If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.
This month’s stumper
A 60-year-old alcoholic man is brought to the emergency department with hematemesis. His pulse is 110 beats per minute, blood pressure is 100/60 mm Hg and respirations are 19 per minute. He has multiple spider angiomata on his back and chest, and bilateral gynecomastia.
Abdominal examination is significant for hepatosplenomegaly, and a distended abdomen which is tympanic on percussion. His testicles are small and a rectal examination produces guaiac-negative stool. His hematocrit is 23 percent. After placement of a nasogastric tube, 400 mL of bright red blood is evacuated.
After initial fluid resuscitation, which of the following is the most appropriate next step in management?
A. Barium swallow.
B. Esophageal balloon tamponade.
D. Exploratory celiotomy.
E. Selective angiography.
F. Transjugular intrahepatic portosystemic shunt.
The correct answer is C.
Kaplan Medical explains why
The patient has a history of alcohol abuse and signs of chronic liver disease, and now presents with an upper gastrointestinal bleed (UGIB). The sudden onset of hematemesis in the absence of abdominal pain in a patient with chronic liver disease is consistent with hemorrhage from esophageal varices.
However, one-half to two-thirds of patients with cirrhosis who present with a UGIB have a nonvariceal source, and many have more than one source. Therefore, prompt identification of the origin of bleeding is crucial to guiding therapy.
Why the other answers are wrong
Choice A: Esophagogastroscopy is the appropriate first step in identifying, and in many cases treating, the source of bleeding. Barium swallow has no role in the diagnosis of a UGIB.
Choice B: Esophageal balloon tamponade is used in patients with a confirmed diagnosis of variceal hemorrhage who continue to bleed despite endoscopic treatment.
Choice D: Emergent celiotomy is reserved for patients who continue to bleed despite endoscopic therapy.
Choice E: Angiography is used only when esophagogastroscopy has failed to reveal a bleeding source.
Choice F: A transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneous connection within the liver, between the portal and systemic circulations. TIPS placement diverts portal blood flow into the hepatic vein and thus decreases the pressure gradient in patients with portal venous hypertension.
TIPS is indicated in acute variceal bleeding that cannot be successfully controlled with medical treatment. Therefore, it would not be used in this patient until other measures have been attempted.
For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.
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