Q 6) A 50 year old male with Crohn disease of ileum had intestinal obstruction. He underwent resection and anastomosis of ileum. 10 days later he arrived in ER with 1l bilious leak from the drains. He is managed with antibiotics, TPN and nil per oral regime. 4 days later his ABG is ph 7.24, PO2 98, PCO2 40 and anion gap of 10.
What is the most likely cause of this ABG
a) Renal failure
b) Diabetic ketoacidosis
d) Small bowel fistula
Q7) Which of the following is not associated with peptic ulcer disease
a. Zollinger Ellsion syndrome
b. Primary hyperparathyroidism
d. Pernicious Anemia
Q8) Which of the following is associated with metabolic alkalosis
a) Gain in fixed acid
b) Loss of base
c) Rise in base excess
Q9) True about reactionary haemorrhage
a) It commonly occurs 24 hours after surgery
b) It is caused due to infection
c) Patient has to be taken to OT for re exploration
d) It is more common than primary haemorrhage
Q10) Which of the following patients of appendicitis do not have increased risk of perforation?
b) Patients On Tacrolimus
d) Pelvic position of appendix
6) d- Small bowel fistula
This patient has a high output fistula with normal anion gap (10-15). The patient has metabolic acidosis with normal anion gap which happens with loss of bicarbonates (Pancreatic fistula, diarrhea, small bowel fistula) or gain of chlorides (excessive Saline infusion)
Pernicous anemia has achlorhdria in which the chances of ulcer formation are rare.
Peptic ulcer is associated with a host of conditions.
|Other rare infections: TB, syphilis, mucormycosis, etc|
|Hormonal or mediator-induced, including acid hypersecretory states|
|Gastrinoma (Zollinger-Ellison syndrome)|
|Basophilia in myeloproliferative disease|
|Antral G cell hyperfunction (existence independent of H. pylori is debatable)|
|NSAIDs and aspirin including low dose aspirin|
|Bisphosphonates (probably when combined with NSAIDs)|
|Clopidogrel (when combined with NSAIDs or in high risk subjects)|
|Corticosteroids (when combined with NSAIDs)|
|Spironolactone (probable, no data with NSAID cotherapy)|
|Chemotherapy (eg, hepatic infusion with 5-fluorouracil)|
|Vascular insufficiency including crack cocaine use|
|Mechanical: Duodenal obstruction (eg, annular pancreas)|
|Comorbid ulcers associated with decompensated chronic disease or acute multisystem failure|
|Stress intensive care unit ulcers|
|Chronic obstructive pulmonary disease (secondary to smoking)|
Increase in base excess is associated with metabolic alkalosis.
Metabolic alkalosis is associated with loss of fixed acids and hypokalemia.Classic example is vomiting in pyloric stenosis.
Reactionary hemorrhage is less common than primary hemorrhage and is most commonly due to dislodgement of clot or over aggressive resuscitation. It is not due to infections
Sometimes it can be due to the slippage of knots or sutures. Most of the times re exploration has to be carried out
Secondary hemorrhage is due to infections.
Bailey & Love's Short Practice of Surgery
Some group of patients have increased risk of perforation of appendix. These groups include
- Extremes of age
- Patients on immunosuppression
- Pelvic appendicits
- Fecolith obstruction
- Diabetes Mellitus