All Q Emergency PDF

Anesthesiology VV ARDS - Timing of a known clinical insult within 2 weeks -> F (1 week) - Abdominal sepsis may be a cause of ARDS -> T - Tidal volume should be adjusted accordingly to the weight of the paDent -> T (5ml/k) - It generally includes the presence of lung edema a...

Anesthesiology VV ARDS - Timing of a known clinical insult within 2 weeks -> F (1 week) - Abdominal sepsis may be a cause of ARDS -> T - Tidal volume should be adjusted accordingly to the weight of the paDent -> T (5ml/k) - It generally includes the presence of lung edema and an increased permeability of alveolar capillary membrane. T - It is similar to the pathophysiology of COVID-19 pneumonia F - It causes hypoxemia normally associated with the presence of intra-pulmonary right-to-left shunting T - In most cases it induces a reduction of the respiratory system compliance T - It generally excludes the presence of lung edema due to increased capillary hydrostatic pressure of the pulmonary circulation T 8) The use of prone position during ARDS: A) It is effective only in case of COVID-19 pneumonia F B) It should be considered in patients with a PaO2/FiO2, value higher than 150 mmHg F C) It often causes an improvement of hypoxemia despite a clear pathophysiological mechanism T D) It is widely applied worldwide T - E) It normally induces a redistribution of lung densities towards the dependent lung regions T In a patient with severe ARDS, the application of PEEP: - It is always indicated T (in general yes but depends on pt) - Its effects depends on the distribution of lung densities T - The application of high levels should be based on the potential for lung recruitment T - It should not excess 10cmH20 F - It may correct hypoxemia by reducing the amount of right to left intrapulmonary shunting T - Acid-base equilibrium - Accordingly to Stewart the pH is independently regulated by pC02, A- and SID -> F - SID is the difference between strong caDons and strong anions -> T - Hypoalbuminemia may lead to metabolic acidosis -> F (cause to metabolic alkalosis) - Saline soluDon per se can lead to hyperchloremic metabolic acidosis -> T - In chronic respiratory diseases kidneys compensate the increase of HCO3- by removing Cl- -> F - Hypoalbuminemia per se sufficient to cause alkalosis T - Chloride excreted more in respiratory acidosis T - Ph is independent regulated by volatile acids, PCO2 and bicarbonate F - SID is equal to the difference between anions and cations F - Follows dissociation equilibrium, mass conservation, electrical neutrality laws T Electrical neutrality, Dissociation equilibrium, (they made a mistake) - High pCO2, per se, causes a decrease in bicarbonate F - Ketone bodies accumulation increase chloride F 3) According to the quantitative (Peter Stewart's) approach to acid-base: - A) pH is independently regulated by pCO2, Atot, and HCO3-, F - C) Hypoalbuminemia per se leads to the development of metabolic alkalosis T - D) Ketoacidosis is due to the increase in chloride concentration F 5) During respiratory acidosis: - A) The increase in PaCO2, per se leads to a reduction in HCO3-, concentration F (leads to an increase to compensate) - B) In chronic states, the renal system increases urinary excretion of chloride as a compensation T - C) pH is generally higher than 7.45 F  - D) PaO2 always decreases F - E) PaCO2, may be even higher than 60 mmHg T - 9) Regarding the potassium metabolism and balance: - A) The daily requirement equals about 2-4 mmol/kg T - B) A plasma K level greater than 5.5 mmol/L is always associated with ECG alterations F - C) In case of DKA treatment, K+ supplementation should start when plasma K+ concentration is lower than 3.5 mmol/L F - D) Rhabdomyolysis may lead to severe hyperkalemia T - E) The treatment of hypokalemia includes also the administration of Ca-Cl or Ca-gluconate F - Sepsis - Sepsis is always associated with hyperlactatemia -> F - Balance fluids are beQer in reducing the alteraDon of the acid base equilibrium -> T 2) A patient with septic shock, at the time of diagnosis: A) Is always oliguric F B) Has always WBC counts greater than 10000/μl F C) Generally presents some signs of altered tissue hypoperfusion T D) May show a plasma lactate level of about 1.5 mmol/L F - E) May not show a clear site of organ infection T - ATLS - Tension pneumothorax is treated with decompression in the 5th intercostal space, midclavicular line -> F Cannulated needle at the 2nd intercostal space - Flail chest is suspected if (non ricordo esaQamente) When the thorax expands and the diaphragm lowers, the flail chest retracts and impedes breathing - The first diagnosDc test in a traumaDzed paDent is CT -> F (us) - If the paDent is bleeding the first thing to do is recognize the source of bleeding and stop it -> T - Always guarantee hypothermia -> F Prevent hypothermia - trauma paDents are more prone to become hypothermic, which has important consequences for example on the coagulaDon. - With a femur fracture the blood loss could be up to 500 ml -> F (1.5L) - In class IV (from the esDmated fluid/hemaDc loss table) RBC transfusion is indicated -> T (3+4) - 4) During B phase of ATLS: - A) It is necessary to evaluate the effectiveness of breathing and ventilation T - B) If suspected, tension pneumothorax should be confirmed with chest X-ray before decompression F - C) In case of flail chest and ineffective ventilation, a positive pressure ventilation should be applied T - D) In case of open PNX, the opening should be tightly closed with a sterile occlusive dressing without any further opening F - E) If detected, a simple PNX should be treated before starting phase C, D and E F - 11) Concerning hemorrhagic shock in a trauma patient: - A) It can be excluded if systolic blood pressure is within normal range F - B) In a patient with abdominal trauma and hemodynamic instability, CT scan is the first line diagnostic test T - C) A normal HR should always exclude the possibility of a clinically relevant hemorrhage F - D) Hypothermia may further deteriorate bleeding T - E) Bleeding source identification and its control is the first step of management in phase C T Concerning emergency airway management - It is necessary in severe traumatic brain injury T  - Severe hypoxemia is the leading complication of intubation in critically ill F (the leading cause- cardiovascular instability, than hypoxemia and cardiac arrest) - Auscultation is the best method to confirm the success of the endotracheal intubation F (: \CAPNOGRAPHY is gold standard) - Propofol is the best induction agent in critically ill patients F/T - Video laryngoscopy may help to increase the success of intubation T Fluid therapy: 6) The intravenous administration of Ringer Lactate: A) Always leads to metabolic alkalosis F B) Generally it does not lead to a clinically relevant increase in pla concentration of lactate T C) May be deleterious on renal function f D) Is not indicated in patients with traumatic brain injury F E) When administered in large quantities, it may cause hypernatremia F 7) In critically ill patients, the use of colloid-containing solutions: A) In case of hemorrhage, it is indicated with the use of HES F/T B) In case of sepsis, it is allowed, with the use of gelatins, in case of severe hypovolemia F/T C) It is generally not indicated when referring to synthetic colloids, due to the lack of clear sign of efficacy, and the high risk of detrimental effects T/F D) Is indicated in case of traumatic brain injury, to maintain cerebral perfusion pressure F/T E) In case of albumin, it may be beneficial during septic shock T Ringer lactate Increases Na T At physiological level doesn't increase lactate T Doesn't cause acidosis T 10) Regarding normal water balance: A) Its aim is to maintain volemia and osmolality of the extracellular (and intracellular) space T B) In normal condition, about 60% of our body weight is made by H2O T C) ADH is a powerful volume-regulator and osmo-regulator T D) The minimal amount of water that should be excreted in normal condition with urine is about 1 liter F (400ml) E) The most representative anion within the intracellular space is H2PO4-, F (potassium) In COVID 19 pneumonia with severe respiratory failure A. Respiratory system compliance is generally higher in relation with the degree of hypoxemia as compared to classical ARDS T B. Hypoxemia may result from an alteration of the normal distribution of lung perfusion T C. The application of respiratory support should be considered only when a respiratory arrest is imminent F D. The application of high levels of transpulmonary pressure occurs only during invasive mechanical ventilation F/T E. The administration of IL-6 receptor blockers are now included in the current WHO international guidelines T Concerning shock: A. A central vein oxygen saturation ScvO2 of 45% may indicate an impaired oxygen delivery T B. Cardiogenic shock is the most common type of shock in general ICU population F/T C. Both high and low heart frequencies may be associated with hypoperfusion T D. Capillary refill time is always normal with systolic arterial pressure of 130mmHg F E. Anaphylaxis is the most common form of distributive shock F (sepsis)/T A patient with a supraventricular tachyarrhythmia (160bbm):  A. Should receive fluids to improve systemic perfusion F/T B. Cardioversion is the best treatment option if associated with signs of hypoperfusion T C. Defibrillation should be considered as soon as possible F/T D. May present a reduced central vein oxygen saturation (ScvO2) T/F E. May have atrial fibrillation if the rhythm is irregular T Cardio VV 1. 35 years old woman without cardiovascular risk factors which are the most probable cause chest pain in emergency department: a. Coronarv artery disease b. Aortic dissection c. Mediastinitis d. Bone/musculoskeletal e. Esophageal perforation 2. Which is the most specific marker of necrosis of cardiac myocytes: а. Troponin I or Troponin T b. Myoglobin C. D-dimer d. Interleukin-6 e. Troponin C 3. Which of the following is the currently recommended tool for troponin dosing? a. Conventional assay b. High-sensitivity assay c. Heart pathway d. Conventional and high-sensitivity assay are the same e. All previous answers are correct 4. The definition of acute myocardial injury is: a. The presence of ST segment elevation on ECG b. The presence of chest pain and ST segment alteration on ECG c. Detection of elevated cardiac troponin above the 99th percentile upper reference limit with rise and or fall. d. Detection of elevated cardiac troponin above the 99th percentile upper reference limit e. The presence of cardiac chest pain with or without ST segment alteration plus detection of elevated cardiac troponin above the 99th percentile. 5. Which of the following is not a cause of type 2 myocardial infarction? а. Anemia b. Sepsis C. Coronary Vasospasm d. Atherosclerotic plaque rupture with occlusive thrombus e. Ventricular tachycardia 7. Which is the first instrumental examination to perform in the emergency department in case of a patients complaining chest pain? a. Blood pressure measurement b. insertion of an iv line C. Evaluation of oxygen saturation d. ECG e. Defibrillation 8. When ECG with posterior leads should be performed? a. Never b. Every time is possible c. In case of anterior ST elevation myocardial infarction to exclude posterior wall involvement d. In case of ST depression in VI-V3 to exclude the presence of posterior wall ST elevation myocardial infarction. e. In case of atrial fibrillation 9. In case of new onset left bundle branch block in a patient presenting to the emergency department with acute retrosternal chest pain irradiated to left arm and associated with cold sweating, how the cardiologist should act? a. It is a "STEMI-like" situation and the patients should receive emergency coronary angiography and PCI in the following 120 minutes. b. The patients can wait until the results of troponin test is available c. The patients should immediately undergo fibrinolysis in any case d. A CT scan of the chest should be performed e. None of the answer above is correct 10. Which of the following are acute STEMI complications? a. Life-threating tachyarrhythmias b. Cardiogenic shock c. Bradyarrhythmias due to AV block d. Pulmonary oedema e. All previous answers are correct 11. Which is the most useful tool to monitor a patient with acute myocardial infarction in order to recognize and treat acute complications? a. Manual defibrillator b. Pulse oxymeter c. Thermometer d. Urinary catheter e. Continues invasive monitoring of radial artery pressure 14. Which of the following combination of medications are used in the acute setting of STEMI? a. Aspirin + clopidogrel or ticagrelor or prasugrel or cangrelor b. Aspirin + fondaparinux c. Clopidogrel + fondaparinux d. Prasugrel + dabigatran e. Prasugrel + apixaban 15. Which is the best option to treat chest pain in patients with acute STEM? a. It is useless to treat pain, you have to reopen the occluded coronary artery b. Ibuprofen c. Pericardial lidocaine d. Careful use of iv opioids e. Nitrates 16. Which is the current ESC guidelines recommended algorithm for rule-in and rule-out of ACS-NSTEMI with high sensitivity cardiac troponins? a. 0-3 h b. 0-6 h C. 0-12 h d. 0-1 h e. None of the above 17. Which of the following are differential diagnoses for ACS in the setting of acute chest pain? a. Myopericarditis b. Acute aortic syndromes C. Takotsubo syndrome d. Pulmonary embolism e. All the above 18. Which is the recommended time for invasive evaluation with coronary angiography in established NSTEMi diagnosis? a. 500lt) Which of the following statements regarding haloperidol is incorrect? a. Contraindicated in Parkinson's disease b. A butyrophenone with shorter duration of action c. It possesses antiemetic action d. It is a mild a blocker e. It has neuroleptic effects with minimal cardiovascular and respiratory effects Which of the following statements about Vasopressin is correct? a. At high dose it works as a partial beta 1 agonist b. It controls water excretion in kidneys by V1 receptors \ c. It is contraindicated in vascular disease d. Do not use with noradrenaline (paradoxical effect) e. At high dose it works as a partial beta 1 agonist Question 1 Vit. K correct answer: it can induce hypersensitivity-due to the presence of castor-oil-f for each quiz there may be one or more correct answers. 2 points for each correct answer; -.5 for each incorrect answer (but then he said that it will be minus 0.3). 1) What is (are) the correct statement about lidocaine? a) It is a local anesthetic that is classified as anti-arrhythmic agent Class IA b) It is a molecule used for prevention of ventricular ectopic beats c) Clearance is overall renal d) Since it is an ester there hypersensitivity problems are rare e) It is a molecule administrable by I.V. 2) Indicate which statement regarding aminophylline is (are) incorrect: a) It is a non-specific inhibitor of phosphodiesterase. b) Increase levels of CAMP: CNS stimulation c) Increase inotropic effects d) Among adverse effects there is convulsions e) Induce negative diuresis effects 3) Indicate which statement regarding acetylcysteine is(are) incorrect: a) it is able to improve scavenger activity of oxygen free radicals b) Among adverse effect there are anaphylactoid reaction c) It can be administered by oral and I.V. d) It is a sulfhydryl group donator e) It can be administered with oxygen by nebulizer 4) Which of the following statement regarding tranexamic acid is (are) incorrect? a) Contraindicated in thromboembolic disease b) It can be administered intravenously. in slow infusion, never as a bolus c) It can not administrable by oral rout (high liver metabolism and inactivation) d) It is an antifibrinolytic drug, that acts by activation of TPA e) indicated in hemorrhage due to thrombolytic therapy 5) Indicate which of the following statement regarding Neostigmine is(are) correct: a) It possesses muscarinic side effects (e.g. hypotension, bradycardia) b) It is not possible the oral administration (gastric degradation) c) improves the intestinal motility d) It is not possible the intramuscular administration (pain) e) contra-indicated in myasthenia gravis 6) Indicate which statement regarding Morphine is (are) not-correct: a) One of the most frequent adverse effect is constipation b) To enhance the effect it is combined with buprenorphine c) It reduces histamine release d) It is not administrable by oral rout due to inactivation e) Its metabolites are inactive 7) Which of the following statement regarding haloperidol is(are) incorrect? a) A butyrophenone with longer duration of action v b) It has neuroleptic effects with minimal cardiovascular and respiratory effects v c) It is a mild beta-blocker d) It possesses prokinetic-action e) Contraindicated in Parkinson's disease 8) Which of the following statement regarding vitamin K is(are) not correct? a) Vitamin K can cause allergic reactions b) It is the essential cofactor for the esterification of coagulation factors vitamin k dependent (VII, IX,X and prothrombin). c) After IV administration, it is necessary to wait about an hour for it to recover the correct hemostasis d) It can be administered both by IV (rapid bolus) and intramuscular (depending on by the severity of the clinical situation) e) It is the essential cofactor for the vascular level production of the factors of the vitamin k dependent coagulation factors (V, IX, X and prothrombin) 9) Indicate which statement regarding Acetazolamide is(are) not correct:  a) It is a diuretic that activates carbonic anhydrase b) It is utilized in the barbituric intoxication: because it competes for the same carrier c) The elective route of administration is the IV d) By IM injection it can cause painful e) It can cause blood disorder (chronic use) 10) Which of the following statement regarding Digoxin is(are) incorrect? a) Intoxication very often causes gastro-enteric symptoms b) It is a sodium-potassium channel blocker c) Administration of Mg is contraindicated in the acute intoxication d) It is excreted by the kidney after liver metabolization and inactivation e) it has a lower binding protein (about 25%) 11) Which of the following statement about Vasopressin is(are) correct? a) It is a peptide of 9 amino-acids b) It controls water excretion in kidneys by V1 receptors c) Do not use with noradrenaline (paradoxical effect) d) it is indicated in the septic shock e) At high dose it works as a partial beta 1 agonist 12) Which of the following statement regarding Ipratropium is(are) not-correct: a) Among adverse effect we find dry mouth b) It can induce urinary retention c) It is an anticholinergic agent, with particular action on nicotinic receptor d) of Hypotonic solution may cause bronchospasm e) it is particularly effective in COPD (used by nebulizer) 13) Which of the following statement regarding Lactulose is(are) not-correct? a) by oral route it can be use on constipation b) by oral route it can be use on hepatic encephalopathy c) It is a beta-galactose-glucose synthetic disaccharide d) osmotic diarrhea is due by the absence of a specific enzyme in the colon e) it can be used to treat galactosaemia 14) Indicate which statement regarding Lepirudin is(are) correct: a) It is a natural polysaccharide obtained from leech (Hirudo medicinalis) b) Contraindicated in pregnancy and lactation c) it is mainly excreted by kidneys d) It is metabolized and excreted by liver e) It is a direct irreversible thrombin activator 15) Indicate which statement is(are) not-correct about Mannitol a) not to be used with furosemide b) Topically administered it can be used as an agent that reduces intraocular pressure c) It can be used in acute renal failure d) it is indicated in the congestive cardiac failure e) Crystallization can occur if the temperature is low ---- new--- Indicate true or false: Dobutamine: 1. Dobutamine have a parDal alfa 1effect 2. Dobutamine has predominant Beta 1 effect T 3. Dobutamine has specific effects on renal or splanchnic blood flow. F  4. In bolus possess a duraDon of acDons higher than dopamine (about one hour) F 5. It is predominantly metabolized by COMT T 6. It is predominantly eliminated by liver F 7. it is incompaDble with alkaline soluDons T 8. Beta blockers administraDon could be reduced its effects. T Diazepam 1. It is a drug that induce the opening of the chloride channel T 2. It is a drug that induce inhibiDon of some areas of CNS T 3. It is a drugs could be induce hypotension T 4. It is a drug that act on Gaba-A receptor as agonist. T 5. It is generally used for the terminaDon of epilepDc fit T 6. the site of acDon is idenDcal to that of barbiturates F 7. it is classified as a barbiturates with a very short duraDon of acDon F Aminophylline 1. It acts as agonist on Beta 2 receptors with a very-long acDng Dme F 2. By nebulizer: hypotonic soluDon may cause bronchospasm T 3. At clinical dosage, it posses a parDal acDon on Alfa 1 receptors F 4. At clinical dosage, it posses a parDal acDon on Alfa 2 receptors F 5. At clinical dosage, it posses a parDal acDon on D receptors F 6. It is a natural methylxanthine T 7. By I.v. it can cause hypotension T 8. One of the most frequent adverse effects is the convulsion T 9. One of the most frequent adverse effects is tachycardia T Digoxin 1. It has a low volume of distribuDon F 2. It is a cardioacDve glycoside with high binding to plasma proteins F 3. it is metabolized by cytochrome p450 isoform 3A4 and for this reason aQenDon must be paid to its interacDons with other drugs F 4. It posses a long half-life (over 5 days) F 5. Adverse effects mainly affect the gastro intesDnal tract with nausea, vomiDng, diarrhea T 6. It could accumulate in renal impairment T 7. It is uDlized in the WPW syndrome F 8. It is uDlized in the supraventricular tachycardia T 9. Could by induce Xanthopia, a skin pigmentaDon disorder F 10. AdministraDon of Calcium is indicated as treatment of acute intoxicaDon. F 11. AdministraDon of Potassium is indicated as treatment of acute intoxicaDon T 12. Vitamin D is indicated as treatment of acute intoxicaDon F Labetalol 1. It is a beta antagonist but possess an alfa agonist acDon. F 2. Different acDon on beta and alfa receptors are affected by the route of administraDon. T 3. It can be used to treat pre-eclampsia T 4. It is mainly used as an anDarrhythmic F 5. It does not cause a high degree of bronchoconstricDon F Dantrolene: 1. Contraindicated in the overdose or consumpDon of 'Ecstasy' F 2. Indicated in the treatment of malignant hyperthermia T 3. Contraindicated in nephropathic paDents F  4. One of the most frequent adverse effects is diarrhea T 5. It is a presynapDc muscle relaxant. F Dalteparin: 1. It acts mainly on factor Xa T 2. It bind less to proteins in plasma than unfracDonated heparin. T 3. They have longer duraDon of acDon if compared by unfracDonated heparin by oral route F (no oral route) 4. Used for prevenDon of cloing in extracorporeal circuits T 5. Indicated in the pulmonary embolism T 6. Being a low molecular weight heparin, protamine sulfate is not its specific anDdote F 7. Due to its low molecular weight, it is able to cross the BBE F 8. Ajer SC injecDon is effecDve for up to one day T ( path diagnostic-therapeutic in the emergency room May 2019: Same as February Boccuzzi: clinical case. dyspneic patient with anterolateral chest pain that worsens with respiratory movements. Prostatic K awaiting therapy. Previous week (?)pain in limb lower part, which appeared edematous and red (?). P 120/80 Fc 80 (?). EGA: satO2... CO2... lactates...? 1) Which diagnostic hypothesis? 2) Exams? 3) Therapy? Surgery ** open questions: on AAST vs WSES classifications for splenic trauma Acute diverticulitis, wses classification and therapeutic guidelines spleen trauma classification and management Closed: Ectopic pregnancy Is classified under inflammatory acute abdomen F First cause of death in pregnancy F Diagnosed with US and pregnancy test T Can be managed also not surgically F stable pt can be treated with methotroxat although surgery is the standard Mesenteric ischemia Acute can be asymptomatic T (non occlusive can start asymptomatic) Thrombotic has 80% history of abdominal angina F (50%) Embolic usually by AF T In chronic MI complications are less frequent T Endoscopy in UGIB Most important exam V Can be used to place elastic ring V Can be used for glue infusion V Mesenteric ischemia - More probable if IBD or infections F - If chronic always involving two vessels (generally 2-3 vessels) T - In thrombotic form the plaque is usually at the very beginning of SMA T - Emboli reach small vessels F - In arterial embolic form small vessels are affected F (distal SMA) - In embolic form embolus usually originates in portal vein F (cardiac origin) Basic treatment of acute pancreatitis includes early fluid resuscitation, analgesia, and which of the following? 1. Antibiotics F 2. ERCP F 3. Enteral nutrition T 4. Total parenteral nutrition F 5. Oral nutrition F Trauma It is, in the world, the first cause of death between 1 and 44 years T It is the third leading cause of death T It is the fourth leading cause of death in the elderly F (third) It has the highest incidence in the African continent T It has the highest incidence in the American continent F Trauma mortality It is distributed in time in binomial mode F (trimodal) It is highest in the first minutes after trauma T It can be minimized by appropriate medical action in patient who arrive at the hospital alive T It is mainly related to abdominal injuries F (head) It is minimal after the first 6 hours F (20%late) O2 consumption after trauma It may be limited due to hypoxia, anemia, shock T If higher than normal, it causes damages at the cellular level T The difference with the ideal consumption, over time constitutes the o2 debt T It can rise above normal with adequate resuscitation of traumatized patients T Mab be minimized taking the patient to the closest hospital F (maybe T, in 20-30 minutes critical point, if repayment is rapid tissue damage is avoided) Common sign and symptoms of hepatic colic are (no idea, could be related to this?: Typical Charcot’s triad of fever, jaundice and right upper quadrant pain. In severe acute cholangitis, also shock and altered mental status (Reynolds’ pentad)) Fever F Jaundice T Intermittent pain T Vomit F GI bleeding F April: Spleen Trauma AAST classification: I 1. Sub capsular hematoma 3cm depth 5. Laceration involving trabecular vessel IV 1. Rupture segmental or hilar vessel V 1. Completely shattered spleen 2. Hilar injury that leads to devascularization of the spleen Treatment Stable: 1-2: observation and monitor 3: observation, prophylactic Angio embolization for selected pt 4: angioembolization Hemodynamically unstable: emergency laparotomy with splenectomy or splenic salvage if suitable. WSES grading system: considers both the patient's condition and the anatomy of lesions based on AAST. I: AAST I-II, stable II: AAST III, stable III: AAST IV-V, stable IV: any AAST but UNSTABLE True or false about peptic ulcer complications, mesenteric ischemia and acute abdomen) ------ Criteria: Diverticulitis- WSES: Uncomplicated stage 0 - Involves a thickening of the colonic wall or a thickening of the pericolic fat layer complicated: Stage 1a - pericolic bubbles or free fluid without abscess ( 5cm within site of diverticulum) Stage 1b - Abscess 4cm Stage 2b - distant air ( approx 5cm from the diverticulum) Stage 3 - Distant fluid without bubbles Stage 4 - Distant fluid with bubbles Guidelines Indications for hospital admission: 1. Complicated diverticulitis 2. Sepsis or SIRS 3. Severe abdominal pain 4. Peritonitis 5. Age>70 yo 6. Significant comorbidities: DM, CVD, liver 7. Immunosuppression 8. No improvement in outpatient Uncomplicated diverticulitis + outpatient: Antibiotics: General no antibiotics Consider oral antibiotics in pt with high risk for poor outcomes: immunosuppression, other comorbidities, signs of systemic disturbance. Option: metronidazole + ciprofloxacin for 4-7 days Supportive care: relative bowel rest with liquids until improvement of symptoms analgesics as needed: acetaminophen, ibuprofen, exycodone) antiemetics as needed. Follow-up in 2-3 days for evaluation No improvement- consider hospitalization and repeat imaging Improvement in symptoms: no need to repeat imaging, Schedule colonoscopy in 3 weeks to exclude tumors Consider elective surgical resection if indicated. Indications for elective surgical resection: ≥ 2 acute attacks treated conservatively 1 attack with hospitalization in +40 yo patients 1 complicated attack 1 attack in immunocompromised Impossible exclusion of carcinoma in diagnostic workup Inpatient treatment: Antibiotics: Broad spectrum IV antibiotic’s, mainly to cover gram negative: metronidazole + ciprofloxacin or Augmentin for 10-14 days Complete bowel rest Parenteral analgesics: acetaminophen, morphine. IV fluids: to correct volume deficits Management of complications: Abscess: Abscess 4cm: US or CT guided percutaneous drainage send aspirate for cultures and tailor antibiotic treatment accordingly. If pt do not improve within 24-48 hours: consider surgery. Micro perforation: treat same as uncomplicated diverticulitis. Purulent peritonitis: If pt is stable consider colectomy and primary anastomosis with or with out stoma Unstable pt with perforation and peritonitis or feculent peritonitis: damage control surgery with primary goal to remove perforated segment, secondary goal is to restore intestinal continuity. Usually done with Hartmann's procedure with temporary abdominal closure. Bowel obstruction: important to differentiate from colon cancer with imaging, management is with surgical resection of the involved bowel segment to relive obstruction. Fistula: rarely close spontaneously, therefore require resection of the involved segment. Bleeding: localize bleeding first using colonoscopy, than segmental colectomy is preformed. Hincley: 1) Hinchey I = localized abscess (para-colonic) 2) Hinchey II = pelvic abscess IIA= distant IIB= large complex abscess with or without fistula extending to the pelvis 3) Hinchey III = purulent peritonitis (the presence of pus in the abdominal cavity) 4) Hinchey IV = fecal peritonitis (Intestinal perforation allowing feces into abdominal cavity). Treatment: 1 and 2:  Abscess 4cm: US or CT guided percutaneous drainage send aspirate for cultures and tailor antibiotic treatment accordingly. If pt do not improve within 24-48 hours: consider surgery. 3 Stable: colectomy and primary anastomosis with or with out stoma Unstable: Hartmanns procedure with temporary abdominal closure 4- Hartmanns procedure with temporary abdominal closure Indications for pancreatic Indications: 1. Biliary disease not controllable with medical / endoscopic therapy 2. Infected necrosis 3. Extended sterile necrosis + multi-organ failure 4. Complications: hemorrhages, abscesses, pseudo-cyst) 5. Increased intra-abdominal pressure Types - Pancreatectomy: high morbidity & mortality, and bears the risk of removal of relevant portions of healthy tissue. Necrosectomy: removal of the necrotic tissue, usually with laparotomy (decreases intra-abdominal pressure) + vacuum Assisted Closure, removal of gallstones. Italian; Acute pancreatitis Acute abdomen classification diagnosis and therapy Intestinal obstructions mechanical ileus and paralytic Good to know: acute cholecystitis, Charcot triad (cholangitis), pancreas It can basically ask for everything, especially: traumatic acute abdomen, spleen and occlusions very frequent intestinal problems, also appendicitis and cholecystitis Distance Meckel's diverticulum - ileocecal valve - 60-100 cm - calculation of a patient's GCS score - what does grade 2b Hinchey classification correspond to - most frequent site of gastric ulcer most frequent cause of (perhaps) acute mesenteric ischemia? options:? - investigation of choice in suspicion of intestinal obstruction - splenic trauma: what Wses III corresponds to most frequent cause of upper digestive bleeding January 2019: indications for the treatment of acute pancreatitiste F: Obstructive jaundice May 2019: Intestinal Ischemia (including Classification From third year Pain from duodenal ulcer is usually a. Diffuse b. In the back c. Epigastric d. In the periumbilical area Diagnosis of acute pancreatitis is usually made with a. Ultrasound b. Clinical evaluation c. Laboratory exam d. CT Scan All of the following are part of the clinical picture of cholecystitis except: a. Fever b. Right upper quadrant abdominal pain c. Jaundice d. Nausea and vomit Common complication of Crohn disease but not of ulcerative colitis is: a. Bleeding b. Diarrhea c. Stricture d. Occlusion All of the following are associated with gallstones except: a. Acute appendicitis b. Acute cholecystitis c. Acute pancreatitis d. Acute cholangitis Diagnosis of acute pancreatitis is usually made with a. Ultrasound b. Clinical evaluation c. Laboratory exam d. CT Scan 370. In acute pancreatitis, which of the following is commonly present: a. Hypercalcemia b. Hypoglycemia c. Jaundice d. Paralytic ileus e. Diarrhea?? The percentage of people over 50 years old with diverticulosis is:?? a. 50 b. 90 С. 30 d. 70 380. Which is the best combined treatment for gallstones associated with choledocholithiasis? a. the surgical removal of gallstones b. Laparoscopic cholecystectomy c. ERCP d. the endo-laparoscopic rendez-vous 383. A biliary colic: a. typically occurs after eating a large, fatty meal b. can be characterized by abnormal laboratory tests c. can be associated to fever and nausea d. all the previous 392. Which of the following is the most common cause of Intestinal obstruction: a. Adhesions b. IBD c. Cancer d. Ulcer the most common causes of bowel obstruction depend on location: SMALL - adhesions or hernias LARGE - malignancy, diverticular disease or volvulus 393. Which of the following types of mesenteric ischemia usually affects younger people? a. NOMI b. Arterial thrombotic c. Venous d. Arterial embolic 396. 70 kg man with hemorrhagic shock, hypotension appears when blood loss is greater than: a. 1. 250ml b. 2.500ml c. 3. 1000ml d. 4. 1500ml e. 5. 2000ml Loss of 500ml → mild tachycardia 399. Definition of acute abdomen? every dysfunction causing pain at the abdominal level lasting a short time (less than a week) in acute settings 400. What is the thing common in every kind of acute abdomen? Abdominal pain 401. What is the difference between a localized and generalized inflammatory problem? Activation of somatic fibers that are irritated through chemicals... 402. Left lower quadrant abdominal pain? Diverticulitis 403. Upper digestive bleeding? Any bleeding that is proximal to ligament of Treitz (in liver,stomach, spleen, pancreas, esophagus, duodenum) 404. Name some cause of bleeding in the upper GI tract? Which kind of cancer can cause the bleeding? Gastritis, esophageal varices, peptic ulcers, Mallory-Weiss tear/ colorectal cancer (polyps) 406. Can you illustrate the diagnostic path in a lower Gl bleeding? What is the name of the clinical exam (clinical maneuver)? Contrast-media CT scan In LGIB perforation leads to: peritonitis Pain from intermittent to sharp and constant means: peritonitis 431. Symptoms of obstructive jaundice: yellowish of skin and sclera severe abdominal pain fever itch chills vomiting nausea Pain from duodenal ulcer is usually a. Diffuse b. In the back c. Epigastric d. In the periumbilical area 95. Hunger pain is a typical symptom of: a. Chronic gastritis b. gastric peptic ulcer c. Gastroesophageal reflux disease d. duodenal peptic ulcer 101. Crohn's disease is a risk factor for peptic ulcer: True 102. To distinguish a malignant ulcer from a benign form is important: a. The color of the ulcer b. The presence of fibrin c. Size and shape of the ulcer d. The bleeding 103. Gastric ulcer is characterized by multiple episodes: False 104. Gastric ulcer is a risk for malignancy: true 105. The typical sign of perforation is: a. Ponytail b. Bird beak c. Black sickle in abdominal cavity d. Mouse tail 106. Gastric ulcer most commonly penetrate in: a. The bowel b. The lung c. The liver d. The pancreas 107. The gold standard test for peptic ulcer is: a. Upper endoscopy b. Colonoscopy c. Barium swallow d. CT scan 108. Duodenal ulcers most commonly penetrate into: a. The lung b. The bowel c. The pancreas d. The liver ------- In the early stages of a mechanical intestinal obstruction of the colon the clinical picture is characterized by a) Fecaloid vomiting b) Cramp-like abdominal pain c) Diffuse abdominal defense d) Suppurative fever I The collateral circulation that connects the inferior mesenteric artery with the superior one is called a) Drummond arch b) Wright's artery c) Rio Branco arch d) Riolano arch I Mirizzi syndrome is caused by a) Gallstones b) Common bile duct stones c) Cholecystocolic fistula d) None of the above I / following symptoms: severe watery diarrhea, hypokalemia, metabolic acidosis, achlorhydria, muscle weakness, nausea, hyperglycemia, hypercalcemia are typical of a) Verner Morrison syndrome b) Crohn's disease c) Hairy polyp of the colon d) Abuse of laxatives Which of these causes is not involved in the etiopathogenesis of acute pancreatitis a) Gallstones b) Alcoholism Portal hypertension