Answer and Explanation 22

22.  B is the correct answer.  The accepted standard of care is attempted barium enema reduction before surgery.  It can be diagnostic and therapeutic.  An NG tube may help symptomatic relief but the patient needs to have this reduced.  A colonoscopy would not be helpful at this point.

Question 22

22.   Your patient is a 55 year old male who presents with abdominal pain nausea and vomiting.  His abdomen is distended.  You have ordered a CT scan that shows a volvulus.  Which of the following is the best management plan?

A.  Consult general surgery, the patient needs to go to the operating room.

B.  Order a barium enema

C.  Consult GI for a colonoscopy

D.  Insert a nasogastric tube and admit the patient to hospital to internal medicine.

Answer and Explanation 21

21.  The correct answer is A.  In the rectal area, there is sensory innervation below the dentate line, above that there is no sensory innervation.  So pathology above that is likely to be painless, and pathology below that is going to be painful.  External hemorrhoids are below the dentate line.  Internal hemorrhoids at least originate above the dentate line.  AVM in the sigmoid and rectal carcinoma would be above the dentate line.

Question 21

21.  Which of the following is not likely to be the cause with painless bright red rectal bleeding?

A.  External hemorrhoids

B.  Internal Hemorrhoids

C.  AVM in the sigmoid

D.  Rectal Carcinoma

Answer and Explanation 20

20.   The correct answer is D.  This is an thrombosed external hemorrhoid.  The patients pain will be dramatically with an incision and drainage of this lesion.  Anusol cream would help the inflammation but not the pain very much.  Bactrim and Keflex would be helpful if this was a peri-rectal abscess.  Referral for a biopsy would appropriate if malignancy was suspected or if you were uncertain about the etiology of the lesion.

Question 20

20.  Your patient is a 50 year old male that presents with severe rectal pain with the lesion shown below.  He has noted some bright red blood with wiping at times.  The pain started today.

Based upon the above above data, which of the following is the best management option?

A.  Start the patient Anusol HC cream

B.  Start the patient of bactrim and keflex

C.  Refer the patient for a biopsy

D.  Incision and drainage of the thrombosed external hemorrhoid

Answer and Explanation 19

19.  D is the correct answer.  This patient has air fluid levels and dilated loops of bowel characteristic of  a small bowel obstruction.  Bentyl is an anti-cholinergic that could potentially slow bowel motility and make the patient worse.  Magnesium Citrate should not be given until the bowel obstruction resolves.  This would increase the pressure at the transition point and decrease the probability that this would reverse medically.  Hydrocodone, an opiate, like bentyl will slow bowel motility.  This patient needs an NG tube and bowel rest.