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Free STEP3 Exam Braindumps (page: 68)

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PDF with 804 Questions

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?

  1. high fiber diet, frequent sitz baths, and topical steroid ointment
  2. rubber band ligation
  3. sclerotherapy injection
  4. infrared coagulation
  5. surgical hemorrhoidectomy

Answer(s): A

Explanation:

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



Which of the following is true regarding anorectal abscess and fistula?

  1. The most common cause is a subepithelial extension of a genital infection.
  2. Conservative management should always be considered for fistula-in-ano as many heal spontaneously.
  3. Most acute anorectal abscesses require a course of antibiotics.
  4. The treatment protocol is not altered for patients with valvular heart disease.
  5. Anal fistula is classified as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric.

Answer(s): E

Explanation:

The most common cause of anorectal fistula and abscess is infection of the anal glands, which empty into the anal canal at the level of the dentate line. Classification of anal fistula is based upon the relationship of the epithelialized tract to the anal sphincter muscle and can be intersphincteric (most common), transsphincteric, suprasphincteric, and extrasphincteric (least common). A symptomatic fistula is an indication for surgery because it rarely heals spontaneously. Despite popular teaching, there is little use for antibiotics in the primary treatment of anal abscess. As a rule, surgical drainage is required and antibiotics are only indicated if cellulitis is present. However, those patients who are immunocompromised, have valvular heart disease, or poorly controlled diabetes should always be considered for antibiotics.



The most common cause of surgery in a patient with Crohn's disease is which of the following?

  1. carcinoma
  2. fistula
  3. bleeding
  4. obstruction
  5. abscess

Answer(s): D

Explanation:

Crohn's disease is a chronic inflammatory disease of the GI tract of unknown etiology. Both medical and surgical treatments are palliative in nature--there is no known "cure." pproximately 70% of patients with Crohn's disease will require an operation during their lifetime. The most common indication for surgery is recurrent bowel obstruction, followed by perforation with abscess and fistula formation.



A 26-year-old male presents with abdominal pain and bloody diarrhea. On examination, he has a low- grade fever and mildly tender abdomen. Lower endoscopy is performed which reveals edematous mucosa with contiguous involvement from the rectum to the left colon. Random biopsies are performed which reveals acute and chronic inflammation of the mucosa and submucosa with multiple crypt abscesses.
There are no granulomas seen.

What can you tell this patient about his condition?

  1. He will likely require an operation.
  2. There is no known cure.
  3. The use of intravenous corticosteroids is contraindicated.
  4. Perianal fistulas are characteristic.
  5. There is a substantially increased longterm risk of developing colon cancer.

Answer(s): E

Explanation:

Ulcerative colitis is a diffuse inflammatory disease of the colon and rectum with unknown etiology. Unlike Crohn's disease, surgical removal of the entire colon and rectum provides a complete cure. Nonetheless, many patients are treated successfully with medical therapy including corticosteroids and can avoid the potential complications of surgery and lifelong ileostomy. Ulcerative colitis usually presents as bloody diarrhea, fever, and abdominal pain. The disease process begins in the rectum, advances proximally in a contiguous fashion, and affects the superficial layers of the colon wall. Crohn's disease is located anywhere from the mouth to anus, has skip lesions, and is transmural in nature. Histologically, superficial inflammation with crypt abscesses is most indicative of ulcerative colitis, whereas deeper involvement with granulomas and fissures are most characteristic of Crohn's disease. Both diseases may present with extraintestinal manifestations such as arthritis, skin lesions, and hepatic dysfunction, but perianal disease with fistula formation is characteristic of Crohn's disease. Patients with ulcerative colitis have a 1020% risk of developing colon cancer within 20 years after diagnosis. The incidence is also increased in those with Crohn's disease but to a lesser extent. Surveillance colonoscopy is essential in patients with long-standing disease






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