A 42-year-old woman presents with abdominal pain for the past 2 days. She describes the pain as
crampy and intermittent in the epigastric area, and it is particularly worse after meals. She has a history
of gastric bypass surgery for weight loss management 2 years ago. On physical examination, she is
afebrile and her abdomen is soft and nontender with no masses.
Laboratory study results are as follows:
White blood cell count:
7400/µL Hemoglobin: 13.2 g/dL
Platelets: 215,000/µL
Albumin: 4.3 g/dL
Aspartate aminotransferase: 334
U/L Alanine transaminase: 282 U/L
Alkaline phosphorus: 115 U/L
Total bilirubin: 1.7 mg/dL
Amylase: 42 U/L
Lipase: 24 U/L
Abdominal ultrasonography demonstrates a normal-appearing liver, mild distension of the gallbladder
with several stones in the fundus of the gallbladder, but no apparent wall thickening or pericholecystic
fluid. The common bile duct is dilated to 1.3 cm. What is the next step in the management of this
patient's condition? endoscopic retrograde cholangiopancreatography (ERCP)
A 39-year-old man with a history of rheumatoid arthritis maintained on methotrexate is evaluated for a
several-month history of progressive fatigue, a 10-pound weight loss, and, recently, dark urine output
for the past 2 weeks.On physical examination, he is noted to have slight scleral icterus and a mildly
prominent liver edge. He does not appear to have any other stigmata of chronic liver disease. He is not
currently on any medications other than methotrexate and folic acid.Laboratory studies reveal the
following:
White blood cell count:
7700/µL Hemoglobin: 11.8 g/dL
Platelets: 150,000/ µL
Albumin: 3.6 g/dL
Aspartate aminotransferase: 78
U/L Alanine transaminase: 92 U/L
Alkaline phosphorus: 275 U/L
Total bilirubin: 4.8 mg/dL
,International normalized ratio: 1.3. Given these findings, magnetic resonance
cholangiopancreatography is ordered that demonstrates a hypertrophied caudate lobe with mild
intrahepatic biliary ductal dilatation and several areas of ductal narrowing. No other masses are seen.
Liver biopsy is performed and is notable for epithelial cell necrosis, ductopenia, and concentric fibrosis
around the bile ducts.Other than initiating treatment with ursodeoxycholic acid (UDCA), what else
should be recommended at this time? Colonoscopy
A 51-year-old man with hypertension and hyperlipidemia is found to have a mild elevation in his alanine
transaminase (ALT) level of 58 U/L with otherwise normal liver enzyme levels. He is taking simvastatin
20 mg, and he is otherwise asymptomatic with no significant abdominal complaints. Work-up for viral
hepatitis and other heritable and autoimmune liver diseases is unremarkable. Right upper quadrant
ultrasonography demonstrates a normal-appearing liver with no cholelithiasis and normal bile ducts.
There does appear to be extensive calcification of the gallbladder wall but with no obvious mass or
polyps. What is the next step in the management of this patient's condition? referral for
cholecystectomy
A 45-year-old woman with hypertension, type 2 diabetes mellitus, and morbid obesity presents to you
with intermittent, right-sided abdominal pain and dyspepsia. These symptoms have been present for the
past 6 months, but she experienced a severe episode 3 days ago lasting for approximately 4 hours. Her
current medications include losartan, metformin, and baby aspirin. She denies any recent use of
nonsteroidal anti-inflammatory drugs, acetaminophen, or alcohol. On physical examination, her blood
pressure is 140/85 mm Hg, pulse is 80 beats/minute, and she is afebrile. She does not have jaundice, and
abdominal examination reveals mild tenderness in the epigastrium.
Laboratory study results are as follows:
White blood cell count: 10,400/µL
Hemoglobin: 12.8 g/dL
Albumin: 4.1 g/dL
Aspartate aminotransferase: 245
U/L Alanine transaminase: 175 U/L
Alkaline phosphorus: 245 U/L
Total bilirubin: 3.7 mg/dL
Amylase: 335 U/L
Lipase: 520 U/L
,Due to her poor oral intake, you admit her for hydration and further work-up. Laboratory values on
hospital day 2 demonstrate improving liver chemistries as well as an amylase level of 175 U/L and a
lipase level of 330 U/L. Serologies for hepatitis A, B, and C are negative. Right-upper quadrant
ultrasonography reveals a liver with mild fatty infiltration, a normal caliber common bile duct, and no
gallbladder wall thickening or pericholecystic fluid. There are several shadowing lucencies with the
gallbladder suggestive of stones. Computed tomography is also obtained and demonstrates mild
pancreatic inflammation. She is feeling well, does not have pain on a low-fat diet, and she insists on
being discharged. What should be the next step in the management of her condition? Consult with a
surgeon to determine need for cholecystectomy.
A 52-year-old man with severe emphysema is admitted to the hospital with an exacerbation. On
hospital day 2, his clinical condition worsens with increasing oxygen requirements and significant
tachypnea that requires he be transferred to the intensive care unit and be intubated.He is started on
broad-spectrum antibiotics with initial improvement; however, by day 7, his white blood cell count is
increased to 19,000/µL. Repeat blood cultures do not have any growth by 72 hours, and there is no
evidence of urinary or Clostridium difficile infection, and Doppler ultrasonography of the lower
extremities does not reveal any clots.Right upper quadrant ultrasonography demonstrates a thickened,
distended gallbladder with no sludge or stones and mild pericholecystic fluid. The common bile duct
measures 4 mm. The patient remains on norepinephrine for blood pressure support.What is the next
step in the management of this patient's condition? cholecystostomy tube placement
A 42-year-old woman with history of asthma and hyperlipidemia presents with 2 days of anorexia
followed by nausea and vomiting. She also has developed abdominal pain that was initially periumbilical
and now has migrated to the right lower quadrant.On physical examination, the patient has a
temperature of 39 °C and her pulse is 122 beats/minute. There is localized tenderness in the right lower
quadrant. Complete blood count shows leukocytosis with left shift. Abdominal x-ray is shown in the
Figure. Appendicitis with appendicolith
A 53-year-old woman with a 15-year history of ulcerative pancolitis well-controlled by nonsteroidal anti-
inflammatory drugs presents to you for routine surveillance colonoscopy. Four-quadrant biopsies are
taken every 10 cm throughout the colon, and pathology reveals evidence of high-grade dysplasia but no
adenocarcinoma in 2 separate locations.What should be the next step in the management of this
patient's condition? Referral to a colorectal surgeon to consider total colectomy
A 47-year-old woman presents with a perirectal abscess that has formed a fistula. Which of the
following diseases is most likely to be associated with a predisposition to fistula formation in this
patient? Crohn disease
A 70-year-old woman presents with sharp, left-sided abdominal pain for the last 2 days. She tells you
that the pain is associated with nausea, vomiting, chills, and malaise. She denies any diarrhea.Her vital
, signs are: blood pressure 130/80 mm Hg, pulse 110 beats/minute, respiratory rate 18 breaths/minute,
and temperature 100.9° F. Abdominal examination reveals left lower abdominal tenderness, distention,
and normal bowel sounds with voluntary guarding and rigidity.Which of the following tests is most
useful for establishing a diagnosis? computed tomography (CT) of the abdomen
A 45-year-old man presents with frank blood in his stools for the past 2 months. His bowel
movements are not painful, but he experiences a sensation of incomplete evacuation and urgency
after each bowel movement. Complete blood count reveals a white blood cell count of 9500/µL, a
hemoglobin level of
12.8 g/dL, and platelet count of 552,000/µL.Colonoscopy is performed, and it demonstrates uniform
erythema and inflammation throughout the rectosigmoid, descending, and transverse colon. Biopsies
demonstrate inflammation extending to the submucosa with crypt abscesses consistent with ulcerative
colitis.Which of the following regimens is the most appropriate initial treatment for his ulcerative colitis
(UC)? Start oral mesalamine 800 mg 3 times a day in combination with mesalamine enemas every
hour until proctitis symptoms resolve.
A 60-year-old woman with arthritis and chronic intermittent diarrhea has an acute worsening of her
diarrhea with abdominal pain and distention. She has been unable to eat and has unintentionally lost 10
pounds.Her vital signs are: temperature 99.5° F, blood pressure 100/60 mm Hg, and pulse 94
beats/minute.She was unable to sit still on the examination table because of her abdominal pain. Her
heart beat is regular. Her lungs are clear. Her abdomen is diffusely tender with hypoactive bowel
sounds. She has red, tender lesions on her shins. Her rectal examination is guaiac positive.
Laboratory values show the following:
White blood cells: 9000/µL
Hemoglobin: 12 g/dL
Potassium: 2.9 mEq/L
Aspartate transaminase: 45
U/L Albumin: 3.2 g/dL
Her x-ray shows an extremely distended colon.What is her likely diagnosis? toxic megacolon
A 72-year-old woman with a history of type 2 diabetes mellitus, coronary artery disease with multiple
stents, atrial fibrillation (AF), and longstanding irritable bowel syndrome presents with persistent
severe left-sided abdominal pain for the past 12 hours. Other than working in her garden for most of
the day, she denies any other significant activity. She also reports loose stools that have now become
bloody.
There is no history of eating new foods, traveling, or being exposed to any sick contacts.Vital signs are:
blood pressure 160/94 mm Hg, pulse 105 beats/minute and regular, respiratory rate 16
breaths/minute, and temperature 100.5 °F. The abdomen is soft, nondistended, with normal bowel
sounds, and not
crampy and intermittent in the epigastric area, and it is particularly worse after meals. She has a history
of gastric bypass surgery for weight loss management 2 years ago. On physical examination, she is
afebrile and her abdomen is soft and nontender with no masses.
Laboratory study results are as follows:
White blood cell count:
7400/µL Hemoglobin: 13.2 g/dL
Platelets: 215,000/µL
Albumin: 4.3 g/dL
Aspartate aminotransferase: 334
U/L Alanine transaminase: 282 U/L
Alkaline phosphorus: 115 U/L
Total bilirubin: 1.7 mg/dL
Amylase: 42 U/L
Lipase: 24 U/L
Abdominal ultrasonography demonstrates a normal-appearing liver, mild distension of the gallbladder
with several stones in the fundus of the gallbladder, but no apparent wall thickening or pericholecystic
fluid. The common bile duct is dilated to 1.3 cm. What is the next step in the management of this
patient's condition? endoscopic retrograde cholangiopancreatography (ERCP)
A 39-year-old man with a history of rheumatoid arthritis maintained on methotrexate is evaluated for a
several-month history of progressive fatigue, a 10-pound weight loss, and, recently, dark urine output
for the past 2 weeks.On physical examination, he is noted to have slight scleral icterus and a mildly
prominent liver edge. He does not appear to have any other stigmata of chronic liver disease. He is not
currently on any medications other than methotrexate and folic acid.Laboratory studies reveal the
following:
White blood cell count:
7700/µL Hemoglobin: 11.8 g/dL
Platelets: 150,000/ µL
Albumin: 3.6 g/dL
Aspartate aminotransferase: 78
U/L Alanine transaminase: 92 U/L
Alkaline phosphorus: 275 U/L
Total bilirubin: 4.8 mg/dL
,International normalized ratio: 1.3. Given these findings, magnetic resonance
cholangiopancreatography is ordered that demonstrates a hypertrophied caudate lobe with mild
intrahepatic biliary ductal dilatation and several areas of ductal narrowing. No other masses are seen.
Liver biopsy is performed and is notable for epithelial cell necrosis, ductopenia, and concentric fibrosis
around the bile ducts.Other than initiating treatment with ursodeoxycholic acid (UDCA), what else
should be recommended at this time? Colonoscopy
A 51-year-old man with hypertension and hyperlipidemia is found to have a mild elevation in his alanine
transaminase (ALT) level of 58 U/L with otherwise normal liver enzyme levels. He is taking simvastatin
20 mg, and he is otherwise asymptomatic with no significant abdominal complaints. Work-up for viral
hepatitis and other heritable and autoimmune liver diseases is unremarkable. Right upper quadrant
ultrasonography demonstrates a normal-appearing liver with no cholelithiasis and normal bile ducts.
There does appear to be extensive calcification of the gallbladder wall but with no obvious mass or
polyps. What is the next step in the management of this patient's condition? referral for
cholecystectomy
A 45-year-old woman with hypertension, type 2 diabetes mellitus, and morbid obesity presents to you
with intermittent, right-sided abdominal pain and dyspepsia. These symptoms have been present for the
past 6 months, but she experienced a severe episode 3 days ago lasting for approximately 4 hours. Her
current medications include losartan, metformin, and baby aspirin. She denies any recent use of
nonsteroidal anti-inflammatory drugs, acetaminophen, or alcohol. On physical examination, her blood
pressure is 140/85 mm Hg, pulse is 80 beats/minute, and she is afebrile. She does not have jaundice, and
abdominal examination reveals mild tenderness in the epigastrium.
Laboratory study results are as follows:
White blood cell count: 10,400/µL
Hemoglobin: 12.8 g/dL
Albumin: 4.1 g/dL
Aspartate aminotransferase: 245
U/L Alanine transaminase: 175 U/L
Alkaline phosphorus: 245 U/L
Total bilirubin: 3.7 mg/dL
Amylase: 335 U/L
Lipase: 520 U/L
,Due to her poor oral intake, you admit her for hydration and further work-up. Laboratory values on
hospital day 2 demonstrate improving liver chemistries as well as an amylase level of 175 U/L and a
lipase level of 330 U/L. Serologies for hepatitis A, B, and C are negative. Right-upper quadrant
ultrasonography reveals a liver with mild fatty infiltration, a normal caliber common bile duct, and no
gallbladder wall thickening or pericholecystic fluid. There are several shadowing lucencies with the
gallbladder suggestive of stones. Computed tomography is also obtained and demonstrates mild
pancreatic inflammation. She is feeling well, does not have pain on a low-fat diet, and she insists on
being discharged. What should be the next step in the management of her condition? Consult with a
surgeon to determine need for cholecystectomy.
A 52-year-old man with severe emphysema is admitted to the hospital with an exacerbation. On
hospital day 2, his clinical condition worsens with increasing oxygen requirements and significant
tachypnea that requires he be transferred to the intensive care unit and be intubated.He is started on
broad-spectrum antibiotics with initial improvement; however, by day 7, his white blood cell count is
increased to 19,000/µL. Repeat blood cultures do not have any growth by 72 hours, and there is no
evidence of urinary or Clostridium difficile infection, and Doppler ultrasonography of the lower
extremities does not reveal any clots.Right upper quadrant ultrasonography demonstrates a thickened,
distended gallbladder with no sludge or stones and mild pericholecystic fluid. The common bile duct
measures 4 mm. The patient remains on norepinephrine for blood pressure support.What is the next
step in the management of this patient's condition? cholecystostomy tube placement
A 42-year-old woman with history of asthma and hyperlipidemia presents with 2 days of anorexia
followed by nausea and vomiting. She also has developed abdominal pain that was initially periumbilical
and now has migrated to the right lower quadrant.On physical examination, the patient has a
temperature of 39 °C and her pulse is 122 beats/minute. There is localized tenderness in the right lower
quadrant. Complete blood count shows leukocytosis with left shift. Abdominal x-ray is shown in the
Figure. Appendicitis with appendicolith
A 53-year-old woman with a 15-year history of ulcerative pancolitis well-controlled by nonsteroidal anti-
inflammatory drugs presents to you for routine surveillance colonoscopy. Four-quadrant biopsies are
taken every 10 cm throughout the colon, and pathology reveals evidence of high-grade dysplasia but no
adenocarcinoma in 2 separate locations.What should be the next step in the management of this
patient's condition? Referral to a colorectal surgeon to consider total colectomy
A 47-year-old woman presents with a perirectal abscess that has formed a fistula. Which of the
following diseases is most likely to be associated with a predisposition to fistula formation in this
patient? Crohn disease
A 70-year-old woman presents with sharp, left-sided abdominal pain for the last 2 days. She tells you
that the pain is associated with nausea, vomiting, chills, and malaise. She denies any diarrhea.Her vital
, signs are: blood pressure 130/80 mm Hg, pulse 110 beats/minute, respiratory rate 18 breaths/minute,
and temperature 100.9° F. Abdominal examination reveals left lower abdominal tenderness, distention,
and normal bowel sounds with voluntary guarding and rigidity.Which of the following tests is most
useful for establishing a diagnosis? computed tomography (CT) of the abdomen
A 45-year-old man presents with frank blood in his stools for the past 2 months. His bowel
movements are not painful, but he experiences a sensation of incomplete evacuation and urgency
after each bowel movement. Complete blood count reveals a white blood cell count of 9500/µL, a
hemoglobin level of
12.8 g/dL, and platelet count of 552,000/µL.Colonoscopy is performed, and it demonstrates uniform
erythema and inflammation throughout the rectosigmoid, descending, and transverse colon. Biopsies
demonstrate inflammation extending to the submucosa with crypt abscesses consistent with ulcerative
colitis.Which of the following regimens is the most appropriate initial treatment for his ulcerative colitis
(UC)? Start oral mesalamine 800 mg 3 times a day in combination with mesalamine enemas every
hour until proctitis symptoms resolve.
A 60-year-old woman with arthritis and chronic intermittent diarrhea has an acute worsening of her
diarrhea with abdominal pain and distention. She has been unable to eat and has unintentionally lost 10
pounds.Her vital signs are: temperature 99.5° F, blood pressure 100/60 mm Hg, and pulse 94
beats/minute.She was unable to sit still on the examination table because of her abdominal pain. Her
heart beat is regular. Her lungs are clear. Her abdomen is diffusely tender with hypoactive bowel
sounds. She has red, tender lesions on her shins. Her rectal examination is guaiac positive.
Laboratory values show the following:
White blood cells: 9000/µL
Hemoglobin: 12 g/dL
Potassium: 2.9 mEq/L
Aspartate transaminase: 45
U/L Albumin: 3.2 g/dL
Her x-ray shows an extremely distended colon.What is her likely diagnosis? toxic megacolon
A 72-year-old woman with a history of type 2 diabetes mellitus, coronary artery disease with multiple
stents, atrial fibrillation (AF), and longstanding irritable bowel syndrome presents with persistent
severe left-sided abdominal pain for the past 12 hours. Other than working in her garden for most of
the day, she denies any other significant activity. She also reports loose stools that have now become
bloody.
There is no history of eating new foods, traveling, or being exposed to any sick contacts.Vital signs are:
blood pressure 160/94 mm Hg, pulse 105 beats/minute and regular, respiratory rate 16
breaths/minute, and temperature 100.5 °F. The abdomen is soft, nondistended, with normal bowel
sounds, and not
