What about this question.

[RussianJoo]

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this if from an nbme exam.. 67 year old women has vaginal bleeding.. on exam the uterus is consistent with a 10 week gestation and is irregular... what's the most appropriate next step?

A) Endometrial biopsy

B) transvaginal U/S

C) Colposcopy

D) Endometrial ablation.

 

[beponychick]

This is from from Form 2 right? I just took that one right now.

I believe the answer is A. A postmenopausal lady her age should not have vaginal bleeding. So I'm suspecting endometrial cancer.

 

[RussianJoo]

yep form 2... what did you think? i thought the q's were way too short..and there were some really tricky ones there.. i think it was a waste of $45... cause the real test isn't going to be as representative also it came out in 2004... i think i am going to do nbme4 next...

yeah i guess what about the irregaular large uterus? can you do an endometrial biopsy with leiomyomas?

I put U/S to take a look before we go in there and start doing a D and C...

 

[RussianJoo]

What about this q....

77 year old lady collapsed at home a few hours after an onset of massive bright red rectal bleeding and brought to the ED. BP was 90/60 HR was 130/min exam showed no abnormalities, NG tube yeilded clear aspirae. her Hct was like 26% which one is most likely?

A) Colon Cancer
B) Diverticulosis
C)Doudnel Ulcer
D) Hemorrhoids
E) IBD

 

[astronomylover]

I think its B diverticulosis because that is the only one out of all the choices that can cause an acute GI bleed that massive and dangerous. Colona Ca would not be acute and wouldnt cause that much bleeding. Cant be duodenal ulcer because NG aspirate was clear. Hemorroids wouldnt also cause such massive acute bleeding. And IBD, well i doubt it either.

 

[RussianJoo]

I think its B diverticulosis because that is the only one out of all the choices that can cause an acute GI bleed that massive and dangerous. Colona Ca would not be acute and wouldnt cause that much bleeding. Cant be duodenal ulcer because NG aspirate was clear. Hemorroids wouldnt also cause such massive acute bleeding. And IBD, well i doubt it either.

yeah but NG aspirate was clear meaning they didn't get down into the duodenum.. if they would have have it would have sucked up bile, and it was clear meaning just gastric juices so they just got it into the stomach..

I put duodenal ulcer i think those bleed more than diverticulosis.. but then again the whole age thing means that they have diverticulosis, probably more commonly than ulcers.

 

[beponychick]

What about this q....

77 year old lady collapsed at home a few hours after an onset of massive bright red rectal bleeding and brought to the ED. BP was 90/60 HR was 130/min exam showed no abnormalities, NG tube yeilded clear aspirae. her Hct was like 26% which one is most likely?

A) Colon Cancer
B) Diverticulosis
C)Doudnel Ulcer
D) Hemorrhoids
E) IBD

I put diverticulosis. Since the aspirate is clear (and not coffee ground) you can pretty much exclude an UGI bleed. And diverticulosis is one of the main causes of painless rectal bleeding in the elderly.

 

[beponychick]

yep form 2... what did you think? i thought the q's were way too short..and there were some really tricky ones there.. i think it was a waste of $45... cause the real test isn't going to be as representative also it came out in 2004... i think i am going to do nbme4 next...

yeah i guess what about the irregaular large uterus? can you do an endometrial biopsy with leiomyomas?

I put U/S to take a look before we go in there and start doing a D and C...

Yeah, the questions were pretty short but some were difficult. I dont know. I did ok on it. My test is in two weeks so we'll see with another form. I dont want to take too many of these because of the money issue and no answers. Are you going to do UW practice exam? I did it for step 1 and like it.

 

[Instatewaiter]

yeah but NG aspirate was clear meaning they didn't get down into the duodenum.. if they would have have it would have sucked up bile, and it was clear meaning just gastric juices so they just got it into the stomach..

I put duodenal ulcer i think those bleed more than diverticulosis.. but then again the whole age thing means that they have diverticulosis, probably more commonly than ulcers.

Diverticulosis the most common cause of lower GI bleeding in the elderly.

AVM is second.

 

[Instatewaiter]

yeah but NG aspirate was clear meaning they didn't get down into the duodenum.. if they would have have it would have sucked up bile, and it was clear meaning just gastric juices so they just got it into the stomach..

I put duodenal ulcer i think those bleed more than diverticulosis.. but then again the whole age thing means that they have diverticulosis, probably more commonly than ulcers.

this if from an nbme exam.. 67 year old women has vaginal bleeding.. on exam the uterus is consistent with a 10 week gestation and is irregular... what's the most appropriate next step?

A) Endometrial biopsy

B) transvaginal U/S

C) Colposcopy

D) Endometrial ablation.

Sounds like she has fibroids but irregular bleeding in a post-menopausal woman... you HAVE to r/o endometrial cancer. The transvaginal u/s is not going to give you the answer because even if you do find fibroids, you still dont know if she has endometrial cancer. The stripe may be thick but you still have to do the biopsy.

However + biopsy--> take out the uterus which also takes care of the fibroids.

Biopsy - then you can do your ultrasound.

 

[RussianJoo]

Yeah, the questions were pretty short but some were difficult. I dont know. I did ok on it. My test is in two weeks so we'll see with another form. I dont want to take too many of these because of the money issue and no answers. Are you going to do UW practice exam? I did it for step 1 and like it.

I have been doing them for about a week... i take my exam in 1 week... wan to read FA and keep doing as many UW q's as i can... i did ok too, but i don't want to do just ok on the real thing...

 

[RussianJoo]

Sounds like she has fibroids but irregular bleeding in a post-menopausal woman... you HAVE to r/o endometrial cancer. The transvaginal u/s is not going to give you the answer because even if you do find fibroids, you still dont know if she has endometrial cancer. The stripe may be thick but you still have to do the biopsy.

However + biopsy--> take out the uterus which also takes care of the fibroids.

Biopsy - then you can do your ultrasound.

So you shouldn't be worried about perforating the uterus? I know that U/S won't give you the diagnosis but that's not what the q asked.. it asked for the next most appropriate step....

 

[jmebb12]

Can someone tell me what "UW self-assessment" is or post a link that takes me to the site. Thanks a bunch!

 

[hj0517]

with the endometrial one - I was taught that postmenopausal + bleeding PV = Ca endometrium until proven otherwise. Next step in management is always pipelle biopsy.

Bulky uterus could just be advanced Ca endo.

Dont complicate matters - I've found that most of this stuff in 2CK are things that I picked up / was taught during my specialties rotations.

 

[Scaredshizzles]

with the endometrial one - I was taught that postmenopausal + bleeding PV = Ca endometrium until proven otherwise. Next step in management is always pipelle biopsy.

Bulky uterus could just be advanced Ca endo.

Dont complicate matters - I've found that most of this stuff in 2CK are things that I picked up / was taught during my specialties rotations.

I think it would be pretty unusual to do just an endometrial biopsy and not a trans vag ultrasound when available in the office...Neither is really a gold standard test in this case, and they can supplement each other....the u/s can identify actual masses/polyps that probably need to be diagnosed with something better than a pipette biopsy and can show the endo stripe thickness. The biopsy can identify abnormal cells, but it is hard to get a great sampling with endo biopsy and is undoubtedly operator dependent. When readily available, I think a trans vag ultrasound would be done too, but not necessarily first...(although I think it would make sense to do it first, when possible.)

Are all gynos equipped with ultrasound in their office? No. If I had to guess, the answer here probably is the biopsy, but it is one of those things in flux and within a few years the answer will probably be some sort of imaging modality first.

 

[Winged Scapula]

This is fun...

for the first question:

1) most Ob-Gyns do have US in their office, but not the TV probe. But why does that matter? You can send the patient out for the study. You do not have to have a diagnosis "in the real world" when the patient walks out of the office. Some OBG may go ahead and do the biopsy but on tests the answer is almost always "do things the right way and in the right order" which is usually some imaging study first then biopsy. If the study shows large bulky mets everywhere, her treatment will be different than if only the uterus appears to be involved.

2) however, a TV US should be the first step, followed by biopsy. As noted but many of you, PV bleeding in a post-menopausal woman is endometrial CA until proven otherwise. The TV US can also give you information about spread outside of the uterus which would be important to know, although it won't change the fact that she needs a biopsy followed by staging with CT if positive.

second (GI Bleed).

1) those that stated the "GI aspirate is clear so that means the duodenum wasn't sampled" are correct. To completely rule out an UGIB, you must get past the pylorus and obtain bile. Bleeding DUs are more common than bleeding GUs and if you only sample the stomach, you haven't ruled out a duodenal source.

2) all of the options can give rectal bleeding - colon ca, hemorrhoids, tics, DU, IBD.

However, the most likely source of bleeding significant enough to cause hypotension and tachycardia would be diverticulosis. Roids can cause massive bleeding but patients aren't usually unstable. Cancers can bleed acutely but typically again not to this amount. Same for IBD.

She needs to be scoped for a diagnosis but my vote is tics.

 

[Scaredshizzles]

This is fun...

for the first question:

1) most Ob-Gyns do have US in their office, but not the TV probe. But why does that matter? You can send the patient out for the study. You do not have to have a diagnosis "in the real world" when the patient walks out of the office. Some OBG may go ahead and do the biopsy but on tests the answer is almost always "do things the right way and in the right order" which is usually some imaging study first then biopsy. If the study shows large bulky mets everywhere, her treatment will be different than if only the uterus appears to be involved.

2) however, a TV US should be the first step, followed by biopsy. As noted but many of you, PV bleeding in a post-menopausal woman is endometrial CA until proven otherwise. The TV US can also give you information about spread outside of the uterus which would be important to know, although it won't change the fact that she needs a biopsy followed by staging with CT if positive.

second (GI Bleed).

I'm having trouble finding the ACOG guidelines, but I did see these Canadian guidelines from 2000...


[FONT=Arial,Helvetica][SIZE=-1]Another Canadian source detailing procedures to follow is the[/SIZE].
[FONT=Arial,Helvetica][SIZE=-1]PRACTICE GUIDELINES POLICY STATEMENT* No. 86, February 2000 from the Canadian Society of Gynecologists and Obstetricans which can be downloaded from [/SIZE].
[FONT=Arial,Helvetica][SIZE=-1]http://sogc.medical.org/SOGCnet/sogc_docs/common/guide/pdfs/ps86.pdf[/SIZE].
[FONT=Arial,Helvetica][SIZE=-1]Diagnosis of Endometrial Cancer in Women with Abnormal Vaginal Bleeding [/SIZE].
[FONT=Arial,Helvetica][SIZE=-1][Extract only][/SIZE].
[FONT=Arial,Helvetica][SIZE=-1]RECOMMENDATIONS [/SIZE].

1. [FONT=Arial,Helvetica][SIZE=-1]Office endometrial biopsy should be the initial diagnostic procedure of choice due to its convenience, accuracy, availabil-ity, safety and low cost (Grade B).[/SIZE].
2. [FONT=Arial,Helvetica][SIZE=-1]If an office endometrial biopsy cannot be performed or the sample is insufficient, then patients should be triaged according to their risk for endometrial cancer. Those felt to be at low risk for endometrial cancer or in whom atrophy is suspected or who are medically unfit, should proceed to transvaginal ultrasound. Those at high risk (i.e. obese, nulliparous, post-menopausal, diabetic women, or those taking tamoxifen) should proceed to D&C, with or without hysteroscopy, as a negative ultrasound would not necessarily be completely reassuring and a positive ultrasound would require tissue sampling regardless (Grade B).[/SIZE].
3. [FONT=Arial,Helvetica][SIZE=-1]There is no consensus in the literature as to what the cut-off value for normal endometrial thickness should be. It has been reported as anywhere from four mm to eight mm.[/SIZE].

Although what did make this case different was that you have already established uterine contour irregularity on physical exam. Which again would want me to get a tvag u/s to look at what sort of polyps or fibroids (although those hsould be shrunk given her postmenopausal age) or masses you got going on.

But, I have a suspician the answer might be endometrial biopsy..Which is unfortunate because it is dumb, as this patient would probably get both. As far as getting the u/s first or second, I don't think it is that important as endometrial biopsy samples by pipelle are done completely blindly anyway....They stick a straw like device through the cervix and suck out some tissue...You can see why you might not get an adequate sample...especially in a woman with blood clots/active bleeding up there.

 

[Scaredshizzles]

I think the other case was your classic example of a painless diverticular hemorrhage dumping a large quantity of bright red blood. Unfortunately by the time she gets to the hospital the bleeding may have already stopped and there might be difficulty in finding the source. Perhaps the question said "clear bile colored fluid" or something like that.

 

[SOUNDMAN]

Although I rarely ever diagree with WS on stuff, I'm going to respectfully do it here on the vaginal bleeding in a post menopausal woman.

Just doing a quick search on uptodate, the workup says biopsy first would be recommended as the above post mentions. That is what I would put on the test atleast, in real-life, yea you would do both.

 

[hj0517]

I have to agree with soundman - and scared shizzles endometrial thickening is not immediately obvious on US (endo hyp defined as >5mm) and is a diagnosis based on pipelle biopsy (no 1. on the recommended guidelines by ACOG, RCOG and NICE)

 

[Scaredshizzles]

Although I rarely ever diagree with WS on stuff, I'm going to respectfully do it here on the vaginal bleeding in a post menopausal woman.

Just doing a quick search on uptodate, the workup says biopsy first would be recommended as the above post mentions. That is what I would put on the test atleast, in real-life, yea you would do both.

Yea, I just don't like examinations designed such that no matter how much you know, you're going to get a fairly large number of questions wrong anyway. But that is how board exams are designed. You shouldn't have to have ACOG guidelines for every possible obgyn workup in front of you in order to answer these questions the way you want them to. If reasonable people can disagree on what to do or what the answer is, it shouldn't be examined in that way.

Regarding endometrial thickness, there is certainly controversy on how accurately it can be estimated on trans vag u/s even---but you do in fact mark the size on the u/s whenever you have a bleeder. But I don't even think you can estimate thickness based on an endometrial biopsy...Even if you did it in such a way that you suctioned out a column perfectly perpendicular to the right portion of the uterus....the biopsy sample tends to fall apart very easily...it is very difficult to measure it and I've never seen it measured unless the pathologist does it.

 

[Winged Scapula]

Although I rarely ever diagree with WS on stuff, I'm going to respectfully do it here on the vaginal bleeding in a post menopausal woman.

Just doing a quick search on uptodate, the workup says biopsy first would be recommended as the above post mentions. That is what I would put on the test atleast, in real-life, yea you would do both.

Ha ha you're allowed to disagree with me even disrepsectfully.

And you guys may very well be right; you've presented some thought provoking ideas.

Of course these exams are not realistic because you would do lots of things at the same time without itemizing things systematically.

I don't think it unreasonable to do the biopsy first, especially if there are high risk factors, but in practice (which as well all know, may not reflect examination questions) you would probably get the US first (according to my OB-Gyn friend I ran into in the hospital after I posted the above). My friend the OB-Gyn is in an MOB across from a radiology facility, so she said she would send the patient down for the TV US and then have her come back the same day for the biopsy. Different practice patterns I suppose but that is what we see in this community.

IMHO the purpose of the TV US wasn't to estimate endometrial thickness (because that is irrelevant to the symptomatic patient at this point) but to look at adnexal structures. A negative US wouldn't change the fact that this patient needs a biopsy, so I can agree that perhaps biopsy should come first in this case.

 

[Winged Scapula]

I think the other case was your classic example of a painless diverticular hemorrhage dumping a large quantity of bright red blood. Unfortunately by the time she gets to the hospital the bleeding may have already stopped and there might be difficulty in finding the source. Perhaps the question said "clear bile colored fluid" or something like that.

Perhaps but you usually find adherent clot or ooze on colonoscopy or can localize with a tagged RBC scan.

On rare occasions, you can't find the source and must go to push enteroscopy with or without ex-lap.