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vomiting

Practice targeted AMC-style multiple-choice questions on vomiting.

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Post-embolization arteriogram showing coiled aneurysm (indicated by yellow arrows) of the posteriorcerebral artery with a residual aneurysmal sac.
Image by Promod Pillai, Aftab Karim, Anil Nanda CC BY 2.0 · Source

A 72-year-old woman with a history of well-controlled hypertension presents with sudden-onset headache and vomiting. Neurological exam reveals mild neck stiffness but is otherwise normal. A CT angiogram reveals a posterior communicating artery aneurysm, which was subsequently coiled. The image shows a post-coiling angiogram. 24 hours post-procedure, she develops worsening headache and new-onset right-sided weakness. What is the MOST appropriate next step?

A. Start aspirin and clopidogrel
B. Increase the dose of her antihypertensive medication
C. Perform lumbar puncture
D. Repeat CT angiogram
E. Administer nimodipine
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents with abdominal distension, obstipation, and vomiting. He has a history of prior abdominal surgery. An upright abdominal X-ray is performed. What is the MOST appropriate next step in management?

A. Colonoscopy
B. Surgical consultation
C. Barium enema
D. Stool softeners
E. Oral antibiotics
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 38-year-old male presents to the emergency department with a 2-day history of intermittent abdominal pain, nausea, and vomiting. He reports passing dark, tarry stools. He has a known history of multiple cutaneous hemangiomas since childhood. On examination, his abdomen is distended and tender to palpation, particularly in the periumbilical region. Bowel sounds are hyperactive. Vitals are: HR 110 bpm, BP 100/60 mmHg, RR 20 breaths/min, SpO2 97% on room air, Temp 37.2°C. A CT scan of the abdomen and pelvis is performed, and a representative image is shown. Given the clinical presentation and imaging findings, what is the MOST appropriate initial management strategy?

A. Endoscopic evaluation with possible cauterization
B. Initiation of high-dose corticosteroids
C. Administration of intravenous antibiotics
D. Surgical exploration
E. Observation with serial abdominal examinations
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset, intermittent, severe abdominal pain, vomiting, and lethargy. On examination, he is pale and has a palpable mass in the right upper quadrant. Vitals are stable. An ultrasound is performed, shown above. Based on the clinical presentation and the provided image, what is the most appropriate next step in the management of this patient?

A. Urgent surgical consultation for laparotomy
B. Administration of broad-spectrum antibiotics
C. CT scan of the abdomen and pelvis
D. Admission for observation and serial abdominal exams
E. Air enema reduction
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation, the laboratory results, and the findings demonstrated in the image, which of the following represents the most appropriate immediate therapeutic intervention?

A. Intravenous administration of 5% dextrose in 0.45% sodium chloride.
B. Oral rehydration therapy with an electrolyte solution.
C. Urgent surgical consultation for pyloromyotomy without prior fluid resuscitation.
D. Placement of a nasogastric tube for continuous gastric drainage.
E. Intravenous administration of 0.9% sodium chloride with added potassium chloride.
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with intermittent abdominal pain, vomiting, and currant jelly stools. An ultrasound is performed, revealing the finding shown. What is the MOST appropriate next step in the management of this patient?

A. Appendectomy
B. Exploratory laparotomy
C. Air enema
D. Stool culture
E. Observation and intravenous fluids
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A previously well 3-year-old boy presents to the emergency department with a 12-hour history of sudden onset, intermittent, severe, colicky abdominal pain, associated with non-bilious vomiting. Between episodes, he appears lethargic and pale. His vital signs are stable: HR 110, BP 90/60, RR 24, Temp 37.2. Abdominal examination reveals mild distension and tenderness, but no guarding or rebound. Bowel sounds are present. A point-of-care ultrasound is performed by the emergency physician. Considering the clinical presentation, the patient's current stable vital signs, and the specific findings demonstrated in the provided ultrasound image, which of the following represents the single most appropriate immediate next step in the management of this patient in an Australian tertiary paediatric centre?

A. Proceed directly to surgical exploration.
B. Attempt pneumatic or hydrostatic reduction under fluoroscopic guidance.
C. Obtain a CT scan of the abdomen and pelvis.
D. Administer IV fluids and observe for resolution.
E. Discharge home with pain relief and follow-up.
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 3-week-old male infant is brought to the emergency department by his parents due to persistent, non-bilious vomiting after each feeding for the past week. The vomiting has become increasingly forceful. The infant appears mildly dehydrated, and his weight has remained stable since birth. On examination, an olive-shaped mass is palpated in the epigastric region when the infant is not actively vomiting. An upper GI series is performed, and the image is shown. What is the most appropriate next step in the management of this patient?

A. Initiate a trial of thickened feeds
B. Surgical pyloromyotomy
C. Administer intravenous ondansetron and observe
D. Start erythromycin to stimulate gastric emptying
E. Perform an upper endoscopy with biopsy
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 5-week-old male presents with projectile vomiting. Ultrasound (shown). What electrolyte abnormality is MOST likely?

A. Hyperchloremic metabolic acidosis
B. Hyperkalemia
C. Hyponatremia
D. Hypophosphatemia
E. Hypochloremic metabolic alkalosis
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old presents with projectile vomiting after feeds. An ultrasound is performed (shown). What is the MOST appropriate next step in management?

A. Trial of thickened feeds
B. Upper endoscopy with biopsy
C. Reassurance and close follow-up
D. Start erythromycin
E. Surgical consultation for pyloromyotomy
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A 62-year-old man presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. He has a history of poorly controlled hypertension and is currently on no medications. On examination, he is drowsy but arousable, with a blood pressure of 210/120 mmHg and a heart rate of 90 bpm. Neurological examination reveals right-sided hemiparesis and a left gaze preference. A CT scan of the head shows a large hyperdense area in the left basal ganglia with surrounding edema. What is the most appropriate initial management for this patient?

A. Immediate surgical evacuation of the hematoma
B. Intravenous labetalol to lower blood pressure
C. Oral antihypertensive therapy to gradually lower blood pressure
D. Intravenous mannitol to reduce intracranial pressure
E. Intravenous thrombolysis to dissolve the clot
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A 68-year-old man with a history of poorly controlled type 2 diabetes, hypertension, and chronic kidney disease (stage 3) presents to the emergency department with severe abdominal pain and vomiting. On examination, he has a distended abdomen with diffuse tenderness and guarding. His vital signs show a blood pressure of 90/60 mmHg, heart rate of 110 bpm, and a temperature of 38.5°C. Laboratory tests reveal leukocytosis, elevated serum lactate, and worsening renal function. A CT scan of the abdomen shows pneumoperitoneum and free fluid, suggesting perforated viscus. What is the most appropriate next step in the management of this patient?

A. Immediate exploratory laparotomy
B. Administer intravenous fluids and reassess in 2 hours
C. Initiate broad-spectrum antibiotics and observe
D. Consult nephrology for dialysis before surgery
E. Perform a diagnostic laparoscopy
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 63-year-old woman with a 20-year history of Crohn's disease presents with worsening abdominal pain, bloating, and occasional post-prandial vomiting. She is currently managed with mesalazine and budesonide. Physical examination reveals mild right lower quadrant tenderness. Laboratory tests show a slightly elevated CRP. Given her presentation and the provided imaging, what is the most appropriate next step in her management?

A. Perform an urgent colonoscopy with biopsies
B. Increase the dose of budesonide
C. Continue current medical therapy and monitor symptoms
D. Switch mesalazine to an oral corticosteroid like prednisone
E. Refer for surgical assessment for potential stricture or complication
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 3-week-old male presents with projectile vomiting after feeds. An upper GI series is performed (image shown). What is the MOST appropriate next step in management?

A. Barium swallow study
B. Surgical pyloromyotomy
C. Medical management with erythromycin
D. Trial of thickened feeds
E. Upper endoscopy with biopsy
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset, intermittent, severe abdominal pain, vomiting, and lethargy. On examination, he is pale and has a palpable mass in the right upper quadrant. Vitals are stable. An ultrasound is performed, shown above. Considering the clinical presentation and the findings in the image, what is the most appropriate initial management step?

A. Admit for intravenous fluids and serial abdominal examinations
B. Perform an upper gastrointestinal series with small bowel follow-through
C. Obtain a contrast-enhanced CT scan of the abdomen and pelvis
D. Pneumatic or hydrostatic reduction under fluoroscopy
E. Urgent laparotomy for manual reduction
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A neonate, born at 38 weeks gestation, presents with bilious vomiting starting 12 hours after birth. Antenatal ultrasound revealed polyhydramnios. On examination, the baby is active and has a distended upper abdomen but a scaphoid lower abdomen. An abdominal X-ray shows a 'double bubble' sign. Which of the following is the most appropriate next step in the management of this neonate, considering potential associated complications?

A. Immediately perform a contrast enema to rule out meconium ileus as a cause of the obstruction.
B. Initiate intravenous fluids, nasogastric decompression, and prepare for surgical intervention after stabilization.
C. Begin feeds with a hydrolysed formula to assess tolerance and rule out milk protein allergy.
D. Start the neonate on broad-spectrum antibiotics to cover potential bacterial translocation.
E. Perform an upper gastrointestinal endoscopy to visualize the obstruction and obtain biopsies.
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male presents with vomiting and abdominal pain. An abdominal X-ray is performed. What is the MOST likely underlying cause?

A. Appendicitis
B. Diverticulitis
C. Volvulus
D. Adhesions from prior surgery
E. Pancreatitis
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Ultrasonographic picture taken from a patient with left ureteral stone with hydronephrosis, created in Taiwan
Image by morning2k CC BY 2.5 · Source

A 45-year-old male presents to the ED with left flank pain that started suddenly 6 hours ago. He describes the pain as a sharp, cramping sensation radiating to his groin. He also reports nausea and one episode of vomiting. His vital signs are stable: BP 120/80 mmHg, HR 78 bpm, RR 16 breaths/min, Temp 37.1°C. Urine dipstick shows 2+ blood. A renal ultrasound is performed, and the image is shown. Assuming the patient's pain is not controlled with oral analgesics, what is the MOST appropriate next step?

A. Consult urology for emergent ureteroscopy
B. Start intravenous fluids at 250 mL/hr
C. Order a non-contrast CT scan of the abdomen and pelvis
D. Discharge home with tamsulosin and analgesics
E. Administer intravenous ketorolac
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 5-week-old male infant presents to the emergency department with a 3-day history of non-bilious, projectile vomiting after each feed. He is otherwise well-appearing and afebrile. His mother reports that he is feeding well but seems increasingly hungry after vomiting. On examination, the infant is alert and active, with slightly dry mucous membranes. Abdominal examination is unremarkable, with no palpable masses. An ultrasound of the abdomen is performed, the image of which is shown. What is the most appropriate next step in the management of this patient?

A. Surgical consultation for pyloromyotomy
B. Administer intravenous ondansetron and observe
C. Upper gastrointestinal endoscopy with biopsy
D. Discharge home with instructions for frequent small-volume feeds
E. Initiate a trial of thickened feeds
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A 45-year-old man presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. He describes the headache as the worst he has ever experienced. He has a history of hypertension but is otherwise healthy. On examination, he is alert but in distress due to the headache. His blood pressure is 180/110 mmHg, heart rate is 90 bpm, and he has no focal neurological deficits. A CT scan of the head shows no acute intracranial hemorrhage. What is the next best step in management?

A. Administer analgesics and observe
B. Repeat CT scan with contrast
C. MRI of the brain
D. Lumbar puncture
E. Start antihypertensive therapy
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A neonate is born at term following an uneventful pregnancy. Immediately after birth, the baby develops bilious vomiting. Abdominal examination reveals epigastric distension, but the rest of the abdomen is scaphoid. An abdominal X-ray is performed. Which of the following findings on the abdominal X-ray would be most consistent with the likely diagnosis?

A. Double-bubble sign
B. Multiple air-fluid levels throughout the abdomen
C. Free air under the diaphragm
D. Pneumatosis intestinalis
E. Ground glass appearance
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 6-week-old male infant presents with a 2-week history of progressively worsening projectile non-bilious vomiting after feeds. He has lost weight and appears lethargic. Initial bloods show a hypochloremic, hypokalaemic metabolic alkalosis. After fluid resuscitation, the image is obtained. What is the most appropriate definitive management for this patient?

A. Further imaging with abdominal ultrasound
B. Placement of nasogastric tube for gastric decompression
C. Trial of medical management with atropine
D. Discharge home with thickened feeds and anti-reflux medication
E. Surgical pyloromyotomy
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 32-year-old male presents to the emergency department complaining of intermittent abdominal pain, nausea, and vomiting for the past 24 hours. He reports passing a small amount of blood in his stool this morning. He denies any fever or chills. His past medical history is significant for multiple cutaneous hemangiomas, which he has had since childhood. On physical examination, his abdomen is mildly distended and tender to palpation in the periumbilical region. Bowel sounds are hyperactive. The patient is hemodynamically stable. A CT scan of the abdomen is performed, the results of which are shown. Given the clinical presentation and imaging findings, what is the MOST appropriate next step in the management of this patient?

A. Initiation of high-dose corticosteroids
B. Surgical exploration
C. Colonoscopy with biopsy
D. Barium enema
E. Observation with serial abdominal examinations
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 78-year-old male presents with persistent vomiting and epigastric pain. He reports a history of NSAID use for chronic arthritis. An X-ray is performed. Which of the following is the MOST likely complication associated with this finding?

A. Aortic dissection
B. Gastric volvulus
C. Pneumonia
D. Pericarditis
E. Esophageal stricture
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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 28-year-old female presents to the ED with acute onset right lower quadrant pain. She reports nausea and vomiting. Her last menstrual period was 6 weeks ago, and she denies any vaginal bleeding. She is hemodynamically stable. A CT scan of the abdomen and pelvis is performed, with a relevant image shown. What is the MOST appropriate next step in the management of this patient?

A. Emergency hysterectomy
B. Laparoscopic cystectomy
C. Administration of broad-spectrum antibiotics
D. Initiate anticoagulation therapy
E. Expectant management with analgesia
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Ultrasonographic picture taken from a patient with left ureteral stone with hydronephrosis, created in Taiwan
Image by morning2k CC BY 2.5 · Source

A 38-year-old male presents to the emergency department complaining of sudden onset, severe left flank pain that radiates to his groin. He reports associated nausea and vomiting. He denies any fever, dysuria, or hematuria. His vital signs are stable: blood pressure 120/80 mmHg, heart rate 88 bpm, respiratory rate 16 breaths/min, and temperature 37.0°C. A urinalysis reveals microscopic hematuria. A point-of-care ultrasound is performed, and the image is shown. Given the clinical presentation and ultrasound findings, what is the MOST appropriate next step in management?

A. Consult nephrology for possible percutaneous nephrostomy
B. Insert a Foley catheter to monitor urine output
C. Prescribe oral antibiotics for presumed pyelonephritis
D. Order a non-contrast CT scan of the abdomen and pelvis
E. Administer intravenous ketorolac and discharge with outpatient urology follow-up
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in the management of this infant?

A. Administer intravenous ondansetron and observe for improvement in vomiting.
B. Discharge home with instructions for smaller, more frequent feeds and review by the general practitioner in 24 hours.
C. Insert a nasogastric tube for continuous drainage and commence total parenteral nutrition.
D. Obtain an urgent upper gastrointestinal contrast study to confirm the diagnosis and assess for malrotation.
E. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium chloride supplementation, and arrange urgent surgical consultation.
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 75-year-old female presents to the emergency department with a 24-hour history of worsening colicky abdominal pain, nausea, and multiple episodes of bilious vomiting. She reports no passage of flatus or stool for the past 18 hours. Her past medical history includes an open appendectomy 30 years ago and a hysterectomy 10 years ago. On examination, she is afebrile, heart rate 92 bpm, blood pressure 130/80 mmHg, respiratory rate 18/min, oxygen saturation 98% on room air. Her abdomen is distended and diffusely tender to palpation, with high-pitched tinkling bowel sounds on auscultation. A plain abdominal X-ray series, including the image provided, was obtained. Considering the patient's clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate immediate next step in her management?

A. Administer a large volume enema
B. Administer broad-spectrum intravenous antibiotics
C. Order a CT scan of the abdomen and pelvis with intravenous contrast
D. Proceed directly to exploratory laparotomy
E. Insert a nasogastric tube for decompression
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 6-week-old male infant presents to the emergency department with a 5-day history of progressively worsening non-bilious vomiting, which has become projectile over the past 48 hours. He is exclusively formula-fed and his parents report decreased wet nappies and increased irritability. On examination, he is alert but appears slightly lethargic. His weight is below his birth weight. Capillary refill time is 3 seconds. Vitals are: HR 150 bpm, RR 40 bpm, T 37.2°C, BP 85/50 mmHg. Abdominal examination is soft, non-distended, and no masses are definitely palpable. Initial blood gas shows pH 7.52, pCO2 40 mmHg, HCO3 32 mmol/L, Na+ 130 mmol/L, K+ 3.0 mmol/L, Cl- 85 mmol/L. Urea and creatinine are mildly elevated. An imaging study was performed, shown above. Considering the clinical presentation and the findings on the imaging study, which of the following is the most critical immediate management step?

A. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium supplementation.
B. Insert a nasogastric tube for gastric decompression.
C. Administer intravenous ondansetron to control vomiting.
D. Arrange for urgent surgical consultation for pyloromyotomy.
E. Obtain a paediatric surgical ultrasound of the abdomen.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation, the laboratory findings, and the abnormality demonstrated in the provided image, which of the following best explains the mechanism leading to the observed electrolyte and acid-base derangements?

A. Loss of gastric acid (HCl) through vomiting, leading to compensatory renal hydrogen ion excretion and potassium wasting.
B. Increased aldosterone secretion due to dehydration, causing sodium retention and potassium excretion.
C. Excessive sodium and water loss in stool due to malabsorption.
D. Shift of potassium into intracellular space due to metabolic alkalosis.
E. Impaired renal bicarbonate excretion due to decreased glomerular filtration rate from dehydration.
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A 62-year-old woman presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. She describes the headache as the worst she has ever experienced. Her medical history includes hypertension and hyperlipidemia, for which she is on regular medication. On examination, she is alert but in distress, with a blood pressure of 180/100 mmHg, heart rate of 90 bpm, and respiratory rate of 18 breaths per minute. Neurological examination reveals neck stiffness but no focal neurological deficits. A CT scan of the head shows no acute intracranial hemorrhage. Which of the following is the most appropriate next step in management?

A. Start intravenous antihypertensive therapy
B. Administer antiemetics and observe
C. MRI of the brain
D. Repeat CT scan with contrast
E. Lumbar puncture
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset intermittent severe abdominal pain, vomiting, and lethargy. On examination, he is pale but haemodynamically stable. Abdominal examination reveals a palpable mass in the right upper quadrant. An ultrasound is performed (image provided). What is the most appropriate next step in management?

A. Administration of broad-spectrum antibiotics
B. Admission for observation and IV fluids
C. Abdominal CT scan with contrast
D. Immediate surgical exploration
E. Air or hydrostatic enema reduction
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 5-week-old male presents with projectile vomiting after feeds. He is irritable and appears dehydrated. An upper GI contrast study is performed, with relevant images attached. What is the MOST likely underlying cause?

A. Malrotation with volvulus
B. Duodenal atresia
C. Gastroesophageal reflux
D. Hypertrophy of the pyloric sphincter
E. Esophageal stricture
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 62-year-old male presents with acute onset of LLQ pain, fever, and vomiting. His WBC count is elevated. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the most appropriate next step in management?

A. Flexible sigmoidoscopy
B. IV antibiotics and bowel rest
C. Stool softeners
D. Surgical resection
E. High-fiber diet
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 75-year-old female presents to the emergency department with a 24-hour history of worsening colicky abdominal pain, nausea, and multiple episodes of bilious vomiting. She reports no passage of flatus or stool for the past 18 hours. Her past medical history includes an open appendectomy 30 years ago and a hysterectomy 10 years ago. On examination, she is afebrile, heart rate 92 bpm, blood pressure 130/80 mmHg, respiratory rate 18/min, oxygen saturation 98% on room air. Her abdomen is distended and diffusely tender to palpation, with high-pitched tinkling bowel sounds on auscultation. A plain abdominal X-ray series, including the image provided, was obtained. Considering the patient's clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate immediate next step in her management?

A. Perform an upper gastrointestinal endoscopy.
B. Arrange for an urgent contrast-enhanced computed tomography scan of the abdomen and pelvis.
C. Discharge the patient home with oral analgesia and instructions to return if symptoms worsen.
D. Administer a high-dose osmotic laxative orally.
E. Proceed directly to exploratory laparotomy.
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 3-week-old male infant is brought to the emergency department by his parents. They report that he has been experiencing projectile vomiting after every feed for the past week. The vomiting is non-bilious. He appears dehydrated, with sunken fontanelles and decreased skin turgor. His weight has decreased since his last check-up. An abdominal X-ray is ordered, the results of which are shown. What is the most appropriate next step in the management of this patient?

A. Surgical consultation for pyloromyotomy
B. Discharge home with oral rehydration solution
C. Perform an upper endoscopy
D. Start feeds with thickened formula
E. Administer intravenous antibiotics
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 68-year-old male with a history of reflux presents with epigastric pain and vomiting. An X-ray is performed (shown). What is the most likely complication?

A. Gastric volvulus
B. Pericarditis
C. Esophageal stricture
D. Aortic dissection
E. Pneumonia
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male presents with abdominal distension, vomiting, and inability to pass flatus for 48 hours. He has a history of prior bowel resection. Examination reveals a tympanitic abdomen and tenderness to palpation. His vitals are stable. An abdominal X-ray is performed, as shown. Considering the clinical context and the radiographic findings, what is the MOST likely underlying cause of this presentation?

A. Post-surgical adhesions
B. Inflammatory bowel disease stricture
C. Volvulus
D. Hernia
E. Malignancy
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old infant presents with a 1-week history of increasing non-bilious projectile vomiting after feeds. He is otherwise well, afebrile, and has wet nappies. Examination is unremarkable. An ultrasound is performed, shown in the image. Considering the clinical presentation and the findings in the provided image, what is the most appropriate definitive surgical intervention for this condition?

A. Antrectomy
B. Laparoscopic Nissen fundoplication
C. Ramstedt pyloromyotomy
D. Gastrostomy tube insertion
E. Pyloric dilatation
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 75-year-old female presents to the emergency department with a 24-hour history of worsening colicky abdominal pain, nausea, and multiple episodes of bilious vomiting. She reports no passage of flatus or stool for the past 18 hours. Her past medical history includes an open appendectomy 30 years ago and a hysterectomy 10 years ago. On examination, she is afebrile, heart rate 92 bpm, blood pressure 130/80 mmHg, respiratory rate 18/min, oxygen saturation 98% on room air. Her abdomen is distended and diffusely tender to palpation, with high-pitched tinkling bowel sounds on auscultation. A plain abdominal X-ray series, including the image provided, was obtained. Given the clinical presentation and the findings demonstrated in the provided image, which of the following is the most appropriate *next* investigation to guide definitive management?

A. Repeat plain abdominal X-ray series in 6 hours
B. Upper endoscopy
C. Barium enema
D. MRI of the abdomen
E. CT scan of the abdomen and pelvis with intravenous contrast
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male presents with abdominal distension, vomiting, and inability to pass flatus for 48 hours. He has a history of prior bowel resection. Examination reveals a tympanitic abdomen and tenderness to palpation. His vitals are stable. An abdominal X-ray is performed, as shown. Considering the clinical context and the radiographic findings, what is the primary purpose of inserting a nasogastric tube in this patient?

A. Obtaining a sample of gastric contents for analysis.
B. Administering oral contrast for further imaging.
C. Decompressing the dilated bowel loops and reducing vomiting.
D. Providing nutritional support to the patient.
E. Facilitating the passage of flatus.
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 4-week-old male presents with projectile vomiting after feeding. He is irritable and appears dehydrated. An upper GI series is performed, as shown. After addressing immediate concerns, what is the MOST appropriate next step?

A. Perform an upper endoscopy with biopsy
B. Administer intravenous antibiotics
C. Surgical pyloromyotomy
D. Start H2 receptor antagonist therapy
E. Initiate a trial of thickened feeds
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A 65-year-old man presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension and is currently on antihypertensive medication. On examination, he is alert but in distress due to the headache. His blood pressure is 180/110 mmHg, heart rate is 90 bpm, and he has no focal neurological deficits. A CT scan of the head shows a subarachnoid hemorrhage. Which of the following is the most appropriate initial management step in this patient?

A. Administer nimodipine to prevent cerebral vasospasm
B. Perform immediate surgical clipping of the aneurysm
C. Administer mannitol to reduce intracranial pressure
D. Start intravenous labetalol to control blood pressure
E. Initiate anticonvulsant therapy to prevent seizures
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents to the emergency department with a 12-hour history of intermittent, severe abdominal pain, drawing his legs up to his chest. He has vomited several times. His vital signs are stable: HR 110, BP 95/60, RR 24, Temp 37.2°C. On examination, he is irritable but comfortable between episodes of pain. His abdomen is soft but mildly distended. A focused abdominal ultrasound is performed, yielding the image provided. Based on the clinical presentation and the findings shown, what is the most appropriate next step in the management of this patient?

A. Pneumatic reduction under fluoroscopy
B. Abdominal CT scan with contrast
C. Admission for observation and serial abdominal exams
D. Immediate surgical consultation for laparotomy
E. Administration of broad-spectrum intravenous antibiotics
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with a 12-hour history of intermittent, severe abdominal pain, drawing his legs up to his chest. He has vomited several times. His vital signs are stable: HR 110, BP 95/60, RR 24, Temp 37.2°C. On examination, he is irritable but comfortable between episodes of pain. His abdomen is soft but mildly distended. A focused abdominal ultrasound is performed, yielding the image provided. Based on the clinical presentation and the findings shown, what is the most appropriate initial therapeutic intervention?

A. Intravenous fluid resuscitation and pain control
B. Administer a nasogastric tube for decompression and observe
C. Air or hydrostatic enema under fluoroscopic guidance
D. Obtain a CT scan of the abdomen
E. Urgent surgical exploration
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A 32-year-old woman presents to the emergency department with severe right lower quadrant abdominal pain, nausea, and vomiting. She reports her last menstrual period was 6 weeks ago. On examination, she has tenderness and guarding in the right lower quadrant. A urine pregnancy test is positive. What is the most appropriate next step in management?

A. Prescribe analgesics and discharge
B. Schedule an exploratory laparotomy
C. Perform a transvaginal ultrasound
D. Administer methotrexate
E. Order a CT scan of the abdomen
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset intermittent severe abdominal pain, vomiting, and lethargy. On examination, he is pale but haemodynamically stable. Abdominal examination reveals a palpable mass in the right upper quadrant. An ultrasound is performed (image provided). What is the most appropriate next step in management?

A. Admission for observation and IV fluids
B. Air or hydrostatic enema reduction
C. Urgent surgical exploration
D. Abdominal CT scan with contrast
E. Intravenous antibiotics
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male presents with projectile vomiting after feeds. He is otherwise well-appearing, with normal vital signs. An abdominal ultrasound is performed (image attached). What is the MOST appropriate next step in management?

A. Initiate a proton pump inhibitor
B. Surgical consultation for pyloromyotomy
C. Reassurance and close follow-up
D. Upper endoscopy with biopsy
E. Trial of thickened feeds
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 42-year-old male presents to the emergency department with a 3-day history of colicky abdominal pain, nausea, and vomiting. He reports that he has not had a bowel movement in 2 days and has noticed some blood in his vomit. He has a known history of multiple cutaneous hemangiomas since childhood. On examination, his abdomen is distended and tympanic, with tenderness to palpation in all quadrants. Bowel sounds are high-pitched and infrequent. Vitals are stable. A CT scan of the abdomen and pelvis is performed, and a representative image is shown. What is the MOST likely underlying cause of the patient's acute presentation, considering his history and the imaging findings?

A. Sigmoid volvulus
B. Bleeding from intestinal hemangiomas leading to intussusception
C. Appendicitis with perforation
D. Crohn's disease exacerbation
E. Adhesions from previous abdominal surgery
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with intermittent abdominal pain, vomiting, and currant jelly stools. An ultrasound is performed, revealing the image shown. What is the MOST appropriate next step in management?

A. Observation and supportive care
B. Surgical resection
C. IV antibiotics
D. Appendectomy
E. Air enema
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