Hepatic Failure/GI/Endocrine Emergencies
Answer: B
Intravenous acetylcysteine increases transplant-free
survival rates for patients with NAI-ALF, particu-
larly for patients with low-grade encephalopathy. Oral
acetylcysteine has not been studied in a randomized
controlled trial for NAI-ALF (Answer C is incorrect),
and the dosing strategy for NAI-ALF is different from
the 21-hour intravenous regimen for acetaminophen
overdose (Answer A is incorrect). The dosing strategy
for NAI-ALF is a 72-hour regimen with a 150-mg/kg
bolus, followed by a 12.5-mg/kg/hour dose for 4 hours
and then a 6.25-mg/kg/hour dose for 67 hours (Answer
B is correct). Oral glutamine is not used for NAI-ALF;
it has been studied to aid in the healing of GI fistulas
(Answer D is incorrect).
Osmotic agents are first-line treatment for control of
ICP. Although hypertonic saline prevents ICP eleva-
tions, the continuous infusion is not used for acute
control (Answer A is incorrect). For acute control of ICP
elevations, mannitol boluses are used first line provided
serum osmolaity is less than 320 (Answer B is cor-
rect). Hyperventilation and barbiturates are only used
to control ICP elevations when other options have failed
(Answers C and D are incorrect).
Answer: C
This patient has severe acute necrotizing pancreatitis
because she has not improved after the first 48 hours,
and her CT reveals pancreatitic necrosis involving more
than 30% of her pancreas. There appears to be no benefit
with using prophylactic antibiotics for patients with nec-
rotizing AP, in reducing either mortality rates or rates of
pancreatic and extrapancreatic infections, particularly
in more recent studies (Answers A and D are incorrect).
Surgical management for sterile necrosis is only recom-
mended if patients have gastric outlet obstruction and/
or bile duct obstruction (Answer B is incorrect). For
patients with severe acute necrotizing pancreatitis, it is
recommended to defer antibiotics unless there is sug-
gestion of infection or if patients have not improved
within 7–10 days (Answer C is correct).
Answer: D
Somatostatin significantly decreases fistula output
compared with placebo (Answer A is incorrect). Total
parenteral nutrition increases spontaneous closure rates
by reducing GI secretions (Answer C is incorrect),
and octreotide had a beneficial effect on fistula output
in one small study (Answer B is incorrect). Although
glutamine has been associated with spontaneous rates
of fistula closure, it has been not been associated with
reduced fistula output (Answer D is correct).
Answer: B
Of the possible answers, only alvimopan has been shown
to reduce the incidence of ileus postoperatively (Answer
B is correct). Metoclopramide has shown mixed results,
though the antiemetic properties may be beneficial as
adjunctive therapy in POI, and octreotide is not used in
the prevention of POI (Answers C and D are incorrect).
All opioids can contribute equally to POI (Answer A is
incorrect).
Answer: A
According to the simplified Apfel risk score criteria,
this patient has four risk factors for developing PONV
(female sex, nonsmoker, history of motion sickness, and
perioperative opioids). These risk factors place her at high
risk of developing PONV, estimated at greater than 80%
(Answers B and D are incorrect). Patients with a high risk
of PONV should receive more than two pharmacologic
interventions to prevent PONV (Answer A is correct;
Answer C is incorrect).
Answer: D
Frank bloody output from the rectum is more indicative
of a lower GI bleed than an UGIB. However, patients
with a brisk UGIB may present with bright red blood per
rectum. Although a lower GI bleed is more likely, the
patient should be initiated on a PPI infusion and undergo
an esophagogastroduodenoscopy as soon as possible
(Answer D is correct). After the esophagogastroduo-
denoscopy, the patient should have a colonoscopy. The
priority in this patient’s case is to evaluate for an UGIB
because the finding of “coffee-ground” material on
NG lavage suggests that the bleeding source is UGIB