WBR0524

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 65 yr old male comes to the emergency department with severe upper abdominal pain. The pain started suddenly and is of 9/10 on pain grading scale. The pain is radiating to back and aggravated upon any movement. His past history is significant for peptic ulcer disease and is on H2 blockers and proton pump inhibitors. He is a known hypertensive on thiazide medications. He doesn’t smoke or consume alcohol. He denies any bloody vomit, constipation, diarrhea and black stools. On examination pulse is 110/min and BP is 110/60 mmHg. Abdomen is markedly tender and he does not allow further investigations. Cardiovascular and respiratory examinations are normal. Lab investigations show hemoglobin and hematocrit of 13 g/dl and 36, respectively, Na:142 mEq/L, K : 3 mEq/L, Cl: 105 mEq/L, Bi: 24 mEq/L, BUN: mg/dl, glucose: 110 mg/dl, Ca: 10mg/dl and elevated amylase levels. Which of the following is the diagnostic test of choice in this patient?]]
Answer A	AnswerA::Abdominal CT
Answer A Explanation	[[AnswerAExp::Incorrect : When there is no free air on the plain film and diagnostic uncertainty persists, a high resolution CT should be performed using water soluble oral contrast and carefully examined for free air or fluid, mucosal disease, local inflammation such as fat stranding, and evidence of contrast extravasation.]]
Answer B	AnswerB::Abdominal X-ray
Answer B Explanation	AnswerBExp::'''Correct''' : An upright chest film and abdominal films should be examined for free air. Careful interpretation can detect diagnostic free air in most cases. If free air is found, no additional diagnostic studies are necessary.
Answer C	AnswerC::Gastrodeodenogram
Answer C Explanation	[[AnswerCExp::Incorrect : If a CT is not available or is not needed for clinical diagnosis, a carefully performed gastroduodenogram using water soluble contrast is likely to detect most macro-leaks. Leakage of water soluble contrast (Gastrografin) is a useful confirmatory. test.]]
Answer D	AnswerD::Serum lipase
Answer D Explanation	[[AnswerDExp::Incorrect : Serum amylase and lipase are useful for diagnosis of acute pancreatitis and not peptic ulcer disease.]]
Answer E	AnswerE::Abdominal USG
Answer E Explanation	[[AnswerEExp::Incorrect : Abdominal USG are not as useful as abdominal X-ray for ruling out perforation emergencies.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::The major complications of peptic ulcer disease include bleeding, perforation, penetration, and gastric outlet obstruction. Although a history of preceding ulcer symptoms is common, many patients have no preceding typical peptic ulcer symptoms or known disease. Ulcer perforation should be suspected in patients with a history of peptic ulcer symptoms who develop the sudden onset of severe, diffuse abdominal pain. Rapid diagnosis is essential since the prognosis is excellent within the first six hours, but deteriorates with more than a 12-hour delay. The presence of free air is highly suggestive of perforated duodenal ulcer (DU), although about 10 to 20 percent of patients with a perforated DU will not have free air in which case CT abdomen help in making the diagnosis. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Peptic ulcer disease
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