Gastrointestinal Emergencies practice questions

Answer: B) Splenic injury

• AIncorrect. This doesn't fit trauma.
• BCorrect. Blood irritating the diaphragm refers pain to the shoulder.
• CIncorrect. Referred pain suggests spleen.
• DIncorrect. This doesn't fit.

Answer: A) Intravesicular (bladder) pressure measured through the indwelling urinary catheter

Intra-abdominal pressure is measured indirectly through the bladder via a Foley catheter. IAH is IAP of 12 mm Hg or higher, and abdominal compartment syndrome is sustained IAP above 20 mm Hg with new organ dysfunction.

• ACorrect. Indirect intravesicular measurement is the gold standard. Instill 25 mL of sterile saline, zero the transducer at the midaxillary line at the iliac crest, and read at end-expiration with the patient supine. Sustained IAP above 20 mm Hg with new organ dysfunction defines abdominal compartment syndrome.
• BIncorrect. Girth shows distension, but it does not measure intra-abdominal pressure and is not used to define intra-abdominal hypertension or compartment syndrome.
• CIncorrect. Physical examination alone is unreliable for detecting raised intra-abdominal pressure. A tense abdomen should prompt objective IAP measurement.
• DIncorrect. CVP may be falsely raised by intra-abdominal hypertension, but it does not measure intra-abdominal pressure and cannot diagnose abdominal compartment syndrome.

Answer: A) A sunken fontanelle and no tears

• ACorrect. Report it promptly.
• BIncorrect. That suggests good hydration.
• CIncorrect. That suggests good hydration.
• DIncorrect. That suggests raised pressure.

Answer: A) Acute mesenteric ischemia

• ACorrect. Emboli can block bowel arteries.
• BIncorrect. Pain out of proportion is a red flag.
• CIncorrect. The exam and history suggest ischemia.
• DIncorrect. It's a red flag presentation.

Answer: A) Endotracheal intubation, then placement of a balloon tamponade tube such as a Sengstaken-Blakemore tube

When variceal bleeding continues despite drugs and endoscopy, a balloon tamponade tube can control it temporarily after the airway is secured with intubation. The tube serves as a bridge to repeat endoscopy or TIPS.

• ACorrect. The inflated balloons press directly on the varices and give temporary control of the bleeding. Intubation is required first because of the high risk of aspiration and airway obstruction. The tube is a short-term bridge (the esophageal balloon usually stays inflated no longer than 24 hours) to repeat endoscopy or TIPS.
• BIncorrect. Balloon tamponade carries a high risk of aspiration and airway obstruction, especially with active hematemesis. Endotracheal intubation is required before the tube is inserted.
• CIncorrect. Iced saline lavage does not compress or control variceal bleeding and is not a recommended hemostatic measure. A standard NG tube provides no tamponade.
• DIncorrect. Acid suppression helps with peptic ulcer bleeding but does not lower portal pressure or control variceal bleeding. It is not a rescue measure when drugs and endoscopy have failed.

Answer: A) Intussusception

• ACorrect. Prompt reduction is needed.
• BIncorrect. This causes projectile vomiting in young infants.
• CIncorrect. Currant jelly stools suggest intussusception.
• DIncorrect. This doesn't cause these stools.

Answer: B) A Mallory-Weiss tear at the gastroesophageal junction

Bright red hematemesis after forceful retching, with no signs of mediastinal or subcutaneous air, points to a Mallory-Weiss mucosal tear. A full-thickness rupture (Boerhaave syndrome) lets air escape into the mediastinum and chest.

• AIncorrect. Forceful vomiting can rupture the full thickness of the esophageal wall. This lets air leak into the mediastinum and chest, and the patient usually has severe chest pain and subcutaneous emphysema. This patient has none of those findings.
• BCorrect. Forceful retching or vomiting can tear the mucous membrane where the lower esophagus joins the stomach. The result is bright red hematemesis, and the bleeding often stops by itself. Because only the lining is torn, no air leaks into the mediastinum.
• CIncorrect. A perforated ulcer causes peritonitis with severe abdominal pain and fever. It is not typically a small bleed that follows retching in a patient who is otherwise stable.
• DIncorrect. Varices form because of portal hypertension, usually from cirrhosis. They tend to bleed heavily and cause instability, and they do not depend on retching first. This patient has no liver disease, a small bleed, and stable vital signs.

Answer: C) Cover the site and replace the tube promptly

• AIncorrect. It needs replacement.
• BIncorrect. The tract may close.
• CCorrect. The tract can begin closing within hours.
• DIncorrect. That's unsafe.

Answer: D) Keep the patient NPO and prepare for prompt endoscopic removal

A sharp object lodged in the esophagus can perforate it, so expect to keep the patient NPO and prepare for prompt endoscopic removal. Watching for passage, barium studies, and emetics delay care or add risk.

• AIncorrect. Observation may suit some small, blunt objects, such as coins in low-risk children. A sharp object in the esophagus can perforate the wall, so it should not be left in place to see whether it passes.
• BIncorrect. The object is already located, and the study would only delay removal. If perforation is a concern, water-soluble contrast is preferred because barium leaking into the mediastinum can cause chemical mediastinitis.
• CIncorrect. Emetics are ineffective for esophageal foreign bodies and can be dangerous. Forceful vomiting can drive a sharp object into the esophageal wall.
• DCorrect. Esophageal foreign bodies are most often removed endoscopically, and sharp objects carry a high risk of perforation, so removal should be prompt. Keeping the patient NPO prepares them for the procedure.

Answer: B) Fecal-oral route

• AIncorrect. That is hepatitis B or C.
• BCorrect. Contaminated food and water spread it.
• CIncorrect. It is fecal-oral.
• DIncorrect. It is fecal-oral.