WBR0266

Author	Vendhan Ramanujam
Exam Type	USMLE Step 3
Main Category	Emergency Room
Sub Category	Gastrointestinal, Surgery
Prompt	A 36 year old man who sustained a gunshot wound to the left buttock is brought to the ER. No exit wound is found during examination. He is hemodynamically stable with a blood pressure of 110/70 mm Hg. His heart rate is 90/min and his respiratory rate is 16/min. An X ray of the abdomen shows the bullet to be located in his right lower quadrant. The most appropriate management of a suspected rectal injury in this patient will include
Answer A	Barium studies of the colon and rectum
Answer A Explanation	Incorrect-The use of barium is contraindicated since spillage of barium mixed with feces into the peritoneal cavity would increase the likelihood of subsequent intraabdominal abscess.
Answer B	Barium studies of the bullet track
Answer B Explanation	Incorrect-The use of barium is contraindicated since spillage of barium mixed with feces into the peritoneal cavity would increase the likelihood of subsequent intraabdominal abscess.
Answer C	Endoscopy of the bullet track
Answer C Explanation	Incorrect-Instrumentation of the bullet track is also contraindicated because of the risk of injury to adjacent structures (e.g., bladder, ureters, iliac vessels).
Answer D	Angiography
Answer D Explanation	Incorrect-Angiography is not a sensitive method for demonstrating injury to the intestinal wall.
Answer E	Sigmoidoscopy in the emergency room
Answer E Explanation	Correct-Penetrating injury to the intraperitoneal or extraperitoneal rectum should be diagnosed by immediate sigmoidoscopy. When sigmoidoscopy is inconclusive, contrast studies of the rectum using a watersoluble radiopaque medium such as gastrografin can be done.
Right Answer	E
Explanation	[[Explanation::Penetrating injury to the intraperitoneal or extraperitoneal rectum should be diagnosed by immediate sigmoidoscopy. When sigmoidoscopy is inconclusive, contrast studies of the rectum using a watersoluble radiopaque medium such as gastrograffin can be done. Educational Objective: Penetrating injury to the intraperitoneal or extraperitoneal rectum should be diagnosed by immediate sigmoidoscopy. Only when sigmoidoscopy is inconclusive, contrast studies of the rectum using a watersoluble radiopaque medium such as gastrograffin can be done. Barium studies and instrumentation to track the bullet are contraindicated. Educational Objective: References: ]]
Approved	Yes
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