Aligned with the National Board of Medical Examiners format. Authored & peer-reviewed by faculty, clinicians, and clerkship directors.
Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.
A 74-year-old man is brought to the ED from a psychiatric facility. He has had massive abdominal distension for 2 days, with mild abdominal pain. He has never had any abdominal surgeries and has been obstipated for 12 hours. He has no hernias on exam. The patient is familiar to you and has been treated nonoperatively once before for a similar clinical presentation. Which of the following combinations correctly matches the imaging modality with the expected finding for this patient?
This patient most likely has experienced repeated bouts of colonic volvulus with intermittent abdominal pain, distension, and obstruction. Colonic volvulus occurs when the bowel becomes twisted along its mesenteric axis, resulting in complete obstruction of its lumen, obstipation, pain, and massive rapid-onset distension. There is also a concomitant risk of bowel ischemia. Sigmoid volvulus most commonly occurs between 60 and 80 years of age and accounts for two-thirds of all cases of colonic volvulus. Radiographic findings often lead to a prompt diagnosis. The abdominal X-ray would most likely show a massively dilated sigmoid colon. This dilated segment of sigmoid colon is sometimes described as a bent inner tube.
Abdominal X-ray and free air below the diaphragm (A) is the radiographic finding expected after bowel perforation. The free air under the diaphragm is most clearly seen between the liver and the diaphragm. Patients typically present with peritonitis. Although free air beneath the diaphragm is expected with bowel perforation, there is a rare instance in which free air beneath the diaphragm is actually colon between the liver and diaphragm and is a benign condition. This is referred to as Chilaiditi sign. CT of abdomen and pelvis with oral contrast and free air below the diaphragm (C) would be expected with bowel perforation, but this is not the correct combination in this patient due to his nontender abdomen. Gastrografin small bowel follow-through and transition point (D) is a radiographic test best used to diagnose a small bowel obstruction. The acute and recurrent presentation of symptoms, lack of previous abdominal surgery, and negative hernia exam make a small bowel obstruction less likely than colonic volvulus. Small bowel follow-through is excellent for demonstrating an obstruction, and a visualized transition point defines a complete small bowel obstruction.
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