CPEN Gastrointestinal Emergencies 4 — Questions and Answers
Question 1: A 16-year-old with a history of alcohol use presents with epigastric pain radiating to the back, nausea, and vomiting. Serum lipase is 800 U/L. What is the most important initial management priority?
- Start enteral nutrition within 2 hours
- Aggressive IV fluid resuscitation with lactated Ringer's solution (Correct answer)
- Administer IV proton pump inhibitor
- Obtain immediate ERCP
Correct answer: Aggressive IV fluid resuscitation with lactated Ringer's solution
Aggressive IV fluid resuscitation is the cornerstone of acute pancreatitis management, with lactated Ringer's preferred to reduce systemic inflammation.
Question 2: A 2-year-old presents with painless, maroon-colored rectal bleeding. The child is hemodynamically stable. Which diagnostic study is most appropriate to identify the bleeding source?
- Barium enema
- CT angiography
- Technetium-99m pertechnetate (Meckel) scan (Correct answer)
- Upper endoscopy
Correct answer: Technetium-99m pertechnetate (Meckel) scan
Painless lower GI bleeding in a toddler is classic for a Meckel diverticulum containing ectopic gastric mucosa, and a Meckel scan is the preferred diagnostic test.
Question 3: A child with end-stage liver disease presents with massive hematemesis. Which medication should be given immediately while preparing for endoscopy?
- Omeprazole IV
- Octreotide IV (Correct answer)
- Vasopressin IM
- Propranolol PO
Correct answer: Octreotide IV
Octreotide (a somatostatin analogue) reduces portal pressure by causing splanchnic vasoconstriction and is the preferred pharmacologic agent for acute variceal bleeding in children.
Question 4: A 9-year-old is brought in after ingesting an unknown quantity of acetaminophen 3 hours ago. Labs are pending. Which antidote should be administered?
- Flumazenil
- N-acetylcysteine (NAC) (Correct answer)
- Naloxone
- Activated charcoal alone is sufficient
Correct answer: N-acetylcysteine (NAC)
N-acetylcysteine is the antidote for acetaminophen toxicity and is most effective when started within 8 hours of ingestion, before hepatic injury occurs.
Question 5: An 8-year-old with sickle cell disease presents with acute right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a distended gallbladder. Which complication is most concerning?
- Simple cholelithiasis
- Acute cholecystitis with possible perforation (Correct answer)
- Hepatic veno-occlusive disease
- Biliary atresia
Correct answer: Acute cholecystitis with possible perforation
Children with sickle cell disease are at high risk for pigment gallstones and acute cholecystitis, which can progress to perforation if not managed promptly.
Question 6: A 3-month-old is brought in with a 2-day history of vomiting, dehydration, and a palpable olive-shaped mass in the epigastrium. Which diagnostic finding on ultrasound confirms the diagnosis?
- Pyloric channel length > 16 mm and muscle thickness > 4 mm (Correct answer)
- Intraluminal target sign with layering
- Dilated loops of small bowel with air-fluid levels
- Free air under the diaphragm
Correct answer: Pyloric channel length > 16 mm and muscle thickness > 4 mm
Hypertrophic pyloric stenosis is confirmed on ultrasound when pyloric muscle thickness exceeds 4 mm and channel length exceeds 16 mm.
Question 7: A 12-year-old with a history of umbilical hernia repair now presents with sudden periumbilical pain, nausea, and a firm, tender, irreducible bulge at the umbilicus. What is the most appropriate action?
- Apply manual reduction with sedation and admit for observation
- Discharge with instructions to follow up with surgery in one week
- Immediate surgical consultation for incarcerated hernia (Correct answer)
- Administer high-dose analgesics and attempt forceful reduction
Correct answer: Immediate surgical consultation for incarcerated hernia
An irreducible (incarcerated) hernia risks strangulation and bowel ischemia, requiring immediate surgical consultation.
CPEN Gastrointestinal Emergencies 4
A 16-year-old with a history of alcohol use presents with epigastric pain radiating to the back, nausea, and vomiting.
Serum lipase is 800 U/L.
What is the most important initial management priority?