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Free STEP3 Exam Braindumps (page: 70)

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PDF with 804 Questions

Biopsy of a 4-cm sessile polyp of the cecum during a routine screening colonoscopy reveals it to be a villous adenoma with atypia. Attempt at piecemeal snare polypectomy through the colonoscope is unsuccessful. Which of the following is the most appropriate management?

  1. right hemicolectomy
  2. colonoscopy with electrocoagulation of the tumor
  3. colonoscopy with repeat biopsy in 6 months
  4. open surgery with colotomy and excision of polyp
  5. external beam radiation

Answer(s): A

Explanation:

Villous adenoma is a premalignant condition. The incidence of carcinoma in a polyp depends on the histology type and size of the polyp. Tubular adenomas are the most common type of polyps (6080%), but are the least likely to harbor carcinoma (less than 5% if smaller than 1 cm in diameter). Villous adenomas are the least common type, but overall the most likely to contain malignant foci (50% if greater than 2 cm in diameter). In this patient, a formal right hemicolectomy is indicated due to the high probability of finding cancer in the specimen. A lesser operation, such as open or laparoscopic polypectomy, would then require a second operative procedure if cancer is present. Colonoscopic fulguration of such a large lesion carries a high risk for perforation and would not allow histologic examination. Observation with repeat colonoscopy in 1 year is also inappropriate.



A 56-year-old man comes to the hospital. For the past 5 days he has had colicky abdominal pain, vomiting, abdominal distention, and constipation. The most appropriate measure, after IV hydration and nasogastric decompression, in the initial management of this patient is which of the following?

  1. upper GI endoscopy
  2. supine and erect x-rays of the abdomen
  3. abdominal sonography
  4. antiemetic agents
  5. promotility drugs

Answer(s): B

Explanation:

This patient presents with classic symptoms of a bowel obstruction. The diagnosis is often made by a thorough history and physical examination. Following the initial evaluation, an acute abdominal x-ray series should be obtained, which includes supine and erect views of the abdomen. The diagnosis is confirmed with the presence of dilated loops of bowel with the presence of air-fluid levels. These plain films may also suggest the location of the obstruction (small vs. large intestine). Abdominal ultrasonography has limited role in the diagnosis or management of intestinal obstruction. Serum electrolyte determination helps in identifying the electrolyte disturbances that have taken place. Fluid loss needs to be corrected with rehydration, and nasogastric suction helps in decreasing abdominal distention. Upper GI endoscopy would increase distention, and is contraindicated. Antiemetics should not be given until a definitive diagnosis is made, and then only if indicated; promotility agents have little to no role in the management of a patient with bowel obstruction, and may even be contraindicated.

An annular constricting lesion with overhanging edges is typical of annular carcinoma of the colon. Mechanical small bowel obstruction results in multiple air-fluid levels in distended small bowel loops. Intussusception produces a "corkscrew" appearance on barium enema, and sigmoid volvulus produces a "bird's beak" appearance. In diverticulitis, extravasation of barium outside the lumen of the colon typically is seen.



A 56-year-old man comes to the hospital. For the past 5 days he has had colicky abdominal pain, vomiting, abdominal distention, and constipation

He undergoes barium enema examination. The findings on barium enema, shown in Figure, are most compatible with which of the following diagnoses?

  1. mechanical small bowel obstruction
  2. intussusception
  3. volvulus
  4. carcinoma of the colon
  5. diverticulitis

Answer(s): D

Explanation:

This patient presents with classic symptoms of a bowel obstruction. The diagnosis is often made by a thorough history and physical examination. Following the initial evaluation, an acute abdominal x-ray series should be obtained, which includes supine and erect views of the abdomen. The diagnosis is confirmed with the presence of dilated loops of bowel with the presence of air-fluid levels. These plain films may also suggest the location of the obstruction (small vs. large intestine). Abdominal ultrasonography has limited role in the diagnosis or management of intestinal obstruction. Serum electrolyte determination helps in identifying the electrolyte disturbances that have taken place. Fluid loss needs to be corrected with rehydration, and nasogastric suction helps in decreasing abdominal distention. Upper GI endoscopy would increase distention, and is contraindicated. Antiemetics should not be given until a definitive diagnosis is made, and then only if indicated; promotility agents have little to no role in the management of a patient with bowel obstruction, and may even be contraindicated.

An annular constricting lesion with overhanging edges is typical of annular carcinoma of the colon. Mechanical small bowel obstruction results in multiple air-fluid levels in distended small bowel loops. Intussusception produces a "corkscrew" appearance on barium enema, and sigmoid volvulus produces a "bird's beak" appearance. In diverticulitis, extravasation of barium outside the lumen of the colon typically is seen.



A 56-year-old man comes to the hospital. For the past 5 days he has had colicky abdominal pain, vomiting, abdominal distention, and constipation

During definitive surgical treatment of the lesion shown on the barium enema, the left ureter is accidentally transected at the level of the pelvic brim. What is the most appropriate management of this complication?

  1. ureteroneocystostomy
  2. left to right ureteroureterostomy
  3. anastomosis of the two cut ends over a "double J" stent
  4. nephrectomy
  5. ligation of the transected ends

Answer(s): C

Explanation:

This patient presents with classic symptoms of a bowel obstruction. The diagnosis is often made by a thorough history and physical examination. Following the initial evaluation, an acute abdominal x-ray series should be obtained, which includes supine and erect views of the abdomen. The diagnosis is confirmed with the presence of dilated loops of bowel with the presence of air-fluid levels. These plain films may also suggest the location of the obstruction (small vs. large intestine). Abdominal ultrasonography has limited role in the diagnosis or management of intestinal obstruction. Serum electrolyte determination helps in identifying the electrolyte disturbances that have taken place. Fluid loss needs to be corrected with rehydration, and nasogastric suction helps in decreasing abdominal distention. Upper GI endoscopy would increase distention, and is contraindicated. Antiemetics should not be given until a definitive diagnosis is made, and then only if indicated; promotility agents have little to no role in the management of a patient with bowel obstruction, and may even be contraindicated.

An annular constricting lesion with overhanging edges is typical of annular carcinoma of the colon. Mechanical small bowel obstruction results in multiple air-fluid levels in distended small bowel loops. Intussusception produces a "corkscrew" appearance on barium enema, and sigmoid volvulus produces a "bird's beak" appearance. In diverticulitis, extravasation of barium outside the lumen of the colon typically is seen.






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