CPEN Gastrointestinal Emergencies 5 — Questions and Answers
Question 1: A 5-year-old presents with abdominal pain, vomiting, and bloody diarrhea 3 days after eating undercooked hamburger at a cookout. Labs show thrombocytopenia, anemia, and elevated creatinine. Which complication is developing?
- Intussusception
- Hemolytic uremic syndrome (Correct answer)
- Appendicitis
- Mesenteric adenitis
Correct answer: Hemolytic uremic syndrome
The triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury following E. coli O157:H7 infection is diagnostic of hemolytic uremic syndrome (HUS).
Question 2: A 7-year-old with celiac disease presents with severe abdominal pain, distension, and obstipation after being exposed to gluten. Which complication specific to celiac disease is most concerning?
- Toxic megacolon
- Intussusception
- Celiac crisis with refractory diarrhea and electrolyte imbalance (Correct answer)
- Spontaneous bacterial peritonitis
Correct answer: Celiac crisis with refractory diarrhea and electrolyte imbalance
Celiac crisis is a rare but life-threatening complication triggered by gluten exposure, characterized by severe diarrhea, dehydration, metabolic disturbances, and malnutrition.
Question 3: During assessment of a 4-year-old with abdominal pain, the nurse notes that pain worsens when the right thigh is extended while the patient is lying on the left side. This finding is most consistent with which diagnosis?
- Mesenteric ischemia
- Appendicitis (psoas sign) (Correct answer)
- Intussusception
- Cholecystitis (Murphy sign)
Correct answer: Appendicitis (psoas sign)
The psoas sign—pain on right hip extension—indicates inflammation adjacent to the iliopsoas muscle, classically seen with a retrocecal appendix in appendicitis.
Question 4: A 13-year-old girl presents with acute severe periumbilical pain that has localized to the right lower quadrant. Pregnancy test is positive. Which condition must be immediately excluded before attributing pain to appendicitis?
- Ovarian torsion
- Ectopic pregnancy (Correct answer)
- Endometriosis
- Pelvic inflammatory disease
Correct answer: Ectopic pregnancy
A positive pregnancy test with acute abdominal pain mandates immediate exclusion of ectopic pregnancy, which is life-threatening and can mimic appendicitis.
Question 5: A 6-year-old presents with sudden onset of severe abdominal pain, vomiting, and a distended, tympanitic abdomen. X-ray shows free air under the diaphragm. What is the most critical next step?
- Obtain a CT scan with contrast for better characterization
- Perform nasogastric decompression and arrange emergent surgical consultation (Correct answer)
- Administer a Fleet enema to relieve distension
- Start oral antibiotics and observe for 12 hours
Correct answer: Perform nasogastric decompression and arrange emergent surgical consultation
Free air under the diaphragm indicates intestinal perforation requiring immediate NG decompression, IV antibiotics, and emergent surgical consultation.
Question 6: A 10-month-old is brought in after reportedly ingesting a small magnet set. X-ray confirms two magnets in separate loops of bowel. Why is this particularly dangerous compared to ingesting a single magnet?
- Multiple magnets cause toxic heavy metal poisoning
- Magnets in separate bowel loops attract each other, causing pressure necrosis and perforation (Correct answer)
- Multiple magnets block the pylorus completely
- Two magnets cause a stronger foreign body reaction
Correct answer: Magnets in separate bowel loops attract each other, causing pressure necrosis and perforation
When multiple magnets are in separate loops of bowel, they attract through the intestinal walls, causing pressure necrosis, fistula formation, and perforation.
Question 7: A 15-year-old with inflammatory bowel disease presents with fever, abdominal distension, and a markedly dilated transverse colon on X-ray (> 6 cm). He appears toxic. Which diagnosis is most likely?
- Paralytic ileus
- Toxic megacolon (Correct answer)
- Sigmoid volvulus
- Large bowel obstruction from stricture
Correct answer: Toxic megacolon
Toxic megacolon is defined by colonic dilation greater than 6 cm with systemic toxicity and is a life-threatening complication of inflammatory bowel disease requiring urgent intervention.
CPEN Gastrointestinal Emergencies 5
A 5-year-old presents with abdominal pain, vomiting, and bloody diarrhea 3 days after eating undercooked hamburger at a cookout.
Labs show thrombocytopenia, anemia, and elevated creatinine.
Which complication is developing?