Pregnant, Geriatric, and Immunocompromised Patients
Michelle A. Kominiarek, M.D., Edward F. Hollinger, M.D., Ph.D.
1 A 22-year-old woman who is 8 weeks pregnant arrives at the emergency department with persistent nausea and vomiting. She has not been able to tolerate any liquids for the past 3 days. On physical examination, she is afebrile, her pulse is 110 beats/min, and her blood pressure is 120/70 mm Hg. Her abdomen is soft, nontender, and nondistended. Moderate ketones are found on urinalysis. The next step in her evaluation includes:
A Intravenous hydration
B Liver function tests
C Right upper quadrant ultrasound
D Parenteral nutrition
E Abdominal computed tomography (CT)
Ref.: 1-3
Comments
See Question 3.
Answer
A
2 The differential diagnosis of nausea and vomiting in pregnancy includes all of the following except:
A Appendicitis
B Pyelonephritis
C Diabetic ketoacidosis
D Drug toxicity
E Renal insufficiency
Ref.: 1-3
Comments
See Question 3.
Answer
E
3 Treatment regimens for nausea and vomiting in pregnancy include:
A Vitamin B6
B Acupuncture
C Ginger root
D Dopamine antagonists
E All of the above
Ref.: 2, 3
Comments
Approximately 70% to 85% of pregnant women experience nausea and vomiting of varying intensity and for various lengths of time in pregnancy. Symptoms usually start 5 to 6 weeks after the last menstrual period. The severity and frequency of symptoms generally peak at approximately 9 weeks and then begin to subside. The diagnosis of nausea and vomiting of pregnancy (NVP) can be difficult to make in early pregnancy because many other conditions can cause nausea and vomiting. An important distinguishing feature of NVP is that it usually begins before 10 weeks’ gestation. Nausea and vomiting that begin after 10 weeks are most likely caused by a different etiology. The differential diagnosis includes gastroenteritis, gastroparesis, achalasia, biliary tract disease, hepatitis, intestinal obstruction, peptic ulcer disease, pancreatitis, and appendicitis. Mildly elevated liver enzymes (usually <300 U/L) and serum bilirubin (<4 mg/dL) are encountered in 20% to 30% of pregnant women. Similarly, serum concentrations of amylase and lipase (up to five times higher than normal levels) are seen in 10% to 15%.
The first-line treatment of NVP consists of conservative measures (dietary modifications and vitamin supplementation) along with patient reassurance. Medications effective in reducing nausea and vomiting without an increased risk for teratogenicity include antihistamines, hydroxyzine, meclizine, dopamine antagonists (chlorpromazine, metoclopramide, perphenazine, prochlorperazine, promethazine, trifluoperazine, trimethobenzamide), and pyridoxine. Patients with severe dehydration should be admitted to the hospital and treated with isotonic crystalloid solutions that contain glucose and supplemental potassium chloride.
Answer
E
4 A surgical consultation is requested on a patient who had undergone a cesarean delivery 5 days earlier. At the bedside, the Pfannenstiel incision shows separated skin and subcutaneous tissue with an intact fascia. There are no signs of infection and the probable diagnosis is a seroma. The next step in management is:
A Open the fascia.
B Close the wound with interrupted sutures immediately.
C Arrange for vacuum-assisted closure.
D Instruct the patient on wet-to-dry dressing changes with iodine solution.
E Débride the fascia and subcutaneous tissues.
Ref.: 4
Comment
In the United States, more than 30% of all deliveries are by cesarean section. Disruption of the skin incision is a major source of postoperative morbidity after cesarean delivery and occurs after 2.5% to 16% of procedures. Pfannenstiel incisions are the most common transverse incisions used in obstetrics and gynecology. Hematomas and seromas, common problems after cesarean delivery, require manual opening of the wounds to allow drainage and proper healing. An open wound can be managed in three ways: secondary closure, secondary intention with serial dressing changes, and secondary intention using negative pressure wound therapy. Secondary closure can be performed once a wound is free of infection or necrotic tissue and has started to granulate. This procedure, which may be performed at the bedside with the patient under local anesthesia or sedation (or both), is done within 1 to 4 days after the wound separates or the hematoma or seroma is evacuated. Negative pressure wound therapy, also known as vacuum-assisted closure, received U.S. Food and Drug Administration approval in 1995. In this system, controlled levels of negative pressure help accelerate wound healing by evacuating localized edema. Negative pressure treatment results in faster healing times with fewer associated complications and can be used for noninfected wounds. If a wet-to-dry approach is used, the solution should be nontoxic inasmuch as studies have shown that povidone-iodine, iodophor gauze, and hydrogen peroxide are cytotoxic to white blood cells (WBCs) and other vital wound-healing components. Use of these products can delay wound healing.
Answer
C
5 Risk factors for impaired wound healing after cesarean delivery include all of the following except:
A Obesity
B Diabetes
C Chorioamnionitis
D Prolonged rupture of membranes
E Preterm labor
Ref.: 4-6
Comment
Risk factors for wound breakdown after cesarean section include prolonged duration of surgery, obesity, diabetes, patient age, coincident infection, and poor nutrition. Obesity increases risk, probably as a result of the poor vascularity of subcutaneous fat and the propensity for serous fluid collections and hematoma formation. Suture closure of subcutaneous fat during cesarean delivery results in a 34% decrease in the risk for wound disruption in women with fat thickness greater than 2 cm. Other methods (antibiotic solutions, subcutaneous drains) have not been shown to be effective in preventing wound complications. The explanation for the difference in diabetic wound healing is complex but is probably related to alterations in the inflammatory response and differences in enzyme secretion and growth factor production. Recommendations to improve wound healing in diabetics are to avoid hyperglycemia and regulate insulin doses. Corticosteroids increase the risk for infection by suppressing inflammation, inhibiting leukocyte function, slowing wound contraction, decreasing collagen matrix deposition, and delaying epithelialization. Chorioamnionitis is an infection of the membranes (chorion, amnion) surrounding the fetus. The presence of chorioamnionitis increases the risk for wound infection tenfold. Preterm labor is not a risk factor for impaired wound healing.
Answer
E
6 A 32-year-old gravida 4 who is 29 weeks pregnant reports left leg pain and swelling for 3 days. A diagnosis of deep venous thrombosis (DVT) is suspected. The most appropriate test to diagnose DVT during pregnancy is:
A D dimer
B Contrast-enhanced venography
C Impedance plethysmography
D Compression duplex ultrasound
E Spiral CT of the chest
Ref.: 7
Comment
There is a predisposition for deep venous thrombosis to occur in the left leg (approximately 70% to 90% of cases). This is probably attributed to an exacerbation of the compressive effects of the uterus on the left iliac vein because of it being crossed by the right iliac artery. Clinical suspicion is critical for the diagnosis of DVT. However, many of the classic signs and symptoms of DVT and pulmonary embolism, such as leg swelling, tachycardia, tachypnea, and dyspnea, may be associated with a normal pregnancy. In nonpregnant patients, D-dimer levels have high negative predictive value and can reliably exclude the diagnosis of DVT. However, in pregnancy, the D-dimer level gradually increases, and therefore its value is not reliable in the evaluation of DVT. Contrast-enhanced venography should not be used in pregnant patients because it is invasive and involves a high radiation dose. Although impedance plethysmography has been evaluated in pregnancy and has proven accuracy in excluding DVT, it has been replaced by duplex ultrasound because of its higher sensitivity and specificity and wider availability.
Answer
D
7 Venous thromboembolism occurs four times more often in pregnant patients than in the general population. Physiologic changes that occur during pregnancy include:
A Decreased fibrin generation
B Increased fibrinolytic activity
C Increased levels of coagulation factors II, VII, VIII, and X
D Increased free protein S levels
E Improved venous flow velocity
Ref.: 8
Comment
Pregnancy is classically believed to be a hypercoagulable state. Fibrin production is increased; fibrinolytic activity is decreased; levels of coagulation factors II, VII, VIII, and X are all increased; free protein S levels are decreased; and acquired resistance to activated protein C is common. These physiologic changes, including increased markers of coagulation activation such as prothrombin fragment and D dimer, occur in all pregnancies. In addition, a 50% reduction in venous flow velocity occurs in the legs by 25 to 29 weeks of gestation and lasts until approximately 6 weeks after delivery.
Answer
C
8 The best treatment of acute venous thromboembolism in pregnancy is:
A Warfarin
B Low-molecular-weight heparin
C Unfractionated heparin bridge to a therapeutic international normalized ratio with warfarin
D Aspirin
E Vena cava filter
Ref.: 8
Comment
Treatment and prophylaxis of DVT in pregnancy center on the use of unfractionated heparin or low-molecular-weight heparin because of the teratogenicity associated with warfarin, which is known to cross the placenta. Warfarin-induced embryopathy is characterized by fetal midface hypoplasia, stippled chondral calcifications, scoliosis, short proximal limbs, and short phalanges. It occurs in 5% of fetuses exposed to the drug between 6 and 9 weeks of gestation. Because neither unfractionated heparin nor low-molecular-weight heparin crosses the placenta in a significant amount, there is no possibility of teratogenesis or fetal hemorrhage with these medications. The use of retrievable vena cava filters should be considered only for patients in whom anticoagulation is contraindicated or in whom extensive DVT develops 2 weeks before delivery.
Answer
B
9 Appendiceal perforation is more common in pregnant patients. What percentage of pregnant patients with appendicitis are initially seen with perforation?
A 5%
B 15%
C 25%
D 35%
E 55%
Ref.: 9
Comment
Appendicitis is the most common nonobstetric cause of acute abdominal pain leading to exploratory laparotomy. It occurs in 1 in 1500 deliveries. Urinary tract problems are often the initial diagnosis because up to 20% of pregnant patients with appendicitis have pyuria, hematuria, or both. If a perforation or peritonitis occurs, the fetal loss rate is 10% to 35% because of preterm labor and fetal demise. Preterm labor usually occurs within 5 days of the perforation. Delayed diagnosis is more likely to occur in the second (18%) and third (75%) trimesters. Perforation rates as high as 55% in pregnant patients have been reported, as opposed to 4% to 19% in the general population.
Answer
E
10 The imaging modality of choice for pregnant patients suspected to have appendicitis is:
A Obstructive series
B Right lower quadrant ultrasound
C Abdominal and pelvic CT with oral and intravenous contrast enhancement
D Magnetic resonance imaging (MRI)
E Lower gastrointestinal series (barium enema)
Ref.: 9-12
Comment
Ultrasonography with a graded compression technique is the imaging modality of choice in pregnant patients with right lower quadrant pain because of its availability and lack of ionizing radiation. This approach has some limitations. Graded compression ultrasound may not be feasible because of the size of the enlarged gravid uterus, particularly in the third trimester. Furthermore, a normal appendix is visualized in only 13% to 50% of patients who are not pregnant. The negative predictive value of a nonvisualized appendix is, at best, 90%. Consequently, if the appendix is not visualized and no other cause of the pain can be found, further evaluation is warranted. Computed tomography, which is often the modality of choice in the evaluation of acute appendicitis in patients who are not pregnant, delivers an estimated radiation dose as high as 30 mGy (3 rad) to the uterus with conventional protocols. A barium enema is also associated with significant radiation exposure and has generally been supplanted by other imaging tests for the evaluation of acute appendicitis. MRI has not been found to be safe during pregnancy.
Answer
B
11 Which of the following is true with respect to the management of appendicitis in pregnancy?
A An appendectomy during pregnancy increases the risk for congenital malformations and stillbirth.
B Fetal mortality can approach 35% for a ruptured appendix.
C Negative laparotomy rates of 50% are considered acceptable in the pregnant population.
D To decrease the risk for congenital malformations, antibiotics should not be given.
E Laparoscopic appendectomy is contraindicated during pregnancy.
Ref.: 1, 9, 10
Comment
In pregnancy, an elevated leukocyte count is normal (9 to 15 × 103 cells/mm3). In most cases, there is a gradual upward displacement of the appendix as the pregnancy progresses; however, some more recent studies suggest that there is no change in the location of the appendix during pregnancy. Hemoglobin levels decrease during a pregnancy, and hematuria is not a normal finding in a pregnant patient. An appendectomy does not increase the risk for stillbirth or congenital malformations. A higher negative laparotomy rate (up to 35%) is acceptable in the pregnant population (15% for the nonpregnant population) because of the serious consequences of delayed diagnosis. Perioperative antibiotics are appropriate in the pregnant population but should be tailored to the use of antibiotics with minimal risk for birth defects. A laparoscopic approach during pregnancy is appropriate in most gestations of less than 24 weeks.
Answer
B
12 A 39-year-old gravida 3 para 2 at 32 weeks’ gestation is evaluated for a 3-day history of nausea, vomiting, and anorexia. She also reports abdominal pain, primarily located in the right upper quadrant and epigastric areas. Her blood pressure is 120/60 mm Hg with a pulse of 110 beats/min and a temperature of 98.6° F. After completing the physical examination, the diagnosis of cholelithiasis is entertained. Which of the following conditions must also be considered in the differential diagnosis?
A Acute fatty liver of pregnancy (AFLP)
B Syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP)
C Appendicitis
D Pyelonephritis
E All of the above
Ref.: 1, 9, 13
Comments
See Question 14.
Answer
E
13 The patient’s pain improves with nonoperative management, including intravenous hydration, bowel rest, and analgesics. Her liver function tests, amylase, and lipase are normal. A right upper quadrant ultrasound confirms cholelithiasis without evidence of cholecystitis or obstruction. Select the safest plan for her management:
A Immediate laparoscopic cholecystectomy
B Endoscopic retrograde cholangiopancreatography (ERCP)
C Plan for postpartum cholecystectomy
D Induction of labor
E Continuation of antibiotic prophylaxis until delivery
Ref.: 1, 9, 13
Comments
See Question 14.
Answer
C
14 During pregnancy, when is the optimal time to perform abdominal operations?
A 5 to 9 weeks
B 10 to 13 weeks
C 15 to 18 weeks
D 26 to 28 weeks
E After 32 weeks
Ref.: 1, 9, 13
Comment
Biliary tract diseases are the second most common gastrointestinal disorders that require surgery during pregnancy. Pregnancy predisposes to gallstone formation because of increased bile lithogenicity and decreased gallbladder contractility caused by the effects of progesterone. Gallstones occur in approximately 3% to 12% of pregnant women, but most patients are asymptomatic. The incidence of acute cholecystitis is 1 to 8 per 10,000 pregnancies. Early surgery is recommended to avoid biliary complications because recurrent symptoms are common during pregnancy. Cholecystectomy should be deferred until the second trimester whenever possible. The rationale behind this recommendation is an increased rate of fetal loss with surgery in the first trimester and a greater risk for preterm labor during the third trimester. When symptoms are mild or the patient is in the third trimester, cholecystectomy can often be delayed until after delivery. An operation may need to be performed early for patients with gallstone pancreatitis, choledocholithiasis, or unresolving acute cholecystitis, regardless of gestational age.
Answer
C
15 When performing laparoscopic operations in a pregnant patient, which of the following is recommended?
A Antibiotic prophylaxis with a fluoroquinolone (e.g., levofloxacin)
B Right lateral decubitus positioning
C Limiting carbon dioxide pneumoperitoneum to 12 mm Hg for laparoscopy
D Using an umbilical entry site for laparoscopy for gestational ages beyond 24 weeks
E Performing open rather than laparoscopic procedures after 24 weeks’ gestation
Ref.: 1, 9, 13
Comment
The major general consideration when performing abdominal surgery on a pregnant woman is to maintain adequate perfusion to the uterus and fetus and decreasing maternal risks. To improve venous return, the patient should always be placed in a slight left lateral position. One should also use caution with a Veress needle because the gravid uterus is located closer and closer to the umbilical site with increasing gestational age. Accordingly, one may consider a left upper quadrant entry (Palmer point) at the midclavicular line 1 to 2 cm below the costal margin, open (Hassan) entry techniques, or placing the trocars under direct visualization. Carbon dioxide pneumoperitoneum should be limited to 12 mm Hg. During laparotomy, retractors should not come in contact with the uterus because this could lead to uterine irritability and preterm labor.
Answer
C
16 A 17-year-old gravida 1 at 25 weeks’ gestation is brought to the emergency department after a motor vehicle accident with direct abdominal trauma. She complains of abdominal pain. Initial management should include all of the following except:
A Establishment of the airway
B Maintenance of oxygenation
C Fluid resuscitation
D Administration of corticosteroids for fetal lung maturity
E Left lateral displacement of the uterus
Ref.: 1
Comment
Management of a pregnant trauma patient parallels that of a nonpregnant patient—the initial evaluation includes establishment of the airway, maintenance of oxygenation, and fluid resuscitation. Because the gravid uterus can compress the inferior vena cava in the supine position in the late second and third trimesters, turning the patient to the left side can displace the uterus and increase cardiac output up to 30%. Although this maneuver contradicts the principle of maintaining the patient in a supine position, spinal stabilization precautions can still be taken. For example, the patient may be transported in the left lateral decubitus position or the backboard rotated to the right. Early and rapid fluid resuscitation is important even in a pregnant patient who is normotensive. Corticosteroids are important for fetal lung maturation in the event of preterm delivery; however, they can be administered after the patient is stabilized.
Answer
D
17 What is typically the earliest sign of intravascular volume depletion (hypovolemia) in a young pregnant woman?
A Decreased systolic blood pressure
B Increased respiratory rate
C Increased heart rate
D Decreased heart rate
E Decreased capillary refill
Ref.: 1
Comment
Trauma complicates approximately 6% to 7% of all pregnancies. Regardless of the injury, resuscitation of the mother with treatment of hypovolemia and hypoxia is emphasized during the initial evaluation. Because blood volume expands during pregnancy, a third of the blood volume may be lost without a noticeable change in blood pressure or heart rate. Clinically significant blood loss of up to 2 L, or 30% of the total blood volume, may not be readily apparent. The clinician must be aware of a falsely reassuring hemodynamic state masking ongoing hemorrhage.
Answer
C
18 Which of the following radiologic examinations poses the greatest radiation exposure to a fetus?
A Chest radiograph (two views)
B Abdominal film (single view)
C CT of the head
D CT of the abdomen/pelvis
E CT pelvimetry
Ref.: 14, 15
Comment
In pregnancy, the cumulative radiation dose should be less than 5 rad; this dose has not been associated with an increase in fetal anomalies or loss of pregnancy (Table 36-1).
TABLE 36-1 Estimated Fetal Exposure from Some Common Radiologic Procedures
|
Procedure |
Exposure |
|
Abdominal film (single view) |
100 mrad |
|
Chest radiography (2 views) |
0.02-0.07 mrad |
|
Intravenous pyelography |
≥1 rad* |
|
Hip film (single view) |
200 mrad |
|
Mammography |
7-20 mrad |
|
Barium enema or small bowel series |
2-4 rad |
|
CT of head or chest |
<1 rad |
|
CT of abdomen and lumbar spine |
3.5 rad |
|
CT pelvimetry |
250 mrad |
* The exposure also depends on the number of films.
Answer
D
19 A 25-year-old gravida 1 at 37 weeks’ gestation is being evaluated for right upper quadrant abdominal pain. On examination, she is found to be afebrile with a blood pressure of 130/70 mm Hg, pulse of 110 beats/min, and respiratory rate of 18 breaths/min. She has scleral icterus. Her laboratory results are as follows:
|
Test |
Value |
Normal Range for Pregnancy |
|
Hemoglobin |
12 |
10.5-12 g/dL |
|
White blood cells |
20,000 |
3200-15,000/mL |
|
Platelets |
111,000 |
150,000-350,000/mm3 |
|
Prothrombin time |
40 |
12.5 s |
|
Blood urea nitrogen |
29 |
7-18 mg/dL |
|
Creatinine |
2.8 |
0.6-0.9 mg/dL |
|
Aspartate transaminase |
317 |
7-27 |
|
Alanine transaminase |
297 |
1-21 |
|
Total and direct bilirubin |
7.8/4.6 |
<1.0 mg/dL, <0.4 mg/dL |
|
Glucose |
48 |
70-110 mg/dL |
The most likely diagnosis in this patient is:
A AFLP
B Viral hepatitis
C Thrombotic thrombocytopenic purpura
D Hemolytic-uremic syndrome
E HELLP syndrome
Ref.: 16
Comment:
Acute fatty liver of pregnancy is rare (1 in 7000 to 16,000 deliveries). It occurs more commonly in male fetuses and twins. It is related to an autosomally inherited mutation that causes a deficiency of long-chain 3-hydroxyacyl coenzyme A dehydrogenase, a fatty acid β-oxidation enzyme. AFLP is usually manifested in the third trimester as nausea and vomiting, followed by right upper quadrant pain. A 7- to 10-day prodrome of a viral illness is common as well. Hepatomegaly is rare, but other findings include progressive jaundice, malaise, somnolence, and coma. Laboratory abnormalities include liver and renal dysfunction, coagulopathy, increased ammonia, leukocytosis (20,000 to 50,000), hypoglycemia, and pancreatitis. Although the laboratory results may also be consistent with HELLP syndrome, hypoglycemia is one of the distinguishing factors in AFLP. Treatment consists of supportive measures to correct the coagulopathy, electrolyte abnormalities, and hypoglycemia, as well as prompt delivery. Maternal mortality is very low with early diagnosis, appropriate supportive therapy, and early delivery. The fetal mortality rate associated with AFLP is less than 15%.
Answer
A
20 Many unplanned pregnancies occur after bariatric surgery, in part because of improved fertility rates in patients who were infertile before the procedure. Most experts recommend waiting between bariatric surgery procedures and pregnancy. Select the most appropriate time frame:
A 2 to 3 months
B 6 to 8 months
C 12 to 14 months
D 18 to 24 months
E >2 years
Ref.: 17
Comment
Most clinicians recommend waiting at least 18 months between bariatric surgery and conception. In this case, the fetus is not exposed to a rapid maternal weight loss environment, and the patient can achieve full weight loss goals.
Answer
D
21 The leading cause of maternal morbidity and mortality in the developed world is:
A Postpartum hemorrhage
B Thromboembolism
C Preeclampsia
D Uterine rupture
E Pneumonia
Ref.: 18, 19
Comment
In 2006, the national maternal mortality rate was 13.3 deaths per 100,000 live births. Maternal mortality is defined as the number of maternal deaths (direct and indirect) per 100,000 live births. ‘‘Maternal deaths’’ are defined by the World Health Organization as ‘‘the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.’’ Direct obstetric deaths result primarily from thromboembolic events (19.9%), hemorrhage (18.2%), hypertensive disorders of pregnancy (15.9%), and infectious complications (13.2%). Indirect obstetric deaths arise from preexisting medical conditions, including diabetes, systemic lupus erythematosus, pulmonary disease, and cardiac disease aggravated by the physiologic changes of pregnancy.
Answer
B
22 A 32-year-old woman in the first trimester of her second pregnancy comes to the emergency department because of epigastric pain, anorexia, vomiting, and low-grade fever. Which of the following findings would be considered normal in a pregnant patient?
A WBC count of 20,500 cells/mm3
B Respiratory rate of 40 breaths/min
C PCO2 of 32 mm Hg on arterial blood gas analysis
D Amylase concentration of 500 U/L
E Serum creatinine level of 1.6 mg/dL.
Ref.: 1, 9
Comments
During pregnancy, a number of physiologic changes occur, such as increases in plasma volume and red blood cell mass. The platelet count is generally normal or slightly decreased, whereas the WBC counts increase from 3000 to 15,000 cells/mm3 in the first trimester to 6000 to 16,000 cells/mm3 during the second and third trimesters. Progesterone and increased CO2 production contribute to the hyperpnea of pregnancy. There is a reduction in arterial PCO2from the usual 40 mm Hg to 28 to 35 mm Hg and an increase in arterial oxygen tension (PO2) from 60 mm Hg to 100 mm Hg. This facilitates efficient exchange of gases between the mother and fetus. A respiratory alkalosis with compensatory metabolic acidosis is normal in pregnancy. The glomerular filtration rate increases, with a concomitant decrease in normal serum creatinine levels. Serum osmolality is also decreased. Serum amylase values remain normal to slightly elevated during pregnancy. A significant elevation in amylase along with abdominal pain suggests pancreatitis; in pregnancy, the most common causes of pancreatitis are gallstones and hypertriglyceridemia.
Answer
C
23 A 37-year-old gravida 1 at 31 weeks is taken to the emergency department with complaints of midepigastric pain, nausea, and vomiting that began 30 minutes after eating a fatty meal. Her surgical history is significant for a Roux-en-Y gastric bypass 2 years earlier. Her body mass index is currently 32 kg/m2. On examination, the patient’s temperature is 39° C and her abdomen is diffusely tender with rebound and guarding. The fetal heart rate was slightly tachycardic (170 beats/min), and the cervix was not dilated. The differential diagnosis should include all of the following except:
A Cholelithiasis
B Chorioamnionitis
C Internal hernia
D Pancreatitis
E Preterm labor
Ref.: 1, 9, 17
Comments
See Question 24.
Answer
E
24 The patient’s amylase and lipase levels are normal. Right upper quadrant ultrasonography shows a normal gallbladder and liver. Her abdominal pain worsens, and she is tachycardic to 130 beats/min. The fetal heart rate also continues to be tachycardic (170 beats/min). What is the next step in management?
A Laparotomy
B Cesarean delivery
C Intravenous methylprednisolone to induce fetal lung maturity
D Tocolysis to prevent preterm delivery
E ERCP
Ref.: 1, 9
Comments
The number of bariatric surgery procedures performed annually has dramatically increased—from 12,480 in 1998 to 113,500 in 2005. More than 80% of these patients are female, and one half of the bariatric procedures in 2004 were performed in women of reproductive age with a mean age of 40 years. Evaluation of abdominal pain in pregnancy is complicated by difficulty in differentiating symptoms of pathology from normal, pregnancy-associated symptoms. The evaluation becomes even more difficult in a pregnant patient who has undergone bariatric surgery. Confusion regarding the cause of symptoms can lead to a critical delay in the diagnosis of bariatric surgery complications, including anastomotic leaks, bowel obstruction, internal hernias, ventral hernias, band erosion, and band migration. All gastrointestinal complaints such as nausea, vomiting, and abdominal pain, which occur commonly during pregnancy, should be thoroughly evaluated in a bariatric surgery patient. This patient has an acute abdomen, which is concerning for bowel obstruction or an internal hernia. Although her pregnancy may have an impact on anesthesia and postoperative care, immediate treatment should focus on her abdominal complaints. Cesarean delivery is not indicated. Corticosteroids (betamethasone or dexamethasone) are administered to patients between 24 and 34 weeks’ gestation if delivery is anticipated within 7 days. They promote fetal lung maturity and decrease the risk for interventricular hemorrhage. Other steroids, such as prednisone or methylprednisolone, do not cross the placenta. The patient is not in labor (the cervix is not dilated), so tocolytic agents will not be helpful. ERCP can be performed during pregnancy; fluoroscopy should be limited and the fetus should be shielded, but some radiation exposure will occur. ERCP is unlikely to be helpful in this patient.
Answer
A
25 A 32-year-old woman who is 23 weeks pregnant finds a 1.5-cm firm mass during a breast self-examination. An ultrasound-guided core needle biopsy shows infiltrating ductal carcinoma. Which of the following would be the most appropriate treatment option?
A Lumpectomy, axillary dissection, and immediate radiation therapy and chemotherapy
B Lumpectomy, axillary dissection, immediate chemotherapy, and radiation therapy after delivery
C Lumpectomy, axillary dissection, immediate radiation therapy, and chemotherapy after delivery
D Immediate radiation therapy and chemotherapy followed by surgery after delivery
E Termination of the pregnancy followed immediately by treatment of breast cancer
Ref.: 1
Comments
Breast cancer that is diagnosed during pregnancy or within 1 year after delivery is termed pregnancy-associated breast cancer. Breast cancer represents the most common nongynecologic malignancy associated with pregnancy, and it occurs in 0.01% to 0.03% of pregnancies. It has been associated with delayed diagnosis (mean delay of 1 to 2 months). When compared with matched, nonpregnant patients, women with pregnancy-associated breast cancer have a similar stage-related prognosis but overall worse prognosis because on average they have larger primary tumors and a higher risk for lymph node involvement. Mammography can be performed with the fetus appropriately shielded; however, the increased density of the fibroglandular breast tissue limits its specificity. Ultrasound imaging is useful both for assessing the tumor and for guiding biopsy. Although MRI can be used during pregnancy, gadolinium crosses the placenta and may be associated with a risk for fetal abnormalities. As with breast masses in a nonpregnant patient, a tissue diagnosis is imperative. Either core-needle or fine-needle aspiration biopsy may be used. Surgical resection represents the most important component of treatment. Classically, modified radical mastectomy was considered the standard therapy. More recent data suggest that patients in whom breast cancer is diagnosed later in pregnancy can be treated with immediate breast-conserving lumpectomy and axillary dissection, followed by radiation therapy after delivery. Axillary dissection rather than sentinel lymph node biopsy has been recommended because of the more aggressive nature of pregnancy-associated breast cancer and because no radioisotope is required. Most chemotherapeutic regimens can be administered safely after the first trimester, although changes in plasma volume, protein content, and the volume of distribution associated with chemotherapeutic agents crossing the placenta may complicate dosing. Radiation therapy should be avoided until after delivery because of the risk to the fetus. Pregnancy termination to allow the full gamut of therapeutic options for breast cancer is not recommended because it has not been shown to increase patient survival.
Answer
B
26 A 43-year-old woman is profoundly neutropenic because of intensive chemotherapy for acute myeloid leukemia. She has a temperature of 103.4° F with right lower quadrant pain, guarding, and rebound tenderness, although she remains hemodynamically stable. A kidney, ureter, and bladder film shows an enlarged, fluid-filled cecum with adjacent dilated loops of small bowel. The radiologist suspects that there is some localized pneumatosis in the cecum. What is the most appropriate next step in the management of this patient?
A Barium enema
B Colonoscopy
C Exploratory laparoscopy
D CT scan of the abdomen
E Capsule endoscopy
Ref.: 20, 21
Comments
See Question 27.
Answer
D
27 Abdominal CT scan in the patient in Question 26 demonstrated marked thickening and edema of the cecum with localized pneumatosis. The appendix is not inflamed. The adjacent small bowel is thickened and mildly dilated. Which of the following would be least appropriate?
A Rectal tube decompression of the colon
B Broad-spectrum intravenous antibiotics
C Administration of granulocyte colony-stimulating factor (G-CSF)
D Stool evaluation for Clostridium difficile toxin
E Nasogastric decompression of the stomach
Ref.: 20, 21
Comments
Neutropenic enterocolitis (or Typhilitis) is a necrotizing colitis seen in patients with profound neutropenia that often occurs after myelosuppressive chemotherapy. It can also occur in patients with aplastic anemia, human immunodeficiency virus (HIV) infection, and acute leukemia or after immunosuppressive therapy for solid tumors or organ transplants. The pathogenesis appears to include mucosal injury, bacterial translocation, intramural infection, and bowel wall ischemia with eventual necrosis. Typhilitis is typically characterized by thickening and edema of the cecum, although the distal ileum and ascending colon may also be involved. Typical symptoms include fever and abdominal pain, usually in the right lower quadrant. Other symptoms may include nausea, vomiting, distention, and watery or bloody diarrhea. Abdominal CT is useful in differentiating typhlitis from other causes of abdominal pain, such as appendicitis, abscess, Ogilvie syndrome, or pseudomembranous colitis. Operative findings include cecal wall thickening with edema or air, a soft tissue mass, hemorrhage, or perforation. Ultrasound imaging can also be used, although it is less specific. Barium enema or colonoscopy should be avoided because of the risk for perforation or additional bacterial translocation.
Prompt surgical intervention is required for patients with peritonitis, free perforation, or persistent gastrointestinal bleeding. If surgery is required, a right hemicolectomy and diversion should be performed, with reanastomosis reserved for a later procedure when the patient has stabilized and the neutropenia has resolved. Treatment of patients who do not meet the criteria for surgery includes bowel rest, nasogastric decompression, intravenous hydration, nutritional support, and broad-spectrum antibiotics. G-CSF can be used to accelerate normalization of the leukocyte count. Anticholinergic, antidiarrheal, and opioid analgesics should be avoided because of their propensity to worsen the ileus. Blood and stool cultures and C. difficile toxin assays should be obtained. In patients who do not improve after a short course of antibiotics, antifungal therapy should be added. Rectal tube decompression should be avoided in neutropenic patients because of the risk for mucosal compromise and bacterial translocation.
Answer
A
28 A 62-year-old woman with long-standing end-stage renal disease who is being maintained on peritoneal dialysis (PD) has had several months of intermittent abdominal pain and difficulty obtaining normal dwell volumes for her peritoneal catheter. She goes to the emergency department because she was unable to adequately drain her peritoneal fluid. Review of her medical records reveals that her creatinine level has slowly been increasing for the last several months without any change in her dialysis regimen. Abdominal CT shows ascites; shortened, thickened small bowel mesentery; and diffusely thickened small bowel with areas of luminal narrowing. There are punctuate calcifications throughout the peritoneum. Which of the following is least appropriate?
A Trial of tamoxifen therapy
B Oral steroid pulse
C Replacement of the PD catheter
D Immunosuppressive therapy with azathioprine
E Exploratory laparoscopy and enterolysis
Ref.: 22, 23
Comments
Encapsulating peritoneal sclerosis (EPS, sclerosing peritonitis) is one of the most feared complications of peritoneal dialysis. EPS is characterized by a decrease in the efficacy of PD and the development of extensive intraperitoneal fibrosis, mesenteric shortening, and encasement of the bowel. It can progress to bowel obstruction. Radiologic features include mesenteric, bowel, and peritoneal thickening, often with calcifications. Loculated ascites, adherent bowel loops, and luminal narrowing of the bowel may also be visualized. The etiology of EPS is not well understood. Risk factors include the duration of PD therapy, episodes of peritonitis, and acetate dialysis. Treatment is often unsuccessful. Most patients with EPS are switched to hemodialysis (although such a switch can sometimes precipitate EPS). Steroid therapy, tamoxifen, and immunosuppressive regimens, including azathioprine or cyclosporine, have all been used to treat EPS. When bowel obstruction is present, total parenteral nutrition may be required. The role of surgical therapy for EPS remains controversial. Early results with enterectomy and anastomosis have shown high mortality, but more recent studies suggest a role for early enterolysis.
Answer
C
29 A 54-year-old woman with end-stage renal disease treated by PD complains of abdominal pain and fever. When performing her exchanges she has noted turbid fluid for the last several days. She has been undergoing PD for 3 years and has never had any complications. Which of the following statements is correct?
A She should undergo immediate peritoneal exploration with removal of the dialysis catheter.
B Fungal peritonitis requires long-term antifungal therapy through the PD catheter.
C PD-associated peritonitis from coagulase-negative staphylococci can be cured with antibiotics alone in more than 80% of cases.
D She will need to resume hemodialysis while the infection is treated.
E Broad-spectrum empirical antibiotic therapy is required because peritoneal fluid cultures have little value.
Ref.: 24
Comments
Peritonitis is a common complication of peritoneal dialysis and occurs about 1.4 times per patient-year of PD. It is one of the most important reasons for failure of PD and accounts for nearly one half of all technical failures. Typically, patients have abdominal pain and tenderness (75%), fever (33%), and cloudy dialysate. The diagnosis is confirmed by a fluid leukocyte count of greater than 100/mL with more than one half of the cells being neutrophils. Most infections are caused by gram-positive organisms, but gram-negative bacilli and fungi can also be responsible. Initial treatment should consist of intraperitoneal antibiotics, most commonly vancomycin or a first-generation cephalosporin. About 75% of infections are cured with culture-directed antibiotic therapy without discontinuation of PD. Persistent or recurrent infection may require removal of the PD catheter and a switch to hemodialysis. Cure rates with antibiotics alone are best for coagulase-negative staphylococci (90%) and less for Staphylococcus aureus (66%) or gram-negative bacilli (56%). Fungal infections require prompt removal of the catheter. Prompt treatment of peritoneal infections is important to reduce the formation of adhesions and the loss of peritoneal area, which can limit the patient’s ability to continue with PD.
Answer
C
30 A 76-year-old man with cardiac, liver, and renal disease is admitted to the intensive care unit with fever, hypotension, and abdominal distention. An abdominal ultrasound reveals ascites. His serum albumin level is 3.2 g/dL, and the albumin concentration in the ascites fluid is 2.8 g/dL. This serum-ascites albumin gradient (SAAG) is most supportive of which of the following diagnoses?
A Cardiac ascites
B Cirrhosis
C Myxedema
D Nephrotic syndrome
E Alcoholic hepatitis
Ref.: 24
Comments
The most useful tests for characterizing ascites are cell counts, differential count, and the total protein and albumin concentrations of the fluid. If the fluid has a high neutrophil concentration, an acute inflammatory process is suggested. The serum-ascites albumin gradient provides one of the most useful tools for characterizing the cause of ascites (Box 36-1). SAAG is calculated by subtracting the albumin concentration of the ascites fluid from that of serum. High-SAAG ascites (SAAG ≥1.1 g/dL) is associated with portal hypertension. Causes include cirrhosis, alcoholic or cardiac ascites, liver metastases, fulminant hepatic failure, Budd-Chiari syndrome, myxedema, and portal vein thrombosis. Low-SAAG ascites (SAAG <1.1 g/dL) is associated with tuberculous peritonitis, pancreatic or biliary ascites, nephritic syndrome, and lymphatic leaks.
BOX 36-1
From Runyon B: Ascites: spontaneous bacterial peritonitis. In Sleisenger MH, Feldman M, Friedman LS, editors: Sleisenger and Fordtran’s gastrointestinal and liver disease: pathophysiology, diagnosis, management, ed 7, Philadelphia, 2002, WB Saunders, p 1523.
Classification of Ascites by Serum-Ascites Albumin Gradient
High Gradient (≥1.1 g/dL)
Cirrhosis
Alcoholic hepatitis
Cardiac ascites
Massive liver metastases
Fulminant hepatic failure
Budd-Chiari syndrome
Portal vein thrombosis
Myxedema
Low Gradient (<1.1 g/dL)
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Biliary ascites
Nephrotic syndrome
Postoperative lymphatic leak
Serositis in connective tissue disease
Answer
D
31 A 64-year-old man with end-stage renal disease is visiting from Mexico. He is evaluated in the emergency department for worsening vague abdominal pain, occasional vomiting, and abdominal swelling. The pain has been present intermittently for several months but has worsened over the last few weeks. He has lost about 30 lb and has no appetite or energy. A purified protein derivative (PPD) skin test is positive, and the patient gives a history of being successfully treated for tuberculosis (TB) several years ago. Ultrasound shows moderate ascites with echogenic material within the fluid. Which of the following tests would be most appropriate to confirm a diagnosis of tuberculous peritonitis?
A CT of the abdomen and pelvis
B Percutaneous peritoneal biopsy
C Microscopic examination of peritoneal fluid
D Mycobacterial cultures of peritoneal fluid
E Diagnostic laparoscopy and peritoneal biopsy
Ref.: 24, 25
Comments
Tuberculous peritonitis is most commonly associated with individuals with acquired immunodeficiency syndrome; however, it can also occur in the setting of cirrhosis (especially alcoholic) and chronic renal failure. Most cases result from reactivation of latent peritoneal disease in patients with previous pulmonary TB. Typical complaints include abdominal distention from ascites and generalized abdominal discomfort. Constitutional symptoms, including fever, night sweats, anorexia, and malaise, may also be present. Most patients have a positive PPD skin test. In the absence of cirrhosis, the ascites has a low serum-ascites albumin gradient, high glucose, high protein, and high fluid WBCs, mainly lymphocytes. Abdominal ultrasound may show echogenic material within the ascites, whereas CT shows a thickened, nodular mesentery, lymphadenopathy, and omental thickening. Laparoscopic peritoneal biopsy is diagnostic. Most commonly the peritoneum is studded with multiple small whitish nodules, which on biopsy contain caseating granulomas. Blind peritoneal biopsy has much lower sensitivity than directed biopsy. Microscopic examination of the ascites for acid-fast bacteria is rarely positive, and cultures are relatively insensitive (20%) and require several weeks of incubation. Tuberculous peritonitis can be manifested as a pelvic mass with elevated CA 125, which can lead to an incorrect diagnosis of metastatic ovarian cancer. Treatment consists of 6 to 9 months of antituberculous drugs; regimens typically include rifampin, isoniazid, and pyrazinamide.
Answer
E
32 A 39-year-old HIV-positive man who is noncompliant with his antiretroviral medications wishes a second opinion because of a worsening condition that started a month earlier with abdominal pain, diarrhea, low-grade fever, and malaise. He has a history of Pneumocystis carinii pneumonia. Abdominal CT had shown thickening of the terminal ileum with a small amount of surrounding fluid. Colonoscopy showed circumferential ulcers and inflamed mucosa; biopsy of the cecum and terminal ileum showed granulomas. Therefore, a diagnosis of Crohn disease was made and the patient was treated with steroids. However, 1 month later his symptoms are worse, and repeated CT shows increased cecal and peritoneal thickening, ascites, and large mesenteric lymph nodes with hypodense centers. Suspecting that the initial diagnosis may have been in error, which of the following conditions is the most likely diagnosis?
A Crohn disease
B Cecal carcinoma
C Tuberculous enteritis
D Intestinal amebiasis
E Small bowel lymphoma
Ref.: 26, 27
Comments
The differential diagnosis for ileocecal thickening or a mass includes neoplasms such as lymphoma, sarcoma, and adenocarcinoma; Crohn disease; and infectious causes such as amebiasis, histoplasmosis, actinomycosis, Yersinia, or intestinal TB. Because the symptoms of many of these conditions overlap, a careful diagnostic approach is needed. Commonly, evaluation includes imaging and colonoscopy with biopsy. Many of these conditions may result in ulcers. However, the finding of granulomas on biopsy led to the diagnosis of Crohn disease. Carcinoma or lymphoma biopsy specimens should show malignant cells. A biopsy specimen revealing intestinal amebiasis should show trophozoites, and stool studies and serologic evaluation should confirm the diagnosis. Tuberculous enteritis can be confused with Crohn disease because both have granulomas, although the granulomas in Crohn disease are infrequent, small, nonconfluent, and noncaseating. Tuberculous granulomas are larger and confluent, often with caseating necrosis. Imaging of TB may show large lymph nodes with characteristic central caseous liquefaction. Many patients will have pulmonary manifestations of previous TB infection, although active disease is often not present. Culture results may take several weeks to become positive, and it is being supplanted by polymerase chain reaction (PCR) testing of biopsy specimens. Treatment of intestinal TB consists of antituberculosis drugs, with surgery being reserved for patients with an abscess or fistula, uncontrolled bleeding, perforation, or complete obstruction. Misdiagnosis of TB as Crohn disease is particularly unfortunate because immunosuppressive therapy can result in miliary dissemination.
Answer
C
33 A 48-year-old man underwent HLA-matched allogeneic bone marrow transplantation for myelofibrosis with myeloid metaplasia. One month after discharge, he returned to the clinic with a 2-week history of anorexia, malaise, low-grade fevers, and difficulty swallowing. His tongue was chalky white. Esophagogastroduodenoscopy revealed white plaques throughout the esophagus, and colonoscopy showed linear, well-demarcated ulcers in the terminal ileum and cecum. He was prescribed oral nystatin and treated for his neutropenia. Two days later severe abdominal pain develops, and CT shows a perforation at the distal ileum. Which of the following is the most likely cause of the ileal perforation?
A Epstein-Barr virus (EBV)
B Cytomegalovirus (CMV)
C Parvovirus
D Candida albicans
E Herpes simplex virus
Ref.: 28, 29
Comments
Cytomegalovirus infection can result in serious complications in patients who are immunosuppressed, including patients with HIV infection, organ transplants, or cancer or those receiving immunosuppressive therapy. The most common site of CMV disease is the eye, and CMV retinitis can result in blindness. Gastrointestinal involvement can occur anywhere from the mouth to the anus, although the colon is most commonly involved. Clinical symptoms include fever, malaise, anorexia, nausea, diarrhea, abdominal pain, ileus, and bleeding. Endoscopic evaluation shows well-defined, “punched-out” ulcers. Lesions are usually limited to a segment of the gastrointestinal tract, with diffuse involvement being less common. Biopsies usually show mucosal inflammation, tissue necrosis, and vascular endothelial involvement. Visualization of viral inclusions by light microscopy remains the standard of diagnosis. CMV typically causes gastritis, enteritis, or colitis, but in rare cares it can result in perforation and significant gastrointestinal bleeding. Viral serology and quantitative PCR may be helpful in diagnosing CMV enteritis, but endoscopy with biopsy remains the gold standard. EBV can be associated with viral syndromes and lymphomas but rarely causes perforation. Parvovirus causes anemia. Invasive Candida infections very rarely cause perforation, although this patient did have findings of superficial esophageal candidiasis. Herpes simplex virus has cutaneous manifestations and may result in proctitis, but perforation does not usually occur.
Answer
B
34 Which of the following should not be included in the initial approach to a profoundly neutropenic patient with fever?
A Skin, mucous membrane, and ophthalmoscopic examination
B Inspection and cultures from central venous access
C Digital rectal examination
D Chest radiograph
E Initiation of empirical antibiotic therapy
Ref.: 30
Comments
Determining the cause of a fever in a neutropenic patient requires careful attention to detail because signs of infection or inflammation are often subtle or absent in patients with profound neutropenia. The skin, mucous membranes, and ocular fundi should be carefully examined for an infectious source. All access sites, including intravenous and central lines, should be checked for soft tissue infection or thrombophlebitis. Mucous membranes should be examined for signs of viral or fungal infection. All indwelling catheters should be cultured. Laboratory studies should include urine and blood cultures from peripheral sites and all indwelling lines. Stool should be sent for study if there are any changes in bowel habits. Lumbar puncture should be performed in patients who have altered mental status or localizing symptoms. A chest radiograph should be performed; however, the findings may be subtle or absent even with pneumonia. Chest CT may demonstrate evidence of infection not revealed on radiography. Empiric antibiotic therapy should be initiated promptly and modified on the basis of the results of examination, imaging, and culture. Anorectal infection can be very subtle in immunosuppressed patients. Routine digital rectal examination should be avoided because of the risk of provoking bacteremia. However, if prostatitis or a perirectal abscess is suspected, gentle digital rectal examination can be performed after antibiotic therapy is initiated.
Answer
C
35 Which of the following strategies is least useful for improving surgical outcomes in geriatric patients?
A Preoperative evaluation of medical physiologic status
B Optimization of physical and cognitive function
C Minimization of perioperative nutritional deficiency
D Postoperative assessment for rehabilitation options
E Surgical risk assessment based on a specific diagnosis
Ref.: 31-34
Comments
There are several important factors in achieving positive surgical outcomes in geriatric patients. Assessment of a patient’s preoperative physical and cognitive function, along with optimization of these variables, is critical in elderly patients. Ignorance of these variables may result in more aggressive surgical procedures and poor outcomes. As the risks associated with surgical therapy increase, elderly patients may opt for palliative procedures, which allow resumption of preoperative independence and activities of daily life, as opposed to more radical procedures, which entail a prolonged convalescence and questionable quality of life. Elderly patients may be at risk for malnutritionbecause of physical and cognitive disabilities, poverty, and lack of awareness of the importance of a balanced diet. Patients with more than 10% weight loss and serum albumin level less than 2.5 g/dL should be considered to have protein-energy malnutrition and may benefit from a minimum of 7 to 10 days of nutritional repletion before surgery. Proper preoperative rehabilitation planning has been shown in patients with hip fractures to result in quicker resumption of independent living. Surgical risk assessment is multifactorial and not based on a specific diagnosis. Physical fitness, cognitive fitness, and social factors (e.g., family and financial support), in addition to a specific diagnosis and surgical plan, are part of a thorough preoperative risk assessment.
Answer
E
36 Regarding the following several scenarios, which one of the operations can proceed as scheduled?
A An 80-year-old scheduled for cataract surgery who has a pulse of 60 beats/min and a blood pressure of 180/110 mm Hg and is completely asymptomatic
B A 67-year-old scheduled for left total hip arthroplasty who has a pulse of 80 beats/min and blood pressure of 180/110 mm Hg, is asymptomatic, and takes β-blockers
C A 65-year-old hypertensive scheduled for bilateral total knee arthroplasty who has a pulse of 90 beats/min and a blood pressure of 130/70 mm Hg and who takes angiotensin-converting enzyme (ACE) inhibitors
D An 80-year-old scheduled for bilateral laparoscopic hernia repair who has a pulse of 42 beats/min and a blood pressure of 100/60 mm Hg and who has a pacemaker and takes β-blockers
E None of the above operations should proceed
Ref.: 33-35
Comments
Management of hypertension in the perioperative period remains controversial. However, several studies have consistently shown that a preoperative diastolic blood pressure higher than 110 mm Hg confers increased risk for major morbidity. Aggressive perioperative normalization may not reduce the risk. However, the patient in scenario A is scheduled for a low-risk operation, unlike the patient in scenario B. Therefore, the operation in scenario A can be performed safely as long as the patient has adequate follow-up. Angitensin-converting enzyme inhibitors have been associated with severe perioperative hypotension during major surgery, especially in patients who receive an epidural catheter as part of their management. The patient in scenario D may have a pacemaker malfunction that needs to be evaluated. β-Blockers have been shown to decrease intraoperative ischemia and should be continued. Calcium channel blockers and diuretics may be continued.
Answer
A
37 Following small bowel resection, a 75-year-old patient is agitated and calling out for his deceased wife. He requires restraints. Which of the following statements is incorrect regarding his condition?
A Postoperative delirium may occur in up to 15% of patients 70 years or older.
B Postoperative delirium increases the risk for other complications.
C Preoperative assessment of cognitive function should be routine in patients older than 75 years for major elective surgery.
D Postoperative delirium may indicate the onset of another disease process.
E In geriatric patients, regional anesthesia is associated with a lower incidence of postoperative delirium than general anesthesia is.
Ref.: 35-37
Comments
Postoperative delirium is a common and serious problem in the geriatric population. Delirium occurs in 15% of patients 70 years and older. The risk is greater following orthopedic procedures, with rates as high as 60%. Marcantonio identified seven factors to stratify risk for the development of delirium that are useful in deciding who will benefit from perioperative delirium prevention. New-onset postoperative delirium may be caused by multiple factors, including drugs, disease, and depression. Pain and nausea control is essential, as is the avoidance of anticholinergics, antihistamines, and benzodiazepines, according to the Beers criteria. Controversy exists regarding whether the anesthetic technique has an effect on postoperative delirium. However, recent studies indicate no relationship between the severity of postoperative delirium and anesthetic technique.
Answer
E
38 Which of the following is not true when comparing geriatric patients with younger patients?
A Elderly patients have lower creatinine values.
B The risk for hypothermia is greater in elderly patients.
C Fever is a less reliable sign of infection in elderly patients.
D Colonic pathology is the most common indication for surgery in elderly patients.
E Cardiac complications are the leading cause of perioperative complications in the elderly.
Ref.: 35
Comments
When obstetric procedures are excluded, more than 40% of operations are performed in patients older than 65 years. Elderly surgical patients represent a heterogenous group, and physiologic age is generally of greater importance than chronologic age. To optimize the care of older patients, it is critical to understand age-related changes in physiology. Because decreased muscle mass occurs with aging, baseline serum creatinine levels may decrease in the elderly despite progressive loss of renal function. Geriatric patients are at increased risk for hypothermia because of impaired mechanisms of heat conservation, especially during operative procedures. Decreased muscle mass and metabolic heat production, malnutrition, and increased heat loss as a result of thinning skin all contribute to this phenomenon. Fever is not a reliable indicator of infection in elderly patients and may be absent in up to one third of patients with serious infections. It is important to evaluate the patient’s baseline temperature, with fever being suspected with an elevation in temperature of greater than 2° above baseline. Malnourished geriatric patients or the extremely old are especially unlikely to mount a febrile response to infection. Biliary tract disease, including acute cholecystitis, is the most common indication for surgical intervention in elderly patients. This may be related to the increased lithogenicity of bile and increased prevalence of cholelithiasis. Cardiac complications are the leading cause of perioperative problems and death in all age groups but are of particular importance in elderly patients because of the prevalence of preexisting cardiac dysfunction and poor functional reserve.
Answer
D
39 Following cholecystectomy, an 82-year-old patient has an oxygen saturation of 88% on 2 L of oxygen by nasal cannula. Which of the following is not a probable explanation for this phenomenon?
A Maximal breathing capacity is 50% of what the patient had at age 30.
B The cough mechanism is less effective in elderly patients.
C The pulse oximetry reading is spurious.
D The patient was recently repositioned from supine to a sitting position.
E The patient required conversion from laparoscopic to open cholecystectomy.
Ref.: 31, 32, 35
Comments
Pulmonary complications represent some of the most common adverse events in elderly surgical patients; they account for up to 50% of postoperative complications and 20% of preventable deaths. Decreased strength and endurance of respiratory muscles, decreased lung volumes, and decreased compensatory responses to hypoxia or hypercapnia make tachypnea a less reliable sign of impending respiratory failure. Furthermore, changes in the respiratory system limit the maximal breathing capacity at age 70 to about one half that present at age 30. Decreased airway sensitivity, dysfunctional mucociliary clearance, and decreased muscle strength all contribute to a decreased cough mechanism. Shivering, a common postoperative phenomenon, dramatically increases oxygen consumption, which could cause hypoxia. In addition, movement of the patient could result in a spurious pulse oximetry reading. The patient’s positioning has a direct effect on ventilation-perfusion mismatch and the alveolar-arterial oxygen gradient. In contrast to sitting, a supine position results in closure of small airways in the dependent portion of the lung. This leads to ventilation-perfusion mismatch and may contribute to hypoxemia. Therefore, placing a patient in a sitting position should improve oxygenation. Unlike laparoscopic cholecystectomy, open cholecystectomy entails an upper abdominal incision, which results in decreased tidal volume, impaired diaphragmatic excursion with resultant hypoxemia, and an increased risk for atelectasis and pneumonia.
Answer
D
40 Which of the following statements regarding age-related changes in the cardiovascular system is not correct?
A Ventricular contractility decreases.
B Sympathetic nervous system activity decreases.
C Mean arterial pressure increases.
D Left ventricular afterload increases.
E Myocardial contraction is prolonged.
Ref.: 31, 32, 35
Comments
Aging is associated with functional and structural changes in the heart and blood vessels, as well as alterations in autonomic regulatory mechanisms. The myocardium becomes thicker and stiffer, with reduced conduction fiber density and a decrease in the number of cells within the sinus node. These changes lead to decreased contractility and increased filling pressures. The elastic arteries become larger and stiffer, which results in increased mean arterial pressure and pulse pressure. The larger, stiffer arteries lead to increased pulse wave velocity, which allows earlier reflection of the pulse waves from the peripheral circulation. The reflected waves may reach the heart during end-systole, thereby increasing cardiac afterload. Decreased ventricular compliance and increased afterload cause a compensatory prolongation of myocardial contraction and decreased early ventricular filling time. Because the ventricle has less time to fill, the contribution of the atrium becomes more significant. Thus, elderly patients are less tolerant of arrhythmias such as atrial fibrillation. The activity of the sympathetic nervous system increases, although decreased receptor affinity and alterations in signal transduction lead to decreased β-receptor responsiveness. This impairs an elderly patient’s ability to increase the heart rate and ejection fraction in response to physiologic stress and may contribute to intraoperative hemodynamic lability.
Answer
B
41 A 74-year-old man is admitted for cardiac surgery. His preoperative creatinine level is 1.6 mg/dL. Which of the following statements about renal function in elderly patients is correct?
A Renal blood flow decreases by 10% to 20% by the age of 80.
B Loss of renal mass is most pronounced in the renal medulla.
C Renal capacity to retain sodium is decreased.
D Urinary tract infections are almost always symptomatic.
E Bladder distention is common in elderly patients because the bladder becomes more elastic.
Ref.: 31-33, 35
Comments
Nearly one fourth of all Americans 70 years or older have moderate or severely decreased renal function. With age, there is progressive loss of renal mass (up to 30% at 80 years), especially in the renal cortex. Nephrosclerosisincreases, afferent and efferent arterioles atrophy, and the number of renal tubular cells decreases. Renal blood flow decreases by 5% to 10% per decade, with a 50% decrease being common in elderly patients. On average, the glomerular filtration rate decreases by 45% by age 80. However, the progressive decline in lean body (muscle) mass may result in serum creatinineconcentrations remaining constant or even decreasing. Because of a decline in renin-angiotensin axis activity, the kidneys’ capacity to conserve sodium decreases, thereby leading to a propensity for sodium loss when salt intake is inadequate. There is also a marked decline in the subjective feeling of thirst in response to increases in serum osmolarity. The kidneys become less responsive to antidiuretic hormone. These changes lead to an increased risk for dehydration. Asymptomatic urinary tract infections are more common in elderly patients. Urinary tract infections are responsible for 30% to 50% of all cases of bacteremia in older individuals. Increased collagen content causes the bladder to become less distensible. Prostate hypertrophy can impair bladder emptying in males, and decreased serum estrogen levels and impaired tissue responsiveness to estrogen in females predispose to incontinence.
Answer
C
42 A 77-year-old man is admitted after a radical prostatectomy. On postoperative day 3, a productive cough and fever develop. A chest radiograph shows a right lower lobe infiltrate. Which of the following is correct regarding immune function in older patients?
A WBC counts increase significantly even with mild infections.
B The T-cell response to new antigens is impaired.
C Normal neutrophil counts decline with age.
D Normal acute phase protein levels are decreased.
E Normocytic anemia is uncommon in older patients.
Ref.: 35
Comments
The ability to mount an immune response becomes blunted with age, which leads to increased susceptibility to infections and increased tumorigenesis. These changes are particularly apparent under physiologic stress. Elderly patients with infections often have normal WBC counts, but the differential will show a profound left shift with many immature cells. Although baseline neutrophil counts remain relatively constant, the ability of the bone marrow to increase neutrophil production when indicated is diminished. Decreased T-cell production by the bone marrow, as well as thymic involution, impairs the production and differentiation of naïve T cells and therefore leads to a weakened response to new antigens. Chronic infection with viruses such as CMV may also alter T-cell function. Inflammatory cytokinelevels are persistently elevated, as are levels of acute phase proteins. Chronic inflammation is believed to contribute to frailty, including loss of muscle mass, impaired nutrition, and decreased mobility. It may also contribute to the normocytic anemia commonly seen in elderly patients.
Answer
B
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