with portal hypertension will develop varices. Of those who develop varices, 25% to 30%280 Emergency Medicine will experience hemorrhage. Patients who develop varices from alcohol abuse have an even higher risk of bleeding, especially with ongoing alcohol consumption. This patient has evidence of chronic liver disease with thrombocytopenia and elevated bilirubin and liver enzymes. In alcoholic hepatitis, the AST is greater than the ALT by a factor of 2. Spider angiomata, palmar erythema, and gynecomastia further suggest underlying liver disease. (a) A perforated gastric ulcer typically presents with severe sudden abdominal pain in a patient with a history of PUD. (b) Diverticulosis results from saclike herniations in the colonic mucosa (diverticula) that occur at weak points in the bowel wall, usually where arteries insert. Diverticulosis is most commonly associated with painless rectal bleeding. (c) Splenic laceration generally results from trauma. (e) The most common symptom with rupture of an AAA is sudden and severe abdominal pain. Back pain, also sudden and severe, is noted by half of patients. Incidence of AAA increases with age in both men and women and is typically associated with a history of hypertension.

Question 7

A 55-year-old man is brought to the ED by his They state that he has been vomiting large amounts of bright red blood. The patient is an alcoholic with cirrhotic liver disease and a history of portal hypertension and esophageal varices. His vitals on arrival are HR 110 beats per minute, BP 80/55 mm Hg, RR 22 breaths per minute, and temperature 99°F. The patient appears pale and is in moderate distress. Which of the following is an inappropriate option in the initial management of a hypotensive patient with a history of known esophageal varices presenting with hematemesis?

A	Sengstaken-Blakemore tube placement
B	Two large-bore IV lines and volume repletion with crystalloid solutions
C	Nasogastric (NG) lavage
D	IV octreotide
E	Gastrointestinal (GI) consult

Question 7 Explanation:

Acute GI bleeding develops in fewer than one-third of patients with portal hypertension and varices. With upper GI bleeds, the initial step is assessment of the hemodynamic status. Hypotension with or without tachycardia identifies a highrisk patient with severe acute bleeding. This patient requires immediate treatment. If initial resuscitative efforts fail or if a patient remains hypotensive, more aggressive measures may be required, including consideration of Sengstaken-Blakemore tube is placed to physically tamponade the bleeding source, but this is not part of the initial management and has been associated with adverse reactions. (b) In patients with significant bleeding, two 18-gauge or larger IV lines should be started prior to further diagnostic tests. Blood is sent for CBC, coagulation studies (prothrombin time [PT] with international normalized ratio [INR]), serum creatinine, liver enzymes, and cross-matching for 2 to 4 units or more of packed red blood cells (RBC). Patients with hemodynamic compromise should be resuscitated with crystalloid solutions and cross-matched blood. Cardiac monitoring and supplemental oxygen should also be instituted. (c) An NG tube should be placed in all patients with suspected upper GI bleeding. The aspiration of red blood or “coffee grounds” confirms an upper GI bleeding source, although 10% of patientsGastrointestinal Bleeding Answers 281 with confirmed upper GI bleeding have nonbloody aspirates, especially when bleeding originates in the duodenum. An aspirate of bright red blood indicates active bleeding and is associated with the highest risk of bleeding and complications. Efforts to control bleeding by gastric lavage with large volumes of fluid are of no benefit and increase the risk of aspiration. (d) Octreotide reduces splanchnic blood flow and portal blood pressures and is effective in the initial control of bleeding related to portal hypertension. It should be administered promptly to all patients with active upper GI bleeding and evidence of liver disease or portal hypertension until the source of bleeding can be clarified by endoscopy. (e) A GI consult should be obtained in all cases of high-risk upper GI bleeds. Most patients with upper GI bleeding should undergo upper endoscopy after the patient is hemodynamically stable. High-risk patients or those with continued active bleeding require more urgent endoscopic evaluation to identify the source of bleeding, determine the risk of rebleeding, and provide hemostasis via sclerotherapy or rubber band ligation.

Question 8

A 70-year-old woman presents to the ED with dark stool for 3 She occasionally notes bright red blood mixed with the stool. Review of sys- tems is positive for decreased appetite, constipation, and a 10-lb weight loss over 2 months. She denies abdominal pain, nausea, vomiting, and fever, but feels increased weakness and fatigue. She also describes a raspy cough with white sputum production over the previous 2 weeks. Examination reveals she is pale, with a supine BP of 115/60 mm Hg and HR of 90 beats per minute. Standing BP is 100/50 mm Hg, with a pulse of 105 beats per minute. Which of the following is the most likely diagnosis?

A	Hemorrhoids
B	Diverticulitis
C	Mallory-Weiss tear
D	Diverticulosis
E	Adenocarcinoma

Question 8 Explanation:

The combination of lower GI bleed with weight loss and decreased appetite points toward carcinoma, most likely adenocarcinoma of the colon. The lack of esophageal, abdominal, or rectal pain makes the other choices unlikely, as does the lack of associated symptoms (nausea, vomiting, or fever). Anemia or rectal bleeding in an elderly person should be assumed to be malignancy until proven otherwise. (a) Bleeding with defecation is the most common complaint with hemorrhoids, and unless the hemorrhoids are thrombosed, the bleeding is usually painless. Patients usually report bright red blood on the toilet paper or in the toilet bowl. Weight loss would not be expected, and only in rare circumstances is the blood loss substantial. (b) Diverticulitis occurs with inflammation of a diverticulum and is the most common complication of diverticulosis. Patients typically present with persistent abdominal pain. Initially, the pain may be vague and generalized, but it often becomes localized to the LLQ. Most patients can be managed medically with bowel rest, hydration, analgesics, and antibiotics. (c) A Mallory-Weiss tear is a partial tear of the esophagus that usually results from significant vomiting or retching. (d) Diverticulosis is the presence of diverticula with massive painless lower GI bleeding. It is one of the most common causes of massive GI bleeding in this population. In most instances, the bleeding stops spontaneously

Question 9

A 76-year-old woman with a history of congestive heart failure, coro- nary artery disease, and an “irregular heart beat” is brought to the ED by her She has been complaining of increasing abdominal pain over the past several days. She denies nausea or vomiting and bowel movements remain unchanged. Vitals are HR of 114 beats per minute, BP 110/75 mm Hg, and temperature 98°F. On cardiac examination, her HR is irregularly irregular with no murmur detected. The abdomen is soft, nontender, and nondis- tended. The stool is heme-positive. This patient is at high risk for which of the following conditions?

A	Perforated gastric ulcer
B	Diverticulitis
C	Acute cholecystitis
D	Mesenteric ischemia
E	Sigmoid volvulus

Question 9 Explanation:

Patients with coronary artery disease, valvular heart disease, and arrhythmias, particularly atrial fibrillation, are at high risk for mesenteric ischemia. In addition, age greater than 50 years, congestive heart failure, recent myocardial infarction, critically ill patients with sepsis or hypotension, use of diuretics or vasoconstrictive medications, and hypercoagulable states place patients at higher risk. The most common cause of acute mesenteric ischemia is arterial embolus, which accounts for 50% of cases. The classic finding is “pain out of proportion to examination findings”; that is, a patient complains of severe pain but is not particularly tender on examination. A high degree of suspicion for mesenteric ischemia in an elderly patient with abdominal pain is warranted. (a) Perforated gastric ulcer presents with acute onset of severe epigastric pain and bleeding, generally in someone with PUD. (b) Diverticulitis presents as LLQ pain that is usually described as dull and constant. (c) Acute cholecystitis occurs with an obstruction of the cystic duct with gallstones and is often accompanied by fever, chills, nausea, and a positive Murphy sign. It is the most common surgical emergency in elderly patients. (e) The classic triad for sigmoid volvulus includes abdominal pain, abdominal distention, and constipation. Nausea and vomiting are often present, and diagnosis can be made on plain radiograph in 80% of cases.

Question 10

A 70-year-old woman with a history of hypertension, congestive heart failure, and atrial fibrillation presents to the ED with several hours of acute onset diffuse abdominal She denies any nausea or vomiting. The pain is constant, but she is unable to localize it. She was diagnosed with a renal artery thrombosis several years ago. Vital signs include HR of 95 beats per minute, BP of 110/70 mm Hg, and temperature of 98°F. Her abdomen is soft and mildly tender, despite her reported severe abdominal pain. Her WBC count is 12,000/mL, hematocrit 38%, platelets 250/mL, and lactate 8 mg/dL. The stool is traced heme-positive. You are concerned for acute mesenteric ischemia. What is the best way to diagnose this condition?

A	Serum lactate levels
B	Abdominal radiograph (supine and upright)
C	CT scan
D	Angiography
E	Barium contrast study

Question 10 Explanation:

Angiography remains the “gold standard” in the diagnosis of mesenteric ischemia. Unlike any other diagnostic tools, it is capable of both diagnosing and treating the problem. It is capable of identifying all four types of acute mesenteric ischemia: (1) arterial embolus, (2) arterial thrombosis (3) venous thrombosis, and, under most circumstances, (4) nonocclusive mesenteric ischemia. Angiography should be obtained without delay when the diagnosis is suspected. With the exception of angiography, the results of all other studies are most useful in ruling out other diagnoses or finding out baseline levels. Abdominal radiographs (b) should be performed on any patient with suspected mesenteric ischemia to rule out bowel obstruction or free air. However, in the early stages, plain radiographs are most often normal in patients with mesenteric ischemia and should not be used to rule out this entity. Positive findings include intraluminal gas or gas in the portal venous system, usually coincide with the development of necrotic bowel, and signify a grim prognosis. (c) Because of its availability, speed, and improved quality, CT is often used in the ED for assessing abdominal pain of unclear etiology inGastrointestinal Bleeding Answers 283 high-risk patients. CT may identify indirect signs of ischemia—including edema of the bowel wall or mesentery, abnormal gas patterns, intramural gas, and ascites. Occasionally, CT may accurately identify direct evidence of mesenteric venous thrombosis. As with abdominal radiographs, many patients may have normal or nonspecific findings on CT, so it cannot be used to rule out the diagnosis of mesenteric ischemia. While a few studies have found CT to be as sensitive as angiography, it is not currently the study of choice. (a) The sensitivity of serum lactate is high, nearly 100%, in the presence of mesenteric ischemia, but the specificity is low, ranging from 42% to 87%. Elevated serum lactate may best be used as a predictor of mortality. Some studies suggest that the presence of an unexplained acidosis should prompt a search for reversible causes of mesenteric ischemia. (e) Intraluminal barium contrast studies are contraindicated with suspected mesenteric ischemia because residual contrast material can limit visualization of the vasculature during diagnostic angiography

Question 11

A 55-year-old man with hypertension and end-stage renal disease requiring hemodialysis presents with 2 days of painless He reports similar episodes of bleeding in the past, which were attributed to angiodysplasia. He denies abdominal pain, nausea, vomiting, diarrhea, and fever. His vitals include HR of 90 beats per minute, BP of 145/95 mm Hg, RR of 18 breaths per minute, and temperature of 98°F. His abdomen is soft and nontender and his stool is grossly positive for blood. Which of the fol- lowing statements are true regarding angiodysplasia?

A	They are responsible for over 50% of acute lower GI bleeding.
B	They are more common in younger patients.
C	Angiography is the most sensitive method for identifying angiodysplasias.
D	They are less common in patients with end-stage renal disease.
E	The majority of angiodysplasias are located on the right side of the colon.

Question 11 Explanation:

Angiodysplasias, also known as arteriovenous malformations, are small ectatic blood vessels in the submucosa of the GI tract. More than half of angiodysplasias are located on the right side of the colon. (a) Angiodysplasias are responsible for 3% to 20% of acute lower GI bleeds. (b) Although angiodysplasia accounts for the most common cause of lower GI bleeding in younger patients, its incidence overall increases with age over 50 years. (c) While angiography may identify angiodysplasias, colonoscopy remains the most sensitive diagnostic modality. On colonoscopy, angiodysplasias appear as red, flat lesions, measuring approximately 2 to 20 mm in diameter. (d) Angiodysplasias are associated with many medical problems, including end-stage renal disease, aortic stenosis, and von Willebrand disease, among others.

Question 12

A 49-year-old man is brought to the ED by EMS stating that he vomited approximately three cups of blood over the last 2 He also complains of epigastric pain. While examining the patient, he has another episode of hematemesis. You decide to place an NG tube. You insert the tube, confirm its placement, and attach it to suction. You retrieve 200 mL of coffee-ground blood. What is the most common etiology of an upper GI bleed?

A	Varices
B	Peptic ulcer
C	Gastric erosions
D	Mallory-Weiss tear
E	Esophagitis

Question 12 Explanation:

The most common cause of upper GI bleeds in adults is peptic ulcer disease accounting for approximately 45% of the cases. Hematemesis is the presentation in approximately 50% of patients with upper GI bleeds. The appearance of coffee-grounds in the stomach is caused by the conversion of hemoglobin to hematin or other pigments by hydrochloric acid in the stomach. (a) Varices account for 10%, (c) erosions 23%, (d) Mallory-Weiss tear 7%, and (e) esophagitis 6%.

Question 13

A 68-year-old man presents to the ED 4 hours after an upper endos- copy was performed for 5 months of progressive During the procedure, a 1-cm ulcerated lesion was found and biopsied. Now, the patient complains of severe neck and chest pain. His vitals are as follows: BP 135/80 mm Hg, HR 123 beats per minute, RR 26 breaths per minute, and temperature 101°F. On physical examination, he appears diaphoretic and in moderate distress with crepitus in the neck and a crunching sound over the heart. You obtain an electrocardiogram (ECG), which is notable for sinus tachycardia. After obtaining a surgical consult, which of the fol- lowing is the next best step in management?

A	Perform an immediate bronchoscopy.
B	Give aspirin 325 mg and obtain a cardiology consult for possible cardiac catheterization.
C	Repeat the endoscopy to evaluate the biopsy site.
D	Perform an immediate thoracotomy.
E	Order an immediate esophagram with water-soluble agent.

Question 13 Explanation:

The patient most likely has an esophageal perforation, a serious, life-threatening complication of endoscopy that must be identified and treated quickly. Although sometimes reported as a result of forceful vomiting (eg, Boerhaave syndrome), the most common cause is iatrogenic. These usually occur as a complication of GI procedures, including upper endoscopy, dilation, sclerotherapy, and even NG tube placement or endotracheal intubation. The signs and symptoms may include chest pain near the rupture site, fever, respiratory distress, hoarseness, or dysphagia. Most patients have mediastinal or cervical emphysema, which may be noted by palpation or by a crunching sound heard during auscultation (ie, Hamman sign). An immediate esophagram with a water-soluble agent (eg, Gastrografin) is indicated. (a) Bronchoscopy is used to evaluate a patient with suspected bronchial obstruction or endobronchial disease. It is not indicated in a case of suspected esophageal perforation. (b) The likelihood that this patient’s chest pain is cardiac in origin is fairly small and the ECG demonstrates no ischemic changes. The diagnosis in a patient presenting with pain or fever following esophageal instrumentation should be considered esophageal perforation until proven otherwise. Also, if perforation is suspected, aspirin should be withheld. (c) Repeating the endoscopy may be useful, especially in cases of trauma; however, small perforations may be difficult or impossible to detect. An esophagram is better to evaluate for a suspected perforation. A chest radiograph and an upright abdominal radiograph are usually obtained first and may detect abnormalities in up to 90% of patients. These findings may include subcutaneous emphysema, pneumomediastinum, mediastinal widening, pleural effusion, or pulmonary infiltrate, but radiographic changes may not be present in the first few hours after the perforation. (d) Thoracotomy is the treatment for an esophageal perforation; however, an immediate esophagram with a water-soluble agent should be performed to confirm the diagnosis.

Question 14

A 65-year-old man with a history of occasional painless rectal bleed- ing presents with 2 to 3 days of constant, dull RLQ He also complains of fever, nausea, and decreased appetite. He had a colonoscopy 2 years ago that was significant for sigmoid and cecal diverticula but was otherwise normal. On physical examination he has RLQ tenderness with rebound and guarding. His vitals include HR of 95 beats per minute, BP of 130/85 mm Hg, and temperature of 101.3°F. The abdominal CT demonstrates the presence of sigmoid and cecal diverticula, inflammation of pericolic fat, thickening of the bowel wall, and a fluid-filled appendix. Which of the fol- lowing is the most appropriate next step in management?

A	Discharge the patient with broad-spectrum oral antibiotics and surgical follow-up.
B	Begin IV hydration and broad-spectrum antibiotics, keep the patient npo (noth- ing by mouth), and admit the patient to the hospital.
C	Begin IV antibiotics and call a surgical consult for an emergent operative procedure.
D	Arrange for an emergent barium enema to confirm the diagnosis.
E	Begin sulfasalazine 3 to 4 g/d along with IV steroid therapy.

Question 14 Explanation:

The diagnosis of diverticulitis is made by abdominal CT, which may demonstrate inflammation of pericolic fat, bowel wall thickening, the presence of diverticula, or peridiverticular abscess. The treatment of diverticulitis includes IV hydration, bowel rest, and broad-spectrum antibiotics to cover both aerobic and anaerobic bacteria. These typically include a combination of metronidazole and ciprofloxacin or levofloxacin. Well-appearing patients can be treated as outpatients with oral antibiotics and close follow-up, but patients withGastrointestinal Bleeding Answers 285 fever, signs of localized peritonitis or obstruction, and those who have failed outpatient therapy must be admitted to the hospital. (a) This patient has systemic signs of infection (fever, rebound tenderness, guarding) and should be admitted for IV antibiotics and observation. If the patient manifests signs of bowel obstruction, an NG tube should also be placed. (c) The presentation of diverticulitis may be indistinguishable from acute appendicitis. This occurs when a patient has a redundant sigmoid lying on the right side of the abdomen or, as in this case, when a cecal diverticulum becomes inflamed. In this case, the abdominal CT demonstrates a normal fluid-filled appendix, effectively ruling out appendicitis. A prompt surgical consult should be obtained in the presence of intestinal obstruction, free perforation, abscess, or fistula formation. (d) The presence of diverticulitis is demonstrated on abdominal CT, which is more sensitive than a barium enema. Furthermore, both barium injected under high pressure and colonoscopy in the presence of acute diverticulitis carry the risk of perforation and are relatively contraindicated. (e) An exacerbation of CD, which may also present with RLQ pain and heme-positive stool, may be treated with sulfasalazine and steroid therapy, but neither is appropriate in the treatment of acute diverticulitis.

Question 15

A 20-year-old man presents with several weeks of painful rectal He denies fever, nausea, or vomiting. He is sexually active with women only and usually uses condoms. He denies any history of CD, UC, or malignancy. He states that the pain is most severe during and immedi- ately after defecating. Bleeding is bright red and only enough to stain the toilet paper. Which of the following is the most common etiology of painful rectal bleeding?

A	External hemorrhoid
B	Anal fissure
C	Anorectal tumor
D	Internal hemorrhoid
E	Venereal proctitis

Question 15 Explanation:

Pain and bleeding are common complaints associated with anorectal disorders. A good history and a thorough physical examination, including a digital rectal examination and anoscopy, should be performed whenever feasible. Anal fissures (ie, fissures in ano) result from linear tears of the anal canal at or just inferior to the dentate line and extend along the anal canal to the anal verge. This area has a rich supply of somatic sensory never fibers. Consequently, anal fissures are exquisitely painful and represent the most common cause of painful rectal bleeding in the first year of life and in adults. They are usually produced by the passage of a large, hard stool but may also occur with severe diarrhea. (a) External hemorrhoids also arise from below the dentate line and are covered with well-innervated squamous epithelium making them painful. They often cause bleeding but not as common as anal fissures. (c) Early anorectal malignancies usually present with nonspecific symptoms, such as pruritus, pain, and bleeding mixed with stool, and represent less than 5% of all large bowel malignancies. (d) Internal hemorrhoids are detected by direct visualization using anoscopy. Uncomplicated internal hemorrhoids are painless because of lack of sensory innervation. Consequently, they286 Emergency Medicine present with painless, bright red bleeding with defecation. (e) Most venereal diseases involving the anorectal region present with pruritus, discharge, and mild to moderate pain or irritation, and may intermittently bleed.

Question 16

A 67-year-old woman with a history of hypertension and congestive heart failure presents with “burning” epigastric pain that began 2 hours after eating a She states that she has had similar pain over the past several weeks, and has been taking antacids and a medication that her primary care physician had prescribed with moderate relief. The pain has occurred with increasing frequency and now awakens her from sleep. She states she came to the ED today because the pain was not relieved with her usual medications. She denies nausea, vomiting, diarrhea, or fever. She also denies hematemesis, black stool, or bright red blood per rectum. On physical examination, she is tender at the epigastrium, with an otherwise normal abdominal, pulmonary, and heart examination. Stool guaiac tests positive for occult blood. Which of the following is the most common seri- ous complication of peptic ulcer disease?

A	GI hemorrhage
B	GI perforation
C	GI penetration
D	Gastric outlet obstruction
E	Pernicious anemia

Question 16 Explanation:

The most serious complications of PUD include hemorrhage, perforation, penetration, and gastric outlet obstruction. Hemorrhage, which occurs in 15% of patients, is the most common complication. (b) GI perforation occurs when an ulcer erodes through the stomach or bowel wall, and leaks air and digestive contents into the peritoneal cavity. It occurs in approximately 7% of patients and is the second most common serious complication of PUD. (c) GI penetration is similar to perforation, except the ulcer erodes into another organ, such as the liver or pancreas. (d) Gastric outlet obstruction, which occurs in 2% of patients, occurs because of edema and scarring near the gastric outlet. (e) Pernicious anemia results from an autoimmune disease in which the body develops antibodies to the acid-secreting cells in the gastric mucosa with ensuing loss of intrinsic factor, vitamin B12 malabsorption, and the development of anemia. It is not a complication of PUD.

Question 17

A 78-year-old man with a history of atherosclerotic heart disease and congestive heart failure presents with increasing abdominal The pain began suddenly a day ago and has progressively worsened since then. He denies nausea, vomiting, and diarrhea, but states that he had black tarry stool this morning. He denies any history of prior episodes of similar pain. Vitals are BP 120/65 mm Hg, HR 105 beats per minute, and temperature 99°F. The patient is at high risk for which of the following conditions?

A	Cholecystitis
B	Cecal volvulus
C	Mesenteric ischemia
D	Perforated peptic ulcer
E	Small bowel obstruction

Question 17 Explanation:

The complaint of abdominal pain in the elderly patient should prompt the emergency physician to lower his or her threshold for considering more serious intra-abdominal conditions. Patients with a history of arrhythmias (especially atrial fibrillation), low cardiac output (such as congestive heart failure), or who take particular medications, such as digoxin, are at high risk for the elusive condition of mesenteric ischemia. A history of sudden onset abdominal pain with increasing severity, but with a benign physical examination should prompt consideration of this entity. Mesenteric ischemia is associated with a high mortality rate, and initial diagnosis is often incorrect. The diagnostic study of choice is angiography. (a) Cholecystitis is the most common surgical emergency in elderly patients, but patients often localize pain to the RUQ. Ultrasonography is the initial diagnostic study of choice. (b) Sigmoid volvulus is two to three times more common than cecal volvulus among the elderly and presents with gradually increasing abdominal pain, along with nausea and vomiting. (d) Perforated peptic ulcer often presents with acute-onset epigastric pain followed by peritonitis and GI bleeding, and can be a similarly challenging condition to diagnose in elderly patients, who may lack dramatic pain orGastrointestinal Bleeding Answers 287 impressive peritoneal findings. The diagnostic study of choice is CT scan, although an upright chest or abdominal radiograph, which may show free air under the diaphragm, should be obtained immediately if the diagnosis is suspected. (e) Small bowel obstruction may also present with gradually increasing abdominal pain, nausea, and vomiting. It is not associated with the comorbid conditions listed, but rather with adhesions following abdominal surgery, incarcerated groin hernia, polyps, lymphomas, adenocarcinoma, abdominal abscess, and radiation therapy.

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1. A 51-year-old man is brought to the emergency department (ED) by emergency medical services (EMS) with a blood pressure (BP) of 90/60 mm Hg, heart rate (HR) of 110 beats per minute, respiratory rate (RR) of 18 breaths per minute, and oxygen saturation of 97% on room The patient tells you that he has a history of bleeding ulcers. On examination, his abdomen is tender in the epigastric area. He is guaiac positive, with black stool. He has a bout of hematemesis and you notice that his BP is now 80/50 mm Hg, HR is 114 beats per minute, as he is slowly starting to drift off. Which of the following is the most appropriate next step in therapy?

Assess airway, establish two large-bore intravenous (IV) lines, cross-match for two units of blood, administer 1 to 2 L of normal saline, and schedule an emer- gent endoscopy.
Assess airway, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor.
Place two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy.
Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy.
Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor.

2. A 45-year-old woman presents to the ED with 1 day of painful rectal bleeding. Review of systems is negative for weight loss, abdominal pain, nausea, and On physical examination, you note an exquisitely tender swelling with engorgement and a bluish discoloration distal to the anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg, RR 18 breaths per minute, and temperature 99°F. Which of the following is the next best step in management?

Recommend warm sitz baths, topical analgesics, stool softeners, a high-fiber diet, and arrange for surgical follow-up.
Incision and drainage under local anesthesia or procedural sedation followed by packing and surgical follow-up.
Obtain a complete blood cell (CBC) count, clotting studies, type and cross, and arrange for emergent colonoscopy.
Excision under local anesthesia followed by sitz baths and analgesics.
Surgical consult for immediate operative management.

3. A 20-year-old man presents to the ED with fever and severe right lower quadrant (RLQ) pain for 1 Prior to this episode, he reports 2 months of crampy abdominal pain, generalized malaise, a 10-lb weight loss, and occasional bloody diarrhea. On examination, his HR is 115 beats per minute, BP is 125/70 mm Hg, RR is 18 breaths per minute, and tem- perature is 100.8°F. His only significant past medical history is recurrent perirectal abscesses. On physical examination, the patient appears uncom- fortable and has a tender mass in the RLQ, without guarding or rebound. Rectal examination is positive for trace heme-positive stool. An abdominal computed tomographic (CT) scan reveals no periappendiceal fat stranding. There is inflammation of the distal ileum and several areas of the colon. There are no rectal inflammatory changes. Which of the following is the most likely diagnosis?

Crohn disease (CD)
Ulcerative colitis (UC)
Appendicitis
Pseudomembranous enterocolitis
Diverticulitis

4. A 62-year-old man with a history of hypertension presents to the ED with severe constant mid-epigastric pain for the past Over the last sev- eral months, he has had intermittent pain shortly after eating, but never this severe. He states he now has generalized abdominal pain that began suddenly about 15 minutes ago. He has no history of trauma, has never had surgery, and takes no medications. His vitals include HR of 115 beats per minute lying supine, increasing to 135 when sitting up, BP of 170/105 mm Hg supine, falling to 145/85 mm Hg when sitting up. He appears pale. His abdomen is rigid and diffusely tender with guarding and rebound. Bowel sounds are absent and stool hemoccult is positive. The white blood cell (WBC) count is 8500/mL, hemoglobin 8.5 mg/dL, hematocrit 27%, and platelets 255/mL. Which of the following is the most likely diagnosis?

Boerhaave syndrome
Perforated gastric ulcer
Abdominal aortic aneurysm (AAA)
Inflammatory bowel disease (IBD)
Diverticulosis

5. A 60-year-old man with a history of alcohol abuse presents to the ED with hematemesis for 1 He denies abdominal or chest pain. On physical examination, his eyes appear reddened which he attributes to hav- ing drunken heavily the night before (he also reveals vomiting several times after this recent binge). Vital signs are HR 115 beats per minute, BP 130/85 mm Hg, RR 18 breaths per minute, and temperature 99.5°F. Chest radio- graph is unremarkable. Laboratory results reveal a WBC 10,000/mL, hemo- globin 14 mg/dL, hematocrit 40%, and platelets 210/mL. Which diagnosis is endoscopic evaluation most likely to confirm?

Esophageal varices
Boerhaave syndrome
Curling ulcer
Perforated gastric ulcer
Mallory-Weiss tear

6. A 50-year-old man is brought to the ED by ambulance with significant hematemesis. In the ambulance, paramedics placed two large-bore IVs and began infusing normal In the ED, his HR is 127 beats per minute, BP is 79/45 mm Hg, temperature is 97.9°F, RR is 24 breaths per minute, and oxygen saturation is 96%. On physical examination, his abdomen is nontender, but you note spider angiomata, palmar erythema, and gyneco- mastia. Laboratory results reveal WBC 9000/mL, hematocrit 28%, platelets 40/mL, aspartate transaminase (AST) 675 U/L, alanine transaminase (ALT) 325 U/L, alkaline phosphatase 95 U/L, total bilirubin 14.4 mg/dL, conju- gated bilirubin 12.9 mg/dL, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen (BUN) 20 mg/dL, creatinine 1.1 mg/dL, and glucose 150 mg/dL. Which of the following is the most likely diagnosis?

Perforated gastric ulcer
Diverticulosis
Splenic laceration
Esophageal varices
Ruptured AAA

7. A 55-year-old man is brought to the ED by his They state that he has been vomiting large amounts of bright red blood. The patient is an alcoholic with cirrhotic liver disease and a history of portal hypertension and esophageal varices. His vitals on arrival are HR 110 beats per minute, BP 80/55 mm Hg, RR 22 breaths per minute, and temperature 99°F. The patient appears pale and is in moderate distress. Which of the following is an inappropriate option in the initial management of a hypotensive patient with a history of known esophageal varices presenting with hematemesis?

Sengstaken-Blakemore tube placement
Two large-bore IV lines and volume repletion with crystalloid solutions
Nasogastric (NG) lavage
IV octreotide
Gastrointestinal (GI) consult

8. A 70-year-old woman presents to the ED with dark stool for 3 She occasionally notes bright red blood mixed with the stool. Review of sys- tems is positive for decreased appetite, constipation, and a 10-lb weight loss over 2 months. She denies abdominal pain, nausea, vomiting, and fever, but feels increased weakness and fatigue. She also describes a raspy cough with white sputum production over the previous 2 weeks. Examination reveals she is pale, with a supine BP of 115/60 mm Hg and HR of 90 beats per minute. Standing BP is 100/50 mm Hg, with a pulse of 105 beats per minute. Which of the following is the most likely diagnosis?

Hemorrhoids
Diverticulitis
Mallory-Weiss tear
Diverticulosis
Adenocarcinoma

9. A 76-year-old woman with a history of congestive heart failure, coro- nary artery disease, and an “irregular heart beat” is brought to the ED by her She has been complaining of increasing abdominal pain over the past several days. She denies nausea or vomiting and bowel movements remain unchanged. Vitals are HR of 114 beats per minute, BP 110/75 mm Hg, and temperature 98°F. On cardiac examination, her HR is irregularly irregular with no murmur detected. The abdomen is soft, nontender, and nondis- tended. The stool is heme-positive. This patient is at high risk for which of the following conditions?

Perforated gastric ulcer
Diverticulitis
Acute cholecystitis
Mesenteric ischemia
Sigmoid volvulus

10. A 70-year-old woman with a history of hypertension, congestive heart failure, and atrial fibrillation presents to the ED with several hours of acute onset diffuse abdominal She denies any nausea or vomiting. The pain is constant, but she is unable to localize it. She was diagnosed with a renal artery thrombosis several years ago. Vital signs include HR of 95 beats per minute, BP of 110/70 mm Hg, and temperature of 98°F. Her abdomen is soft and mildly tender, despite her reported severe abdominal pain. Her WBC count is 12,000/mL, hematocrit 38%, platelets 250/mL, and lactate 8 mg/dL. The stool is traced heme-positive. You are concerned for acute mesenteric ischemia. What is the best way to diagnose this condition?

Serum lactate levels
Abdominal radiograph (supine and upright)
CT scan
Angiography
Barium contrast study

11. A 55-year-old man with hypertension and end-stage renal disease requiring hemodialysis presents with 2 days of painless He reports similar episodes of bleeding in the past, which were attributed to angiodysplasia. He denies abdominal pain, nausea, vomiting, diarrhea, and fever. His vitals include HR of 90 beats per minute, BP of 145/95 mm Hg, RR of 18 breaths per minute, and temperature of 98°F. His abdomen is soft and nontender and his stool is grossly positive for blood. Which of the fol- lowing statements are true regarding angiodysplasia?

They are responsible for over 50% of acute lower GI bleeding.
They are more common in younger patients.
Angiography is the most sensitive method for identifying angiodysplasias.
They are less common in patients with end-stage renal disease.
The majority of angiodysplasias are located on the right side of the colon.

12. A 49-year-old man is brought to the ED by EMS stating that he vomited approximately three cups of blood over the last 2 He also complains of epigastric pain. While examining the patient, he has another episode of hematemesis. You decide to place an NG tube. You insert the tube, confirm its placement, and attach it to suction. You retrieve 200 mL of coffee-ground blood. What is the most common etiology of an upper GI bleed?

Varices
Peptic ulcer
Gastric erosions
Mallory-Weiss tear
Esophagitis

13. A 68-year-old man presents to the ED 4 hours after an upper endos- copy was performed for 5 months of progressive During the procedure, a 1-cm ulcerated lesion was found and biopsied. Now, the patient complains of severe neck and chest pain. His vitals are as follows: BP 135/80 mm Hg, HR 123 beats per minute, RR 26 breaths per minute, and temperature 101°F. On physical examination, he appears diaphoretic and in moderate distress with crepitus in the neck and a crunching sound over the heart. You obtain an electrocardiogram (ECG), which is notable for sinus tachycardia. After obtaining a surgical consult, which of the fol- lowing is the next best step in management?

Perform an immediate bronchoscopy.
Give aspirin 325 mg and obtain a cardiology consult for possible cardiac catheterization.
Repeat the endoscopy to evaluate the biopsy site.
Perform an immediate thoracotomy.
Order an immediate esophagram with water-soluble agent.

14. A 65-year-old man with a history of occasional painless rectal bleed- ing presents with 2 to 3 days of constant, dull RLQ He also complains of fever, nausea, and decreased appetite. He had a colonoscopy 2 years ago that was significant for sigmoid and cecal diverticula but was otherwise normal. On physical examination he has RLQ tenderness with rebound and guarding. His vitals include HR of 95 beats per minute, BP of 130/85 mm Hg, and temperature of 101.3°F. The abdominal CT demonstrates the presence of sigmoid and cecal diverticula, inflammation of pericolic fat, thickening of the bowel wall, and a fluid-filled appendix. Which of the fol- lowing is the most appropriate next step in management?

Discharge the patient with broad-spectrum oral antibiotics and surgical follow-up.
Begin IV hydration and broad-spectrum antibiotics, keep the patient npo (noth- ing by mouth), and admit the patient to the hospital.
Begin IV antibiotics and call a surgical consult for an emergent operative procedure.
Arrange for an emergent barium enema to confirm the diagnosis.
Begin sulfasalazine 3 to 4 g/d along with IV steroid therapy.

15. A 20-year-old man presents with several weeks of painful rectal He denies fever, nausea, or vomiting. He is sexually active with women only and usually uses condoms. He denies any history of CD, UC, or malignancy. He states that the pain is most severe during and immedi- ately after defecating. Bleeding is bright red and only enough to stain the toilet paper. Which of the following is the most common etiology of painful rectal bleeding?

External hemorrhoid
Anal fissure
Anorectal tumor
Internal hemorrhoid
Venereal proctitis

16. A 67-year-old woman with a history of hypertension and congestive heart failure presents with “burning” epigastric pain that began 2 hours after eating a She states that she has had similar pain over the past several weeks, and has been taking antacids and a medication that her primary care physician had prescribed with moderate relief. The pain has occurred with increasing frequency and now awakens her from sleep. She states she came to the ED today because the pain was not relieved with her usual medications. She denies nausea, vomiting, diarrhea, or fever. She also denies hematemesis, black stool, or bright red blood per rectum. On physical examination, she is tender at the epigastrium, with an otherwise normal abdominal, pulmonary, and heart examination. Stool guaiac tests positive for occult blood. Which of the following is the most common seri- ous complication of peptic ulcer disease?

GI hemorrhage
GI perforation
GI penetration
Gastric outlet obstruction
Pernicious anemia

17. A 78-year-old man with a history of atherosclerotic heart disease and congestive heart failure presents with increasing abdominal The pain began suddenly a day ago and has progressively worsened since then. He denies nausea, vomiting, and diarrhea, but states that he had black tarry stool this morning. He denies any history of prior episodes of similar pain. Vitals are BP 120/65 mm Hg, HR 105 beats per minute, and temperature 99°F. The patient is at high risk for which of the following conditions?

Cholecystitis
Cecal volvulus
Mesenteric ischemia
Perforated peptic ulcer
Small bowel obstruction

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