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Small Bowel Obstruction MCQs

QUESTION:  A 55 y/o woman presents to the emergency room with crampy abdominal pain. On plain film of her abdomen you notice multiple air-fluid levels and distension of her small bowel. Her colon appears decompressed. She also has pneumobilia despite never having surgery before or manipulation of her biliary system. The most appropriate next action is:

a. Start broad spectrum antibiotics

b. Exploratory laparotomy

c. Percutaneous cholecystostomy tube

d. Endoscopic retrograde cholangiography

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 ANSWER

The asnwer is b. Pneumobilia (in a patient who has never had manipulation of her biliary system) associated with small bowel obstruction is most consistent with gallstone ileus. The gallbladder in this patient has eroded into the duodenum and a large gallstone is now causing a small bowel obstruction. This patient needs exploration.

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QUESTION: The primary surgery for patients with gallstone ileus consist of:

a. open the ileum and removing the obstruction

b. whipple

c. cholecystectomy

d. hepaticojejunostomy

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ANSWER 

The answer is a. The primary surgery in this patient is to relieve the small bowel obstruction. That involves feeling for the gallstone, opening the ileum, and removing the stone. The secondary procedure, if the patient can tolerate it, is cholecystectomy and closure of the hole in the duodenum.

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QUESTION: A patient presents with a small bowel obstruction and the early signs of sepsis. An abdominal xray shows air in the biliary tree. Correct management is:

a. ERCP with sphincterotomy

b. Glucagon

c. Exploratory laparotomy, removal of gallstone from small bowel and cholecystectomy

d. Exploratory laparotomy, removal of gallsone from terminal ileum only

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ANSWER 

The answer is d. Air in the biliary tree with small bowel obstruction is a classic picture of a gallstone ileus. This is a fistula between the gallbladder and the duodenum. Management only necessitates removal of the obstruction. If the patient is stable then cholecystectomy with closure of the duodenum is possible.

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QUESTION: A spry octogenarian who has never before been hospitalized is admitted with signs and symptoms typical of a smal-bowel obstruction. Which of the following clinical findings would provide the most help in ascertaining the diagnosis?

a. Coffee-ground aspirate from the stomach

b. Aerobilia

c. A leukocyte count of 40,000/uL

d. A pH of 7.5, PCO2 of 50 kPa, and paradoxical acid urine

e. A palpable mass in the pelvis

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 ANSWER

 The answer is b. (Greenfield, pp806-807)

 The finding of air in the biliary tract of a nonseptic patient is diagnostic of a biliary enteric fistula.

 When the clinical findings also include small-bowel obstruction in an elderly patient without a history of prior abdominal surgery (a virgin abdomen), the diagnosis of gallstone ileus can be made with a high degree of certainty.

 In this condition, a large chronic gallstone mechanically erodes through the wall of the gallbladder into adjacent stomach or duodenum.

 As the stone moves down the small intestine, mild cramping symtoms are common.

 When the gallstone arrives in the distal ileum, the caliber of the bowel no longer allows passage, and obstruction develops.

 Surgical removal of the gallstone is necessary.

 The disease suggested by the other response items (bleeding ulcer, peritoneal infection, pyloric outlet obstruction, pelvic neoplasm) are common in elderly patients, but each would probably present with symptoms other than those of small-bowel obstruction

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QUESTION: For each patient, select the likely diagnosis.

a. Spontaneous bacterial peritonitis

b. Perforated hollow viscus

c. Ruptured spleen

d. Ruptured echinococcal liver cyst

e. Gallstone ileus

f. Emphysematous cholecystitis

g. Sigmoid volvulus

h. Cecal volvulus

#379: A 65 year old previously healthy man presents with severe abdominal pain that came on suddenly. He has abdominal tenderness and guarding in all four quadrants on physical examination. A radiograph is obtained and demonstrates a radiolucency under the right hemidiaphragm.

#380: An 82 year old nursing home patient presents to the emergency room with vomiting, abdominal pain, and distention. A radiograph is obtained and demonstrates a grossly dilated loop of intestine overlying the sacrum in the shape of an upside-down U.

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ANSWER 

The answers are 379-b; 380-g

(Townsend, pp1226-1227, 1422-1424)

A radiolucency under the right hemidiaphragm demonstrates pneumoperitoneum.

Only a perforated viscus can produce this radiographic appearance in conjunction with diffuse peritonitis.

A perforated diverticulum, perforated gastric ulcer, perforated transverse colon carcinoma, or strangulated hernia with necrotic bowel are all included in the differential dianogsois.

A sigmoid volvulus appears radiographically on plain film of the abdomen as an upside-down U or bent inner tube.

Acute sigmoid volvulus presents in the eldergy with nausea, vomiting, abdominal distention, colicky abdominal pain, and obstipation.

The first diagnostic and often thrapeutic maneuver should be a sigmoidoscopy.

Patients with evidence of necrosis or perforation should undergo emergent exploratory laparotomy

Recurrent sigmoid volvulus should be treated with sigmoid resection.

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QUESTION: A 65 year old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate management of this patient?

[ABDOMINAL X-RAY SHOWING DISTENDED LARGE BOWEL]

a. Urgent colostomy or cecostomy

b. Discontinuation of anticholinergic medications and narcotics and corrections of metabolic disorders

c. Digital disimpaction of fecal mass in the rectum

d. Diagnostic and therapeutic colonoscopy

e. Detorsion of volvulus and colopexy or resection

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ANSWER

The ansewrv is d. (Greenfield, pp810-811)

Ogilvie syndrome describes the condition in which massive cecal and colonic dilation is seen in the absence of mechanical obstruction.

Other terms used to describe this condition are acute colonic pseudo-obstruction, colonic ileus, and functional colonic obstuction.

It tends to occur in elderly patients in the setting of cardiopulmonary insufficiency, in other systemic  disorders that require prolonged bed rest, and in the postoperative state.

The diagnosis of Ogilvie syndrome cannot be confirmed until mechanical obsruction of the distal colon is excluded by colonoscopy or contrast enema.

Anticholinergic agents and narcotics need to be discontinued, but any delay in decompressing the dilated cecum is inappropriate since colonic ischemia and perforation become a distinct hazard as the cecum reaches this degree of dilation (>10 to 12cm).

In patients with less than 10cm of dilation and no evidence of ischemic bwowel, management consists of bowel rest, nasogastric suctioning if vomiting, correction of metabolic abnormalities, and discontinuation of medications that diminish gatrointestinal motility.

In patients with persitent distention or a dilated cecum greater than 10cm, cautious endoscopic colonic decompressoin can be performed, or a sympatholytic agent such as neostigmine can be administered , with appropriate hemodynamic monitoring.

Surgery is indicated in all patients in whom performation or ischemic bowel is suspected.

SOURCES

MCAT

 

USMLE STEP 1

        

CLINICAL ROTATIONS

                      

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