WBR0520

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Inpatient Facilities
Sub Category	SubCategory::Gastrointestinal, SubCategory::Hematology, SubCategory::Surgery
Prompt	[[Prompt::A 55 year old man underwent an abdominoperineal resection for a stage 1 rectal cancer. During the surgery, he received 3 units of packed red blood cells. After successful resection, the patient was sent to the intensive care unit for close monitoring. Five hours later, in the intensive care unit, he started bleeding heavily from his perineal wound. Emergency coagulation studies were ordered and it revealed the following results Prothrombin time: 12 seconds Partial thromboplastin time: 64 seconds Bleeding time: 3 minutes Fibrin degradation products: 3 mg/L Serum fibrinogen: 160 mg/dL Platelet count: 80,000/μL The most likely cause of bleeding in this patient is]]
Answer A	AnswerA::Factor VIII deficiency
Answer A Explanation	[[AnswerAExp::Incorrect-Factor VIII deficiency (hemophilia A) leads to intraoperative bleeding and it would have lead to bleeding earlier in this long operation. Partial thromboplastin time or activated partial thromboplastin time will be prolonged.]]
Answer B	AnswerB::Disseminated intravascular coagulation
Answer B Explanation	[[AnswerBExp::Incorrect-Disseminated intravascular coagulation can cause early postoperative bleeding. But prothrombin time, partial thromboplastin time and bleeding time will be prolonged along with a decrease in platelet counts.]]
Answer C	AnswerC::Blood transfusion reaction
Answer C Explanation	[[AnswerCExp::Incorrect-Blood transfusion reactions can cause diffuse loss of clot integrity and a sudden diffuse bleeding during an operation may be the only evidence of an intraoperative transfusion reaction. In the postoperative period, transfusion reactions usually present as unexplained fever, apprehension, and headache, which all are difficult to interpret in the early postoperative period.]]
Answer D	AnswerD::A bleeding blood vessel in the surgical field
Answer D Explanation	[[AnswerDExp::Correct-Whenever significant bleeding happens in the early postoperative period with normal coagulation profile, the presumption should always be towards an error in the surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively.]]
Answer E	AnswerE::Acquired von Willebrand disease
Answer E Explanation	[[AnswerEExp::Incorrect-Acquired postoperative von Willebrand disease is an uncommon disease, which manifests with prolonged postoperative bleeding and laboratory findings like prolonged partial thromboplastin time or activated partial thromboplastin time and prolonged bleeding time.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::Whenever significant bleeding happens in the early postoperative period, the presumption should always be towards an error in the surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively. The low platelet count here could be due to post transfusion hemodilution. Educational Objective: Whenever significant bleeding happens in the early postoperative period with normal coagulation profile, the presumption should always be towards an error in the surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Factor VIII deficiency, WBRKeyword::hemophilia A, WBRKeyword::von Willebrand disease, WBRKeyword::Disseminated intravascular coagulation
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::