A40-year-old woman presents with epigastric pain and is diagnosed with peptic-ulcer disease. A duodenal ulcer is seen on upper endoscopy.How would you counsel her regarding surgical management options?
Answer(s): E
The indications for surgery for duodenal ulcers include intractability, hemorrhage, obstruction, and perforation. Initial management includes dietary and behavior modification, H2 blockade, proton pump inhibitors, and treatment for H. pylori. Duodenal ulcers are rarely secondary to a malignancy and are related to acid production, unlike gastric ulcers, which have a higher incidence of association with malignant processes. Surgical approaches include: vagotomy (truncal, selective, highly selective), vagotomy combined with antrectomy, or subtotal gastrectomy. There are varying rates of perioperative morbidity and effectiveness reported in the literature. Recurrence rates after vagotomy and pyloroplasty alone approach 30%, in long-term followup. The complication of dumping after a highly selective vagotomy is significantly lower than truncal vagotomy. A drainage procedure after highly selective vagotomy is unnecessary, and vagal denervation of the proximal stomach reduces receptive relaxation.
Which of these statements is true in regard to GI hormones?
Answer(s): A
Gastrin is the humoral mediator of the gastric phase of secretion, and the release of gastrin is stimulated by antral distention, antral protein/ amino acids, and by the vagus itself. Gastrin stimlulates gastric acid secretion, promotes gut motility, and is a trophic factor for gut mucosa. Secretin is released by duodenal mucosal S cells in response to acid and promotes water and bicarbonate secretion from the pancreas. CCK is released in the gut by intestinal mucosal I cells and stimulates emptying of the gallbladder, increases bile flow, and relaxes the sphincter of Oddi. CCK has a structure very similar to gastrin.
A patient presents to the ED complaining of abdominal pain out of proportion to her examination. Initial vital signs are: BP 70/30, HR 120. The patient does report a prior history of abdominal pain after eating. Which of the following statements regarding this condition is most accurate?
Answer(s): B
Severe abdominal pain is the hallmark presentation of acute mesenteric ischemia. The pain is often described as being out of proportion to examination. It is most often caused by an embolic event to the SMA. Patients with cardiac arrhythmias are at greater risk for having an embolic event. Nonocclusive mesenteric ischemia is thought to be due to reactive arterial vasoconstriction and is not a surgically correctible disease. CT scan findings of SMA thrombosis or gas in the bowel wall would necessitate emergency surgery.
A 59-year-old White male with a 40 pack-year history of smoking presents to your clinic complaining of three prior episodes of a "shade passing over his left eye" over the last 2 months. He reports that last week he experienced some weakness in his right arm, which resolved after 5 minutes. Appropriate management and counseling for this patient includes which of the following?
This patient is experiencing multiple transient ischemic attacks (TIAs) associated with carotid artery disease. TIAs last only a few minutes, while RINDs (reversible ischemic neurologic deficit) typically resolve after 24 hours, and strokes result in long-term deficit. The symptoms are typically related to embolic events rather than reduced blood flow. The finding of carotid bruit on examination is more sensitive for coronary artery disease than it is for carotid disease. The initial workup for these patients should be bilateral carotid duplex ultrasound. Operative repair is indicated for asymptomatic patients with >60% stenosis as well as symptomatic patients.
A 65-year-old woman complains that she has become increasingly light-headed after playing golf. She also has had some cramping type pain in her left arm, which coincides with the episodes. She undergoes arteriogram and is found to have a stenotic lesion of her subclavian artery.Which of the following is true?
Answer(s): D
This patient is presenting with subclavian steal syndrome, which is caused by subclavian stenosis proximal to the take off of the verterbral artery. Exertion of the extremity causes blood to be shunted away from the brain to the arm resulting in vertigo or even syncope. These patients usually have diminished radial pulses on the affected side and also have other evidence of atherosclerotic disease. A carotidsubclavian bypass is the operation of choice for these patients.
Post your Comments and Discuss USMLE STEP3 exam prep with other Community members:
Our website is free, but we have to fight against AI bots and content theft. We're sorry for the inconvenience caused by these security measures. You can access the rest of the STEP3 content, but please register or login to continue.