Free Sample COMAT Practice Questions

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Below is a free practice question for general surgery, however our COMAT q-bank contains questions for all 8 subjects.

Your First Free COMAT Practice Question

A 40-year-old male with poor knowledge of his medical history is brought to the emergency room by paramedics. He exhibits altered mental status and complaint of hematemesis. He is unsure of events leading up to presentation but he says that he has been vomiting red blood for the last hour. Vital signs are significant for tachycardia to 125 beats/ minute, blood pressure of 100/85 mm Hg. Physical exam demonstrates an unhealthy appearing male with scleral icterus and a flapping hand tremor. The abdomen exhibits a fluid wave on exam. What is the most likely pathology leading to his hematemesis?

• A) elevated portal pressure
• B) bacterial infection
• C) medication side effect
• D) elevated blood ammonia level
• E) increased abdominal pressure

The Correct Answer and Explanation

Did you get it right? The correct answer is ‘A’.

This patient is presenting with altered mental status, hematemesis, and tachycardia in the setting of cirrhosis, as diagnosed by the scleral icterus, flapping hand tremor, and abdominal fluid wave (suggesting ascites). The hematemesis is likely from a ruptured esophageal varix. The pathology behind formation of varices involves cirrhosis resulting in elevated portal pressures, causing increased flow from the esophageal vein draining into the azygous vein. 

In patients with cirrhosis, portal hypertension leads to increased flow from portal to systemic circulations, causing these collaterals to dilate. The mnemonic “gut, butt, and caput” is often used to remember the locations of these collaterals:

• Gut: esophageal varices occur as blood draining from the left gastric vein drains to the esophageal veins into the azygos vein
• Butt: superior rectal veins drain into the internal iliac and pudendal veins that drain into the iliac and pudendal veins
• Caput: paraumbilical vein drains into subcutaneous veins in the anterior abdominal wall and form caput medusae

Management of patients with variceal hemorrhage centers around restoring hemodynamic stability, maintaining oxygenation, controlling bleeding, and preventing complications. Vasoactive medications such as vasopressin (analog is terlipressin), somatostatin (analog is octreotide) can be used to aid in hemostasis. Endoscopic evaluation and therapy should be performed to attempt hemostasis by variceal ligation or sclerotherapy. If this is unsuccessful, balloon tamponade can be attempted. If a patient is suffering from massive hemorrhage, intubation should be performed to secure the airway prior to further intervention.

Wrong Answer Explanations

Answer B: H pylori infection can lead to peptic ulcer disease. Patients with duodenal ulcers or gastric ulcers can present with hematemesis from erosion into gastric vessels or from mucosal bleeding, however the presentation with cirrhosis should place variceal bleeding at the top of the differential.

Answer C: Non-steroidal anti-inflammatory drugs (NSAIDs) can cause gastric ulceration and bleeding, resulting in hemorrhage. There is no evidence in the question stem to suggest that the patient has a history of NSAID use and variceal bleeding is more likely in a cirrhotic.

Answer D: Uremia is often found in patients with advanced liver disease. In these cases, platelet function can be reduced, there can be underlying thrombocytopenia, and there can be coagulopathy from liver dysfunction and poor synthesis of coagulation factors. All these can cause hemostatic dysfunction in patients with liver disease, but they are not the underlying pathology behind the formation of esophageal varices.

Answer E: Increased abdominal pressure, for example with emesis, can lead to mucosal lacerations, named Mallory-Weiss syndrome that can result in hematemesis. Although this patient has been vomiting, it is more likely that his cirrhosis has led to esophageal varices and his bleeding is from a ruptured varix.

Bottom Line: Cirrhosis can lead to portal hypertension, esophageal varices, and can increase the risk for upper gastrointestinal hemorrhage.

For more information, see: Del Valle J. Del Valle J Chapter 293. Peptic Ulcer Disease and Related Disorders. In: Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012.

Image Source: Akiyama, Tomoyuki, et al. “Endoscopic Therapy Using an Endoscopic Variceal Ligation for Minute Cancer of the Esophagogastric Junction Complicated with Esophageal Varices: a Case Report.” Journal of Medical Case Reports, vol. 4, no. 1, 2010

Methods to achieve hemostasis in patients with acute variceal hemorrhage

Primary and pre-primary prophylaxis against variceal hemorrhage in patients with cirrhosis

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