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  #1  
Old 01-27-2013
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Default GIT question

An 84-year-old woman with coronary artery disease,
congestive heart failure, peripheral vascular
disease, and atrial fi brillation presents to the
emergency department with dizziness, weakness,
and sudden-onset crampy periumbilical
pain. The pain is associated with one episode
of diarrhea and one episode of emesis. The patient
notes she has been having similar pain after meals for “several months” but never this
severe. Her temperature is 37.2°C (98.9°F),
heart rate is 135/min, blood pressure is 96/60
mm Hg, and respiratory rate is 16/min. Physical
examination is notable for a slightly distended
abdomen that is extremely tender to
palpation with diminished bowel sounds.
There is no rigidity or rebound tenderness
noted on the abdominal examination. In addition,
the patient has heme-positive stool. Her
WBC count is 19,500/mm³, hemoglobin is
10.9 g/dL, and platelet count is 159,000/mm³.
Liver function testing results are normal. After
stabilizing the patient, what is the best next
step in management?
(A) Barium enema
(B) Colonoscopy
(C) Laparotomy
(D) Obstruction series
(E) Warfarin therapy
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Old 01-27-2013
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(C) Laparotomy
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  #3  
Old 01-27-2013
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Default (B) Colonoscopy

(B) Colonoscopy
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Old 01-27-2013
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acute mesenteric ischaemia >>>>warfarin therapy
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Old 01-27-2013
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i think c) laparotomy

thanks
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Old 01-27-2013
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Quote:
Originally Posted by aknz View Post
An 84-year-old woman with coronary artery disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation presents to the emergency department with dizziness, weakness, and sudden-onset crampy periumbilical pain. The pain is associated with one episode of diarrhea and one episode of emesis. The patient notes she has been having similar pain after meals for “several months” but never this severe. Her temperature is 37.2°C (98.9°F), heart rate is 135/min, blood pressure is 96/60 mm Hg, and respiratory rate is 16/min. Physical examination is notable for a slightly distended abdomen that is extremely tender to palpation with diminished bowel sounds. There is no rigidity or rebound tenderness noted on the abdominal examination. In addition, the patient has heme-positive stool. Her WBC count is 19,500/mm³, hemoglobin is 10.9 g/dL, and platelet count is 159,000/mm³. Liver function testing results are normal. After stabilizing the patient, what is the best next step in management?
(A) Barium enema= what is the important of Barium E in patient with thromboembolic bowel ischemia---nothings
(B) Colonoscopy= to do what. the diagnosis is clear so the next step is treatment
(C) Laparotomy= exploration + may need to resect the affected portion
(D) Obstruction series= No ostruction
(E) Warfarin therapy=prevent thrombus formation in the heart in patient with AF but it is NOT treatment of choice for thromboembolic bowel ischemia
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Old 01-28-2013
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Quote:
Originally Posted by heartbeat View Post
(A) Barium enema= what is the important of Barium E in patient with thromboembolic bowel ischemia---nothings
(B) Colonoscopy= to do what. the diagnosis is clear so the next step is treatment
(C) Laparotomy= exploration + may need to resect the affected portion
(D) Obstruction series= No ostruction
(E) Warfarin therapy=prevent thrombus formation in the heart in patient with AF but it is NOT treatment of choice for thromboembolic bowel ischemia
Good explanation.
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Old 01-28-2013
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Quote:
Originally Posted by heartbeat View Post
(A) Barium enema= what is the important of Barium E in patient with thromboembolic bowel ischemia---nothings
(B) Colonoscopy= to do what. the diagnosis is clear so the next step is treatment
(C) Laparotomy= exploration + may need to resect the affected portion
(D) Obstruction series= No ostruction
(E) Warfarin therapy=prevent thrombus formation in the heart in patient with AF but it is NOT treatment of choice for thromboembolic bowel ischemia
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Old 01-28-2013
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Uworld said warfarin therapy but its clearly laparotomy. Especially in this case where there are high chances of an infarcted bowel.
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Last edited by Brainiac; 01-28-2013 at 08:27 AM.
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Old 01-30-2013
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Don't you guys think the best initial step should be warfarin therapy? That will cure the pain. Then of course you could proceed with Laparotomy. But I guess laparotomy shouldn't be the first thing to be done in this case.
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Old 01-30-2013
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Quote:
Originally Posted by ali.aggarwal5 View Post
Don't you guys think the best initial step should be warfarin therapy? That will cure the pain. Then of course you could proceed with Laparotomy. But I guess laparotomy shouldn't be the first thing to be done in this case.
This patient has acute (AF>>Embolic, sudden onset) on chronic (H/O Abd. angina, multiple site atherosclerotic arterial disease) mesenteric ischemia leading to bowel infarction ( extremely tender abdomen, hypotension & high WBC count) so she need laparotomy ASAP.
Warfarin is never used for acute conditions. Also, it is used for venous thrombosis not arterial.
The only other treatment (not among the choices) which might have been helpful in earlier stages is intra-arterial thrombolytics/heparin but it's probably too late for her since her bowel has already infarcted (hypotension & high WBC count).
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Last edited by Novobiocin; 01-30-2013 at 09:51 AM.
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