the pancreas by its digestive enzymes. There are many risk factors for pan-
creatitis, the most common being gallstones and alcohol, which account for
more than 80% of the cases. Pancreatitis can be divided into mild and severe
defined by the presence of organ failure or local complications, such as
necrosis, pseudocyst, or abscess. It should be suspected in all patients with
epigastric pain. Elevation in lipase, a pancreatic enzyme, is used to make the
diagnosis of pancreatitis. At five times the upper limit of normal, the speci-
ficity of lipase approaches 100% for pancreatitis.
Abdominal aortic aneurysms (a)may cause epigastric pain with radia-
tion into the back; however, lipase elevation is not seen. Mesenteric ischemia
(b)can cause pancreatitis by diminished blood flow to the pancreas. These
patients are usually very ill-appearing and complain of abdominal pain that
is out of proportion to the physical examination. Bowel perforation (d)usu-
ally presents with abrupt generalized abdominal pain associated with a rigid
abdomen. Cholecystitis (e)usually presents with RUQ pain associated with
obstruction of the cystic duct.
88.The answer is d.(Rosen, p 226.)The patient’s clinical picture is con-
sistent with ovarian torsion.This phenomenon is most common in women
in their mid-twenties. It is caused by the ovary twisting on its stalk,which
leads to occlusion of venous draining from the ovary. This leads to ovarian
edema, hemorrhage, and necrosis. Most occur in the presence of an enlarged
ovary (ie, as a result of cyst, abscess, or tumor). Patients may give a history of
similar pain that resolved spontaneously. The first choice to diagnose ovarian
torsion is with Doppler ultrasoundto demonstrate decreased or absent
blood flow to the ovary. It can also identify an ovarian mass. If suspicion is
high for ovarian torsion, the patient may immediately undergo laparoscopy,
which is diagnostic and potentially therapeutic.
(a)CT scan may be necessary if the Doppler studies are equivocal. How-
ever, if torsion is suspected, the individual should undergo a laparoscopy,
which is the definitive diagnostic procedure. (b)MRI and (c)x-ray have no
role in the diagnosis of ovarian torsion. If there is high enough clinical suspi-
cion, and diagnostic tests are equivocal, laparoscopy (e)can be used to visu-
alize the ovaries in vivo.
89.The answer is e. (Tintinalli, p 582.) Potential complications of
colonoscopy include hemorrhage, perforation, retroperitoneal abscess,
pneumoscrotum, pneumothorax, volvulus, and infection. Perforation of the
colon with pneumoperitoneumis usually evident immediately, but can
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