Following an uneventful appendectomy for acute appendicitis, the pathology report reveals the presence of a 1 cm carcinoid at the tip of the appendix. The patient has been otherwise asymptomatic.What is the most appropriate intervention?
Answer(s): C
Carcinoids are the most common neoplasm of the appendix and arise from Kulchitsky cells, a type of enterochromafin cell. Aside from the appendix, the next most frequent site of involvement is the small bowel followed by the rectum. Appendiceal and rectal carcinoids are almost never associated with carcinoid syndrome unless metastatic disease is present. Small bowel carcinoids are more commonly multifocal, metastatic, and associated with carcinoid syndrome. The majority of appendiceal carcinoids are located at the tip and the extent of surgical resection depends on the size and resulting malignant potential. Lesions less than 1 cm rarely metastasize and therefore require only simple appendectomy as in this question. Lesions greater than 2 cm require a right hemicolectomy due to the high potential for metastasis. Partial small bowel resection is indicated for a carcinoid of the small intestine. Partial cecectomy and total abdominal colectomy are not appropriate options.
A 64-year-old diabetic male undergoes a right hemicolectomy for an adenocarcinoma of the cecum. On the first postoperative night, he becomes tachycardic and is noted to have a temperature of 102.8°F. His surgical incision is tender with erythema and murky discharge.Which of the following is the most important intervention?
Answer(s): D
Postoperative wound infections usually occur between the fifth and eighth postoperative days. Evidence of a wound infection within the first 24 hours after surgery should alert the physician to the possibility of necrotizing fasciitis. Necrotizing fasciitis is a lifethreatening infection most commonly caused by clostridial myositis and hemolytic streptococcus. In addition to spiking temperature, the patient may be septic with tachycardia, leukocytosis, and hemodynamic instability. On examination of the wound, crepitus (gas in the soft tissue) and a dishwater-appearing effluent may be apparent. Early diagnosis by opening the wound and sending a Gram's stain is critical. The Gram's stain will reveal a mixed flora of ramnegative rods and gram-positive cocci. Although broad-spectrum antibiotics are indicated, definitive treatment requires emergent aggressive debridement of the affected tissues. Hyperbaric oxygen treatment has no role in the acute management of necrotizing fasciitis. Diabetic patients are especially prone to necrotizing fasciitis. Fournier's gangrene is a type of necrotizing fasciitis that affects the groin and perineum. The mortality rate can be as high as 75%.
A50-year-old diabetic man is treated as an outpatient with incision and drainage and oral clindamycin for an abscess and cellulitis of the skin on his back. About a week after completing his antibiotic he develops frequent, watery diarrhea. Which of the following is the most appropriate treatment of this complication?
Nearly all broad-spectrum antibiotics may result in superinfection of the colon with Clostridium difficile. This anaerobic enteric pathogen produces a toxin that causes necrosis of the colonic mucous membrane resulting in enterocolitis (pseudomembranous colitis). The infection can occur several weeks after the discontinuation of the inciting antibiotic. The presentation varies from mild diarrhea to systemic illness with abdominal pain, fever, and leukocytosis. Severe cases may progress to colonic dilatation and perforation. Lower endoscopy reveals the characteristic yellow pseudomembranes, which represent ulceration and necrosis. The diagnosis is confirmed with either colonic wall biopsy for the organism, or more commonly with identification of the toxin in stool samples. Orally administered metronidazole is the treatment of choice. Oral vancomycin is also effective, but it is reserved for refractory cases due to its side effect profile and expense.
A62-year-old male on total parenteral nutrition (TPN) for 2 weeks following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.2°F over the last 8 hours. The only abnormal finding on physical examination is erythema and induration around his central line.The most appropriate management is which of the following?
A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever. The catheter site may have erythema, induration, tenderness, and purulent discharge extruding from the skin. Often, however, the skin appears normal. Athorough search for other possible sources of fever including pulmonary, intra-abdominal, urinary, and wound infections is always prudent. Catheter sepsis can be life threatening and early intervention is essential. Peripheral and central blood cultures should be obtained and the catheter must be removed promptly. It is contraindicated to replace the catheter over a guide wire because the skin tract is infected. It is not mandatory to treat with antibiotics unless the fever persists or signs of sepsis are present.
A 48-year-old male truck driver presents for evaluation of bright red rectal bleeding with bowel movements. He also has the feeling that something protrudes through his anus while he strains to move his bowels but that it withdraws into the bowel when he relaxes. He has no abdominal pain, weight loss, or other symptoms. A colonoscopy reveals no polyps or tumors but does note internal hemorrhoids. Which of the following is the best initial treatment for him?
Answer(s): A
Internal hemorrhoids are highly vascularized submucosal cushions located in the anal canal. They are classified as first degree if no prolapse is present; second degree if prolapse occurs with spontaneous reduction; third degree if they require manual reduction; and fourth degree if they are irreducible. Treatment is based on the symptoms and degree of prolapse. Nearly all patients with first- and seconddegree hemorrhoids should initially be placed on a trial of conservative measures including a bowel management program with high fiber diet to avoid straining and constipation, frequent warm baths, and an anti- inflammatory topical cream. If symptoms continue, both rubber band ligation (a small rubber band is placed at the neck of the hemorrhoid resulting in eventual death and detachment of tissue) and infrared coagulation (controlled burn of the vessels at the neck of the hemorrhoid) are good alternatives to surgical therapy. For refractory first- and second-degree hemorrhoids, most third-degree and all fourth-degree hemorrhoids, surgical
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