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Free STEP3 Exam Braindumps (page: 72)

Page 71 of 202
PDF with 804 Questions

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?

  1. The ulcer is most likely secondary to a malignancy. Further workup is needed to rule out distant metastases before considering surgery.
  2. Surgery is the most effective first-line therapy.
  3. Recurrence rate of a duodenal ulcer 15 years after vagotomy and a drainage procedure is less than 5% .
  4. Patients operated on for intractability are more prone to developing postgastrectomy symptoms.
  5. Incidence of dumping syndrome is lower after highly selective vagotomy than after truncal vagotomy.

Answer(s): E

Explanation:

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?

  1. Vagal activation, antral distension, and antral protein are all stimuli for gastrin release.
  2. Secretin stimulates gastrin.
  3. Secretin is released from the antrum of the stomach.
  4. Cholecystokinin (CCK) release is stimulated by fat in the duodenum and results in release of insulin by the pancreas.
  5. CCK is released by the pancreas and relaxes the sphincter of Oddi.

Answer(s): A

Explanation:

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?

  1. A CT scan which shows superior mesenteric artery (SMA) thrombosis or bowel wall thickening requires an immediate operation.
  2. The most common site of embolic event is the SMA.
  3. Nonocclusive mesenteric ischemia is treated with arterial bypass.
  4. Patients with cardiac arrhythmias arenot at increased risk.
  5. After volume resuscitation, the initial diagnostic study for this patient is esophagogastroduodenoscopy (EGD).

Answer(s): B

Explanation:

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?

  1. Initial management of this patient should include bilateral cerebral vessel duplex ultrasonography.
  2. Explanation to him that he has had a stroke and will be referred to a neurologist for management.
  3. The most common cause of strokes in these patients is related to decreased blood flow.
  4. Presence of a carotid bruit confirms the diagnosis and may lead to operative intervention without the need for imaging studies.
  5. The presence of a 50% stenosis in the right carotid artery should lead to bilateral surgical repair.

Answer(s): A

Explanation:

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.






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