Internal medicine board exam

1. ‫א‬ ‫שלב‬ ‫למבחן‬ ‫הכנה‬ ‫קורס‬
'
‫פנימית‬ ‫ברפואה‬
‫מאי‬
2017

2. ‫שאלה‬
1
•
‫הבאים‬ ‫המשפטים‬ ‫איזה‬
‫נכון‬ ‫אינו‬
‫העיכול‬ ‫מדרכי‬ ‫חד‬ ‫דימום‬ ‫עם‬ ‫בקשר‬
-‫א‬
‫שחרה‬ ‫יש‬ ‫כאשר‬
(melena)
‫מעל‬ ‫תמיד‬ ‫הוא‬ ‫הדימום‬ ‫מקור‬
‫הליגמנט‬
‫ע‬
"
‫ש‬
‫טרייץ‬
‫ב‬
-
‫כ‬
-
10%
‫הגס‬ ‫או‬ ‫הדק‬ ‫במעי‬ ‫מקורם‬ ‫בשחרה‬ ‫המתבטאים‬ ‫מהדימומים‬
‫ג‬
-
‫ביציאה‬ ‫טרי‬ ‫דימום‬
,
‫הגס‬ ‫במעי‬ ‫מקורו‬
‫בכ‬
-
85%
‫מהמיקרים‬
‫ד‬
-
‫מהרקטום‬ ‫טרי‬ ‫בדימום‬ ‫להתבטא‬ ‫יכול‬ ‫עליונות‬ ‫עיכול‬ ‫מדרכי‬ ‫חריף‬ ‫דימום‬
‫ה‬
-
‫הדימום‬ ‫צורת‬
(
‫טרי‬ ‫דימום‬ ‫או‬ ‫שחרה‬
)
‫לפליטתו‬ ‫עד‬ ‫העיכול‬ ‫במערכת‬ ‫הדם‬ ‫של‬ ‫השהות‬ ‫בזמן‬ ‫קשורה‬
‫ביציאה‬
‫פרק‬
345 urgent endoscopy
Bedside evaluation also suggests an upper or lower gastrointestinal source of bleeding
in most patients. Over 90% of patients with melena are bleeding proximal to the
ligament of Treitz, and about 85% of patients with hematochezia are bleeding from
the colon. Melena can result from bleeding in the small bowel or right colon,
especially in older patients with slow colonic transit. Conversely, some patients with
massive hematochezia may be bleeding from an upper gastrointestinal source, such as
a gastric Dieulafoy lesion or duodenal ulcer, with rapid intestinal transit. Early upper
endoscopy should be considered in such patients

3. ‫שאלה‬
2
•
‫בן‬ ‫בחולה‬
36
‫האחרונים‬ ‫בחודשים‬ ‫ברזל‬ ‫מחוסר‬ ‫אנמיה‬ ‫עם‬
,
‫של‬ ‫משפחתי‬ ‫סיפור‬ ‫וללא‬ ‫תסמינים‬ ‫כל‬ ‫ללא‬
‫דלקתיות‬ ‫מעי‬ ‫מחלות‬ ‫או‬ ‫ממאירות‬
,
‫ביותר‬ ‫הנכון‬ ‫המומלץ‬ ‫הבירור‬ ‫מה‬
•
‫א‬
-
‫אימונולוגית‬ ‫צואה‬ ‫בדיקת‬
(
‫גבוהה‬ ‫רגישות‬ ‫בעלת‬
)
‫שלילית‬ ‫והיא‬ ‫ובמידה‬ ‫סמוי‬ ‫לדם‬
–
‫ומעקב‬ ‫ברזל‬ ‫בתכשירי‬ ‫טיפול‬
‫ב‬
-
‫גסטרוסקופיה‬ ‫גם‬ ‫לבצע‬ ‫יש‬ ‫תקינה‬ ‫תהיה‬ ‫ואם‬ ‫קולונוסקופיה‬
‫ג‬
-
‫מס‬ ‫כעבור‬ ‫ברזל‬ ‫ורווי‬ ‫המוגלובין‬ ‫אחר‬ ‫ומעקב‬ ‫ברזל‬ ‫בתכשירי‬ ‫טיפול‬
'
‫חודשים‬
.
‫הברזל‬ ‫ברווי‬ ‫ירידה‬ ‫תחול‬ ‫ולא‬ ‫במידה‬
‫המעקב‬ ‫בתקופת‬
,
‫בגיל‬ ‫קולונוסקופיה‬ ‫וביצוע‬ ‫בלבד‬ ‫מעקב‬ ‫להמשיך‬
50
(
‫לצורך‬
"
‫מוקדם‬ ‫גילוי‬
)"
‫ד‬
-
‫הזה‬ ‫בגיל‬
(
36
)
‫במער‬ ‫סרטן‬ ‫של‬ ‫משפחתי‬ ‫סיפור‬ ‫אין‬ ‫כאשר‬ ‫בעקר‬ ‫זעיר‬ ‫לממאירות‬ ‫הסיכוי‬
'
‫ראשון‬ ‫בשלב‬ ‫ולכן‬ ‫העיכול‬
‫צליאק‬ ‫אין‬ ‫שלחולה‬ ‫לוודא‬ ‫יש‬
,
‫ברזל‬ ‫מחוסר‬ ‫אנמיה‬ ‫עם‬ ‫ראשון‬ ‫ביטוי‬ ‫לידי‬ ‫שיבוא‬ ‫אפייני‬ ‫שבמבוגרים‬
‫ה‬
-
‫בירור‬ ‫להשלמת‬ ‫קולונוסקופיה‬ ‫רק‬ ‫לבצע‬ ‫ושליליים‬ ‫ובמידה‬ ‫לצליאק‬ ‫נוגדנים‬ ‫בדיקת‬
‫פרק‬
345
Anemia & occult blood in the stool
Iron-deficiency anemia may be attributed to poor iron absorption (as in celiac sprue) or, more
commonly, chronic blood loss. Intestinal bleeding should be strongly suspected in men and
postmenopausal women with iron-deficiency anemia, and colonoscopy is indicated in such
patients, even in the absence of detectable occult blood in the stool. Approximately 30% will
have large colonic polyps, 10% will have colorectal cancer, and a few additional patients will have
colonic vascular lesions

4. ‫שאלה‬
3
•
‫הבדיקה‬ ‫מהי‬
‫המדוייקת‬
‫ביותר‬
‫לאיבחון‬
‫אכלזיה‬
(Achalasia)
‫א‬
-
‫גסטרוסקופיה‬
‫ב‬
-
‫מנומטריה‬
‫הושט‬ ‫של‬
‫ג‬
-
‫ניגודי‬ ‫חומר‬ ‫עם‬ ‫ושט‬ ‫צילום‬
‫ד‬
-
CT
‫הבטן‬ ‫של‬
‫ה‬
-
‫וידאו‬
-
‫ייעודית‬ ‫קפסולה‬
‫לושט‬
‫פרק‬
347
-
Achalasia
Achalasia is diagnosed by barium swallow x-ray and/or esophageal manometry; endoscopy has a
relatively minor role other than to exclude pseudoachalasia. The barium swallow x-ray
appearance is of a dilated esophagus with poor emptying, an air-fluid level, and tapering at the
LES giving it a beak-like appearance (Fig. 347-5). Occasionally, an epiphrenic diverticulum is
observed. In long-standing achalasia, the esophagus may assume a sigmoid configuration. The
diagnostic criteria for achalasia with esophageal manometry are impaired LES relaxation and
absent peristalsis. High-resolution manometry has somewhat advanced this diagnosis; three
subtypes of achalasia are differentiated based on the pattern of pressurization in the
nonperistaltic esophagus (Fig. 347-6). Because manometry identifies early disease before
esophageal dilatation and food retention, it is the most sensitive diagnostic test

5. ‫שאלה‬
4
•
‫ל‬ ‫באשר‬ ‫נכון‬ ‫הכי‬ ‫מה‬
-
Barrett
‫א‬
-
‫כ‬
-
10%
‫חייהם‬ ‫במהלך‬ ‫ושט‬ ‫סרטן‬ ‫יפתחו‬ ‫מהחולים‬
(
‫גברים‬ ‫בעקר‬
)
‫ב‬
-
‫שטיפול‬ ‫לכך‬ ‫חותכות‬ ‫הוכחות‬ ‫יש‬
‫אנטיסקרטורי‬
(PPI)
‫ב‬ ‫סרטן‬ ‫התפתחות‬ ‫מונע‬ ‫אגרסיבי‬
-
Barrett
‫ג‬
-
‫ב‬ ‫כאשר‬
-
Barrett
‫של‬ ‫שנויים‬ ‫יש‬
high-grade dysplasia
‫המומלץ‬ ‫הטיפול‬
‫הוא‬
‫הושט‬ ‫כריתת‬
‫ד‬
-
‫ב‬ ‫הבחירה‬ ‫טיפול‬
-
Barrett
‫עם‬
high-grade dysplasia
‫הוא‬
Radio-frequency ablation
‫ה‬
-
Barrett
‫ה‬ ‫בשנות‬ ‫בנשים‬ ‫בעקר‬ ‫שכיח‬
-
40
‫לחייהן‬
‫פרק‬
347
–
GERD
‫ו‬
-
Barrett
Barrett’s metaplasia can progress to adenocarcinoma through the intermediate stages of low- and high-grade
dysplasia (Fig. 347-10). Owing to this risk, areas of Barrett’s and especially any included areas of mucosal
irregularity should be extensively biopsied. The rate of cancer development is estimated at 0.1–0.3% per year,
but vagaries in definitional criteria and of the extent of Barrett’s metaplasia requisite to establish the diagnosis
have contributed to variability and inconsistency in this risk assessment. The group at greatest risk is obese
white males in their sixth decade of life. However, despite common practice, the utility of endoscopic screening
and surveillance programs intended to control the adenocarcinoma risk has not been established. Also of note,
no high-level evidence confirms that aggressive antisecretory therapy or antireflux surgery causes regression of
Barrett’s esophagus or prevents adenocarcinoma. Although the management of Barrett’s esophagus remains
controversial, the finding of dysplasia in Barrett’s, particularly high-grade dysplasia, mandates further
intervention. In addition to the high rate of progression to adenocarcinoma, there is also a high prevalence of
unrecognized coexisting cancer with high-grade dysplasia. Nonetheless, treatment remains controversial.
Esophagectomy, intensive endoscopic surveillance, and mucosal ablation have all been advocated. Currently,
esophagectomy is the gold standard treatment for high-grade dysplasia in an otherwise healthy patient with
minimal surgical risk. However, esophagectomy has a mortality ranging from 3–10%, along with substantial
morbidity. That, along with increasing evidence of the effectiveness of endoscopic therapy with purpose-built
radiofrequency ablation devices, has led many to favor this therapy as a preferable management strategy.

6. ‫שאלה‬
5
•
‫קיבה‬ ‫כיב‬ ‫לגבי‬ ‫נכון‬ ‫מה‬
-‫א‬
‫ביופסיות‬ ‫ממנו‬ ‫לקחת‬ ‫ויש‬ ‫לממאיר‬ ‫חשוד‬ ‫בגדר‬ ‫הוא‬ ‫קיבה‬ ‫כיב‬ ‫כל‬
‫ב‬
-
‫קטן‬ ‫קיבה‬ ‫כיב‬ ‫אחרי‬ ‫למעקב‬ ‫חוזרת‬ ‫באנדוסקופיה‬ ‫צורך‬ ‫אין‬
(
<
1
‫סמ‬
'
)
‫ובביופסיות‬ ‫שפיר‬ ‫הנראה‬
‫ממאירות‬ ‫אין‬ ‫מהשוליים‬
‫ג‬
-
‫תריסריון‬ ‫לכיב‬ ‫בניגוד‬
,
‫עם‬ ‫קשורים‬ ‫אינם‬ ‫הקיבה‬ ‫כיבי‬ ‫רוב‬
HP-gastritis
‫ד‬
-
‫נכונות‬ ‫התשובות‬ ‫כל‬
‫ה‬
-
‫נכונות‬ ‫אינן‬ ‫התשובות‬ ‫כל‬
‫פרק‬
348
–
PATHOPHYSIOLOGIC BASIS OF PEPTIC ULCER DISEASE
In contrast to DUs, GUs can represent a malignancy and should be biopsied upon discovery.
Benign GUs are most often found distal to the junction between the antrum and the acid
secretory mucosa. Benign GUs are quite rare in the gastric fundus and are histologically similar to
DUs. Benign GUs associated with H. pylori are also associated with antral gastritis. In contrast,
NSAID-related GUs are not accompanied by chronic active gastritis but may instead have
evidence of a chemical gastropathy, typified by foveolar hyperplasia, edema of the lamina
propria, and epithelial regeneration in the absence of H. pylori. Extension of smooth-muscle
fibers into the upper portions of the mucosa, where they are not typically found, may also occur.

7. ‫שאלה‬
6
•
‫עם‬ ‫לחולה‬ ‫המקובלת‬ ‫הגישה‬ ‫מהי‬
‫דיספפסיה‬
‫חדשה‬
‫א‬
-
‫בחולה‬
<
‫גיל‬
50
‫ללא‬
"
‫אדומים‬ ‫דגלים‬
"
‫בבדיקת‬ ‫להסתפק‬ ‫ניתן‬
‫הליקובקטר‬
(
‫תבחין‬
‫בצואה‬ ‫נוגדנים‬ ‫או‬ ‫נשיפה‬
)
‫חיובי‬ ‫ואם‬
,
‫בטיפול‬ ‫להסתפק‬
‫לארדיקציה‬
‫החיידק‬ ‫של‬
‫ב‬
-
‫חולה‬
>
‫גיל‬
40
‫ללא‬
"
‫אדומים‬ ‫דגלים‬
"
‫להפנות‬ ‫יש‬
‫לגסטרואנטרולוג‬
‫ביצוע‬ ‫לשקול‬ ‫כדי‬
‫גסטרוסקופיה‬
‫ג‬
-
‫בן‬ ‫בחולה‬
35
‫ללא‬
"
‫אדומים‬ ‫דגלים‬
"
‫להכחדת‬ ‫טיפול‬ ‫שקיבל‬
‫הליקובקטר‬
,
‫לבצע‬ ‫יש‬
‫לחיידק‬ ‫נוגדנים‬ ‫בדיקת‬
4
‫לוודא‬ ‫מנת‬ ‫על‬ ‫הטיפול‬ ‫תום‬ ‫לאחר‬ ‫שבועות‬
‫ארדיקציה‬
‫ד‬
-
‫בן‬ ‫בחולה‬
35
‫שסובל‬
‫מדיספפסיה‬
‫ב‬ ‫טיפול‬ ‫לאחר‬ ‫חדשה‬
-
DICLOFENAC
‫שבועיים‬ ‫במשך‬
‫בדם‬ ‫נוגדנים‬ ‫לו‬ ‫ושיש‬
‫להליקובקטר‬
,
‫החיידק‬ ‫להכחדת‬ ‫טיפול‬ ‫לתת‬ ‫צורך‬ ‫אין‬
‫ה‬
-
‫וידוא‬
‫ארדיקציה‬
‫חובה‬ ‫הוא‬ ‫נשיפה‬ ‫תבחין‬ ‫באמצעות‬
4
‫נגד‬ ‫טיפול‬ ‫לאחר‬ ‫שבועות‬
‫הליקובקטר‬
‫בשל‬ ‫שנבדק‬ ‫בחולה‬
‫דיספפסיה‬
‫הטיפול‬ ‫לפני‬ ‫גסטרוסקופיה‬ ‫בדיקת‬ ‫ועבר‬
‫תקינה‬ ‫שהייתה‬
‫תשובה‬
‫בשיקופית‬
‫הבאה‬

8. ‫פרק‬
348
‫ותמונה‬
348-12
.
APPROACH AND THERAPY: SUMMARY
Controversy continues regarding the best approach to
the patient who presents with dyspepsia (Chap. 54). The
discovery of H. pylori and its role in pathogenesis of ulcers has added a
new variable to the equation. Previously, if a patient <50 years of age presented with dyspepsia and without
alarming signs or symptoms suggestive of an ulcer complication or malignancy, an empirical therapeutic trial
with acid suppression was commonly recommended. Although this approach is practiced by some today, an
approach presently gaining approval for the treatment of patients with dyspepsia is outlined in Fig. 348-12. The
referral to a gastroenterologist is for the potential need of endoscopy and subsequent evaluation and
treatment if the endoscopy is negative.
Once an ulcer (GU or DU) is documented, the main issue at stake is whether H. pylori or an NSAID is involved.
With H. pylori present, independent of the NSAID status, triple therapy is recommended for 14 days, followed
by continued acid-suppressing drugs (H2receptor antagonist or PPIs) for a total of 4–6 weeks. Selection of
patients for documentation of H. pylori eradication (organisms gone at least 4 weeks after completing
antibiotics) is an area of some debate. The test of choice for documenting eradication is the laboratory-based
validated monoclonal stool antigen test or a urea breath test (UBT). The patient must be off antisecretory
agents when being tested for eradication of H. pylori with UBT or stool antigen. Serologic testing is not useful
for the purpose of documenting eradication because antibody titers fall slowly and often do not become
undetectable. Two approaches toward documentation of eradication exist: (1) Test for eradication only in
individuals with a complicated course or in individuals who are frail or with multisystem disease who would do
poorly with an ulcer recurrence, and (2) test all patients for successful eradication. Some recommend that
patients with complicated ulcer disease, or who are frail, should be treated with long-term acid suppression,
thus making documentation of H. pylori eradication a moot point. In view of this discrepancy in practice, it
would be best to discuss with the patient the different options available.

9. ‫שאלה‬
7
•
‫לגבי‬ ‫נכון‬ ‫לא‬ ‫מה‬
GASTRINOMA
‫א‬
-
‫הגידולים‬ ‫רוב‬
(
>
50%
)
‫בתריסריון‬ ‫ממוקמים‬
‫ב‬
-
‫ביותר‬ ‫השכיחה‬ ‫הסיבה‬
‫להיפרגסטרינמיה‬
‫היא‬
‫היפוכלורהידריה‬
‫ג‬
-
‫של‬ ‫עליה‬
50
‫פיקוגרם‬
‫ברמת‬ ‫לפחות‬
‫הגסטרין‬
‫בתבחין‬ ‫בדם‬
‫סקרטין‬
‫לנוכחות‬ ‫אבחנתית‬ ‫היא‬
‫גסטרינומה‬
‫ד‬
-
EUS
‫ביותר‬ ‫הרגיש‬ ‫הבדיקה‬ ‫אמצעי‬ ‫הוא‬
(
>
80%
)
‫הראשוני‬ ‫בגידול‬ ‫לגילוי‬
‫ה‬
-
‫ב‬ ‫תשובה‬
+
‫נכונות‬ ‫אינן‬ ‫א‬
‫תשובה‬
:
‫פרק‬
438
ZOLLINGER–ELLISON SYNDROME
+
‫תמונה‬
438-8
Although early studies suggested that the vast majority of gastrinomas occurred
within the pancreas, a significant number of these lesions are extrapancreatic. Over
80% of these tumors are found within the hypothetical gastrinoma triangle
(confluence of the cystic and common bile ducts superiorly, junction of the second
and third portions of the duodenum inferiorly, and junction of the neck and body of
the pancreas medially). Duodenal tumors constitute the most common nonpancreatic
lesion; between 50 and 75% of gastrinomas are found here.
‫המשך‬
‫בשיקופית‬
‫הבאה‬

10. Multiple processes can lead to an elevated fasting gastrin level, the most frequent
of which are gastric hypochlorhydria and achlorhydria, with or without pernicious
anemia. Gastric acid induces feedback inhibition of gastrin release. A decrease in
acid production will subsequently lead to failure of the feedback inhibitory
pathway, resulting in net hypergastrinemia.
Gastrin provocative tests have been developed in an effort to differentiate
between the causes of hypergastrinemia and are especially helpful in patients
with indeterminate acid secretory studies. The tests are the secretin stimulation
test and the calcium infusion study.
The most sensitive and specific gastrin
provocative test for the diagnosis of
gastrinoma is the secretin study.
An increase in gastrin of ≥120 pg within
15 min of secretin injection has a
sensitivity and specificity of >90% for ZES

11. ‫שאלה‬
8
•
‫צליאק‬ ‫מחלת‬ ‫לגבי‬ ‫נכון‬ ‫הבאים‬ ‫מהמשפטים‬ ‫איזה‬
‫א‬
-
‫הדק‬ ‫המעי‬ ‫ביופסיות‬ ‫עם‬ ‫גסטרוסקופיה‬ ‫לבצע‬ ‫יש‬
,
‫האופייניים‬ ‫הפתולוגיים‬ ‫הסימנים‬ ‫היעלמות‬ ‫לוודא‬ ‫מנת‬ ‫על‬
,
‫לאחר‬ ‫חודשיים‬ ‫לפחות‬
‫גלוטן‬ ‫ללא‬ ‫דיאטה‬ ‫תחילת‬
‫ב‬
-
‫נוגדנים‬ ‫בדיקת‬
TTG
‫או‬
EMA
(
‫הדיאטה‬ ‫תחילת‬ ‫לפני‬ ‫חיוביים‬ ‫היו‬ ‫אם‬ ‫רק‬
)
‫דיאטה‬ ‫על‬ ‫שמירה‬ ‫מסמנת‬ ‫דיאטה‬ ‫תחילת‬ ‫אחרי‬ ‫שנה‬ ‫שלילית‬
‫גלוטן‬ ‫ללא‬
‫ג‬
-
‫מס‬ ‫ביופסיות‬ ‫עם‬ ‫גסטרוסקופיה‬ ‫על‬ ‫לחזור‬ ‫צורך‬ ‫יש‬ ‫צליאק‬ ‫מחלת‬ ‫לאבחן‬ ‫כדי‬
'
‫ריפוי‬ ‫לוודא‬ ‫כדי‬ ‫גלוטן‬ ‫ללא‬ ‫דיאטה‬ ‫התחלת‬ ‫לאחר‬ ‫חודשים‬
‫ולבצע‬ ‫הרירית‬ ‫של‬ ‫מוחלט‬
rechallenge
‫מס‬ ‫לאחר‬ ‫התריסריון‬ ‫של‬ ‫חוזרות‬ ‫וביופסיות‬ ‫גלוטן‬ ‫עם‬
'
‫חזרה‬ ‫שהמחלה‬ ‫לוודא‬ ‫כדי‬ ‫חודשים‬
‫ד‬
-
‫הסיסים‬ ‫של‬ ‫מלאה‬ ‫השטחה‬ ‫לראות‬ ‫חובה‬ ‫צליאק‬ ‫מחלת‬ ‫לאבחן‬ ‫כדי‬
(Total Villous Atrophy)
‫בביופסיות‬
‫מהתריסיון‬
‫ה‬
-
‫הם‬ ‫מהתריסריון‬ ‫בביופסיות‬ ‫הפתולוגיים‬ ‫הממצאים‬
‫פתוגנומוניים‬
‫צליאק‬ ‫למחלת‬ ‫ורק‬ ‫אך‬
‫תשובה‬
:
‫פרק‬
349
CELIAC DISEASE
If IgA antiendomysial or tTG antibodies have been detected in serologic studies, they too should disappear after a
gluten-free diet is started. With the increase in the number of patients diagnosed with celiac disease (mostly by
serologic studies), the spectrum of histologic changes seen on duodenal biopsy has increased and includes findings that
are not as severe as the classic changes shown in Fig. 349-4. The classic changes seen on duodenal/jejunal biopsy are
restricted to the mucosa and include (1) an increase in the number of intraepithelial lymphocytes; (2) absence or a
reduced height of villi, which causes a flat appearance with increased crypt cell proliferation resulting in crypt
hyperplasia and loss of villous structure, with consequent villous, but not mucosal, atrophy; (3) a cuboidal appearance
and nuclei that are no longer oriented basally in surface epithelial cells; and (4) increased numbers of lymphocytes and
plasma cells in the lamina propria (Fig. 349-4B). Although these features are characteristic of celiac disease, they
are not diagnostic because a similar appearance can develop in tropical sprue, eosinophilic enteritis, and milk-protein
intolerance in children and occasionally in lymphoma, bacterial overgrowth, Crohn’s disease, and gastrinoma with acid
hypersecretion. However, a characteristic histologic appearance that reverts toward normal after the initiation of a
gluten-free diet establishes the diagnosis of celiac disease (Fig. 349-4C). Readministration of gluten, with or without an
additional small-intestinal biopsy, is not necessary

12. ‫שאלה‬
9
•
‫הקצר‬ ‫המעי‬ ‫תסמונת‬ ‫עם‬ ‫בחולה‬ ‫ההפרעה‬ ‫וסוג‬ ‫התסמינים‬ ‫חומרת‬
-‫א‬
‫הנותר‬ ‫המעי‬ ‫לאורך‬ ‫אלא‬ ‫שנכרת‬ ‫המעי‬ ‫של‬ ‫האנטומי‬ ‫לחלק‬ ‫קשורים‬ ‫אינם‬
‫ב‬
-
‫החסר‬ ‫הסגמנט‬ ‫אורך‬ ‫לא‬ ‫אך‬ ‫שנכרת‬ ‫האנטומי‬ ‫לחלק‬ ‫קשורים‬
‫ג‬
-
‫המסתם‬ ‫של‬ ‫העדרו‬ ‫או‬ ‫לקיומו‬ ‫קשורים‬ ‫אינם‬
‫האליוצקאלי‬
‫הנותר‬ ‫במעי‬
‫ד‬
-
‫הדק‬ ‫המעי‬ ‫חסר‬ ‫במידת‬ ‫ורק‬ ‫אך‬ ‫קשורים‬
,
‫הגס‬ ‫המעי‬ ‫לא‬ ‫אך‬
‫ה‬
-
‫הנותר‬ ‫במעי‬ ‫מחלה‬ ‫נותרת‬ ‫כאשר‬ ‫יותר‬ ‫חמורים‬ ‫להיות‬ ‫עלולים‬
‫תשובה‬
:
‫פרק‬
349
SHORT-BOWEL SYNDROME
Short-bowel syndrome is a descriptive term for the myriad clinical problems that
follow resection of various lengths of small intestine or, on rare occasions, are
congenital (e.g., microvillous inclusion disease). The factors that determine both the
type and degree of symptoms include (1) the specific segment (jejunum vs. ileum)
resected, (2) the length of the resected segment, (3) the integrity of the ileocecal
valve, (4) whether any large intestine has also been removed, (5) residual disease in
the remaining small and/or large intestine (e.g., Crohn’s disease, mesenteric artery
disease), and (6) the degree of adaptation in the remaining intestine. Short-bowel
syndrome can occur in persons of any age, from neonates to the elderly

13. ‫שאלה‬
10
•
‫ביותר‬ ‫הנמוכה‬ ‫בסבירות‬ ‫הוא‬ ‫הבאים‬ ‫מהמצבים‬ ‫איזה‬
,
‫לחסר‬ ‫כגורם‬
‫בויטמין‬
B12
‫א‬
-
‫מזה‬ ‫צמחוני‬
6
‫חודשים‬
‫ב‬
-
‫בן‬ ‫חולה‬
50
‫עם‬
‫גסטריטיס‬
‫אטרופית‬
‫בגיל‬ ‫שאובחנה‬
35
‫ג‬
-
‫במעי‬ ‫חיידקים‬ ‫של‬ ‫יתר‬ ‫צמיחת‬ ‫עם‬ ‫חולה‬
–
bacterial overgrowth
‫לפני‬ ‫קיבה‬ ‫מעקף‬ ‫ניתוח‬ ‫בעקבות‬
10
‫שנים‬
‫ד‬
-
‫מחלת‬ ‫עם‬ ‫חולה‬
‫קרוהן‬
‫בלבד‬ ‫הסופי‬ ‫הדק‬ ‫המעי‬ ‫של‬
‫ה‬
-
‫רבות‬ ‫הסתיידויות‬ ‫ובהדמיה‬ ‫בטן‬ ‫כאב‬ ‫עם‬ ‫רבות‬ ‫שנים‬ ‫אלכוהוליסט‬
‫באיזור‬
‫הלבלב‬
‫תשובה‬
:
‫פרק‬
350e
(
‫כולו‬
)
As a consequence, cobalamin absorption may be abnormal in the following conditions:
• Pernicious anemia. In this disease, immunologically mediated atrophy of gastric parietal cells leads to an absence
of both gastric acid and intrinsic factor secretion.
• Chronic pancreatitis can result from a deficiency of pancreatic proteases to split the cobalamin–R binder complex.
Although 50% of patients with chronic pancreatitis reportedly have an abnormal Schilling test that is corrected by
pancreatic enzyme replacement, cobalamin-responsive macrocytic anemia in chronic pancreatitis is extremely
rare. Although this probably reflects a difference in the digestion/absorption of cobalamin in food versus that in a
crystalline form, the Schilling test still can be used to assess pancreatic exocrine function.
• Achlorhydria is the absence of hydrochloric acid; intrinsic factor is also secreted with acid which is responsible for
splitting cobalamin away from the proteins in food to which it is bound. Up to one-third of individuals >60 years of
age have marginal vitamin B12 absorption because of an inability to release cobalamin from food; these people
have no defects in the absorption of crystalline vitamin B12.
• Bacterial overgrowth syndromes, which are most often secondary to stasis in the small intestine, lead to bacterial
utilization of cobalamin (often referred to as stagnant bowel syndrome; see below).
• Ileal dysfunction (as a result of either inflammation or prior intestinal resection) is due to impaired function of the
mechanism of cobalamin–intrinsic factor uptake by ileal intestinal epithelial cells.

14. ‫שאלה‬
11
•
‫בת‬ ‫חולה‬
26
‫אתיופי‬ ‫ממוצא‬
,
‫לפני‬ ‫לארץ‬ ‫עלתה‬
3
‫שנים‬
,
‫דמי‬ ‫שלשול‬ ‫של‬ ‫מתמשך‬ ‫סיפור‬ ‫עם‬ ‫מגיעה‬
,
‫בטן‬ ‫כאב‬
‫נמוך‬ ‫חום‬ ‫ולעתים‬
.
‫ה‬ ‫בן‬ ‫לאחיה‬
-
30
‫מגיל‬ ‫כיבית‬ ‫קוליטיס‬
15
.
‫נצפה‬ ‫בקולונוסקופיה‬
‫איליום‬
‫תקין‬ ‫סופי‬
,
‫רירית‬
‫בעומק‬ ‫החל‬ ‫מודלקת‬
10
‫סמ‬
'
‫הכבד‬ ‫כפף‬ ‫עד‬ ‫ורציפה‬ ‫הטבעת‬ ‫מפי‬
.
‫ומהרקטום‬ ‫הימני‬ ‫הגס‬ ‫מהמעי‬ ‫ביופסיות‬
‫תקינות‬
.
‫ביופסיות‬
‫מהאיזורים‬
‫עם‬ ‫קשה‬ ‫דלקתי‬ ‫תסנין‬ ‫העלו‬ ‫הגס‬ ‫במעי‬ ‫המודלקים‬
‫קרפיטיטיס‬
‫ו‬
-
Crypt
abscesses
‫רבים‬
,
‫ללא‬
Microscopic skip lesions
‫וללא‬
‫גרנולומות‬
.
‫האבחנה‬ ‫מהי‬
‫ביותר‬ ‫הסבירה‬
?
‫א‬
-
‫הגס‬ ‫המעי‬ ‫של‬ ‫כיבית‬ ‫דלקת‬
–
Ulcerative colitis
‫ב‬
-
‫מחלת‬
‫קרוהן‬
‫הגס‬ ‫המעי‬ ‫של‬
‫ג‬
-
Intermediate (indetermined) colitis
‫ד‬
-
‫חיידקית‬ ‫זיהומית‬ ‫קוליטיס‬
‫ה‬
-
‫המעי‬ ‫של‬ ‫שחפת‬
‫תשובה‬
:
‫פרק‬
351
,
CROHN’S DISEASE: MICROSCOPIC FEATURES
The earliest lesions are aphthoid ulcerations and focal crypt abscesses with loose aggregations of
macrophages, which form noncaseating granulomas in all layers of the bowel wall (Fig. 351-6).
Granulomas can be seen in lymph nodes, mesentery, peritoneum, liver, and pancreas. Although
granulomas are a pathognomonic feature of CD, they are rarely found on mucosal biopsies. Surgical
resection reveals granulomas in about one-half of cases. Other histologic features of CD include
submucosal or subserosal lymphoid aggregates, particularly away from areas of ulceration, gross and
microscopic skip areas, and transmural inflammation that is accompanied by fissures that penetrate
deeply into the bowel wall and sometimes form fistulous tracts or local abscesses.

15. ‫שאלה‬
12
•
‫הבאים‬ ‫והסימנים‬ ‫מהתסמינים‬ ‫איזה‬
‫אינו‬
‫כיבית‬ ‫קוליטיס‬ ‫חומרת‬ ‫להערכת‬ ‫מדד‬
Ulcerative colitis
‫א‬
-
‫מס‬
'
‫ביממה‬ ‫היציאות‬
‫ב‬
-
‫בטן‬ ‫כאב‬ ‫חומרת‬
‫ג‬
-
‫ביציאה‬ ‫הדם‬ ‫כמות‬
-‫ד‬
‫חום‬
‫ה‬
-
‫המוגלובין‬ ‫רמת‬
‫תשובה‬
:
‫טבלה‬
351-4

16. ‫שאלה‬
13
•
‫בן‬ ‫חולה‬
50
,
‫כיבית‬ ‫מקוליטיס‬ ‫הסובל‬
15
‫שנים‬
,
‫ברמיסיה‬
‫ב‬ ‫טיפול‬ ‫תחת‬ ‫קלינית‬
-
MESALAMINE
2
‫גרם‬
‫ביממה‬
,
‫המחלה‬ ‫אחר‬ ‫למעקב‬ ‫שגרתית‬ ‫סקר‬ ‫כבדיקת‬ ‫קולונוסקופיה‬ ‫עובר‬
.
‫היצרות‬ ‫נצפית‬ ‫בבדיקה‬
(
‫סטריקטורה‬
)
‫מודלקת‬ ‫מעט‬ ‫רירית‬ ‫מצופה‬ ‫היורד‬ ‫הגס‬ ‫במעי‬
,
‫מעבר‬ ‫אפשרות‬ ‫ללא‬
.
‫גוש‬ ‫נראה‬ ‫לא‬
.
‫ביופסיות‬
‫עם‬ ‫פעילה‬ ‫קוליטיס‬ ‫מראות‬
‫קריפטיטיס‬
‫וללא‬ ‫צפוף‬ ‫דלקתי‬ ‫ותסנין‬
‫דיספלזיה‬
.
‫שנתיים‬ ‫קודמת‬ ‫בקולונוסקופיה‬
‫הייתה‬ ‫לא‬ ‫לכן‬ ‫קודם‬
‫סטריקטורה‬
.
‫בבדיקת‬
CTE
‫לחלוטין‬ ‫תקין‬ ‫נראה‬ ‫הדק‬ ‫המעי‬ ‫עדכנית‬
.
‫מחלה‬ ‫אין‬
‫פריאנאלית‬
.
‫הבא‬ ‫הצעד‬ ‫מה‬
?
‫א‬
-
‫ממאירות‬ ‫לשלול‬ ‫ניתן‬ ‫ולא‬ ‫מאחר‬ ‫הגס‬ ‫המעי‬ ‫לכריתת‬ ‫להפנות‬
‫ב‬
-
‫בסטרואידים‬ ‫טיפול‬
‫ג‬
-
‫מס‬ ‫כעבור‬ ‫קולונוסקופיה‬ ‫על‬ ‫וחזרה‬ ‫ביולוגית‬ ‫בתרופה‬ ‫טיפול‬
'
‫ממאירות‬ ‫לשלול‬ ‫כדי‬ ‫חודשים‬
‫ד‬
-
‫ה‬ ‫מינון‬ ‫העלאת‬
-
MESALAMINE
‫ל‬
-
4
‫למשך‬ ‫ליממה‬ ‫גרם‬
3
‫מכן‬ ‫לאחר‬ ‫הקולונוסקופיה‬ ‫על‬ ‫וחזרה‬ ‫חודשים‬
‫ה‬
-
‫תסמינים‬ ‫ללא‬ ‫והחולה‬ ‫מאחר‬ ‫הטיפול‬ ‫בשינוי‬ ‫צורך‬ ‫אין‬
.
‫מס‬ ‫כעבור‬ ‫מעקב‬
'
‫חדשים‬
‫תשובה‬
:
‫פרק‬
351
,
ULCERATIVE COLITIS, CLINICAL PRESENTATION, COMPLICATIONS
Strictures occur in 5–10% of patients and are always a concern in UC because of the possibility of
underlying neoplasia. Although benign strictures can form from the inflammation and fibrosis of UC,
strictures that are impassable with the colonoscope should be presumed malignant until proven
otherwise. A stricture that prevents passage of the colonoscope is an indication for surgery. UC patients
occasionally develop anal fissures, perianal abscesses, or hemorrhoids, but the occurrence of extensive
perianal lesions should suggest CD.

17. ‫שאלה‬
14
•
‫בת‬ ‫אישה‬
28
‫שבועיים‬ ‫כבר‬ ‫הנמשכת‬ ‫השתן‬ ‫במתן‬ ‫צריבה‬ ‫בשל‬ ‫המשפחה‬ ‫לרופא‬ ‫מגיעה‬
.
‫היתר‬ ‫בין‬ ‫מספרת‬
‫השתן‬ ‫נוזל‬ ‫בתוך‬ ‫אויר‬ ‫בועות‬ ‫חשה‬ ‫שתן‬ ‫הטלת‬ ‫שבעת‬ ‫גם‬
.
‫האחרונים‬ ‫בחודשיים‬ ‫בשתן‬ ‫חוזרים‬ ‫זיהומים‬ ‫ברקע‬
(
‫שלישי‬ ‫אירוע‬
.)
‫קל‬ ‫חוזר‬ ‫דיפוזי‬ ‫בטן‬ ‫מכאב‬ ‫סובלת‬ ‫האחרונה‬ ‫השנה‬ ‫שבחצי‬ ‫מסתבר‬ ‫מעמיק‬ ‫תחקור‬ ‫לאחר‬
,
‫עד‬ ‫חום‬ ‫של‬ ‫חוזרים‬ ‫אירועים‬
38.5
(
‫בשתן‬ ‫חוזרים‬ ‫לזיהומים‬ ‫שיוחסו‬
)
,
‫רכות‬ ‫יציאות‬
3
‫דם‬ ‫ללא‬ ‫ביממה‬ ‫פעמים‬
.
‫מידי‬ ‫רבה‬ ‫חשיבות‬ ‫אלו‬ ‫לתסמינים‬ ‫ייחסה‬ ‫ולא‬ ‫כרגיל‬ ‫לתפקד‬ ‫ממשיכה‬ ‫זאת‬ ‫אף‬ ‫על‬
.
‫העבודה‬ ‫אבחנת‬ ‫מה‬
‫ביותר‬ ‫הסבירה‬
?
‫א‬
-
‫מחלת‬
‫קרוהן‬
‫אבנים‬ ‫עם‬
(
‫אוקסלאט‬
)
‫החוזרים‬ ‫לזיהומים‬ ‫הסיבה‬ ‫שהם‬ ‫השתן‬ ‫בדרכי‬
‫ב‬
-
‫מחלת‬
‫קרוהן‬
‫תוך‬ ‫מורסה‬ ‫עם‬
‫בטנית‬
‫השתן‬ ‫לשלפוחית‬ ‫שפרצה‬
‫ג‬
-
‫פיסטולה‬
‫אנטרו‬
-
‫וסיקולרית‬
‫מחלת‬ ‫רקע‬ ‫על‬
‫קרוהן‬
‫ד‬
-
‫פיסטולה‬
‫אנטרו‬
-
‫וסיקולרית‬
‫למעי‬ ‫השתן‬ ‫משלפוחית‬ ‫חודרת‬ ‫שאת‬ ‫רקע‬ ‫על‬
‫ה‬
-
‫מהנ‬ ‫אחד‬ ‫לא‬ ‫אף‬
"
‫ל‬
‫תשובה‬
:
‫פרק‬
351
,
- Signs & Symptoms CROHN’S DISEASE
Severe inflammation of the ileocecal region may lead to localized wall thinning, with microperforation
and fistula formation to the adjacent bowel, the skin, or the urinary bladder, or to an abscess cavity in
the mesentery. Enterovesical fistulas typically present as dysuria or recurrent bladder infections or, less
commonly, as pneumaturia or fecaluria. Enterocutaneous fistulas follow tissue planes of least
resistance, usually draining through abdominal surgical scars. Enterovaginal fistulas are rare and present
as dyspareunia or as a feculent or foul-smelling, often painful vaginal discharge. They are unlikely to
develop without a prior hysterectomy.

18. ‫שאלה‬
15
•
‫בדיקות‬ ‫של‬ ‫המקום‬ ‫מה‬
‫סרולוגיות‬
‫דלקתיות‬ ‫מעי‬ ‫מחלות‬ ‫עם‬ ‫בחולים‬
‫א‬
-
‫בדיקת‬
ASCA
‫ו‬
-
pANCA
‫של‬ ‫באבחנה‬ ‫מאד‬ ‫גבוהה‬ ‫חשיבות‬ ‫בעלות‬ ‫הן‬
Inflammatory Bowel Diseases
‫ב‬
-
pANCA
‫הוא‬ ‫חיובי‬
‫פתוגנומוני‬
‫ונמצא‬ ‫כיבית‬ ‫לקוליטיס‬
‫בכ‬
-
90%
‫במחלה‬ ‫מהלוקים‬
‫ג‬
-
ASCA
‫הוא‬
‫פתוגנומוני‬
‫למחלת‬
‫קרוהן‬
‫חיובי‬ ‫ונמצא‬
‫בכ‬
-
90%
‫במחלה‬ ‫מהחולים‬
‫ד‬
-
‫הסמנים‬ ‫שני‬ ‫כאשר‬
‫הסרולוגיים‬
‫שליליים‬
,
‫לשלול‬ ‫אפשר‬
IBD
‫בכלל‬
‫ה‬
-
‫נכונות‬ ‫אינן‬ ‫התשובות‬ ‫כל‬
‫תשובה‬
:
‫פרק‬
351
–
Serologic Markers
Subsets of patients with differing immune responses to microbial antigens have been described, and
serology is often tested for perinuclear antineutrophil cytoplasmic antibodies (pANCAs) and anti-
Saccharomyces cerevisiae antibodies (ASCAs). Unfortunately, these serologic markers are only
marginally useful in helping to make the diagnosis of UC or CD and in predicting the course of disease.
For success in diagnosing IBD and in differentiating between CD and UC, the efficacy of these serologic
tests depends on the prevalence of IBD in a specific population. pANCA positivity is found in about 60–
70% of UC patients and 5–10% of CD patients; 5–15% of first-degree relatives of UC patients are pANCA
positive, whereas only 2–3% of the general population is pANCA positive. Sixty to 70% of CD patients,
10–15% of UC patients, and up to 5% of non-IBD controls are ASCA positive. In a patient population with
a combined prevalence of UC and CD of 62%, pANCA/ASCA serology showed a sensitivity of 64% and a
specificity of 94%. Positive and negative predictive values (PPVs and NPVs) for pANCA/ASCA also vary
based on the prevalence of IBD in a given population. For the patient population with a prevalence of
IBD of 62%, the PPV is 94%, and the NPV is 63%.

19. ‫שאלה‬
16
•
‫ע‬ ‫גסטרוסקופיה‬ ‫של‬ ‫היתרונות‬
"
‫עם‬ ‫חולה‬ ‫של‬ ‫להערכה‬ ‫בריום‬ ‫בליעת‬ ‫צילום‬ ‫פ‬
‫דיספגיה‬
‫הבאים‬ ‫כל‬ ‫את‬ ‫כוללים‬
,
‫למעט‬
:
‫א‬
-
‫ביופסיות‬ ‫לנטילת‬ ‫האפשרות‬
‫ב‬
-
‫ומורפולוגיה‬ ‫תפקוד‬ ‫להעריך‬ ‫האפשרות‬
‫ג‬
-
‫הרירית‬ ‫של‬ ‫צבע‬ ‫בשינויי‬ ‫להבחין‬ ‫האפשרות‬
,
‫כמו‬
Barrett
‫ד‬
-
‫ברירית‬ ‫ממצאים‬ ‫לזיהוי‬ ‫יותר‬ ‫רגיש‬
‫ה‬
-
‫טיפולית‬ ‫התערבות‬ ‫מאפשר‬
‫תשובה‬
:
‫פרק‬
347
Endoscopy, also known as esophagogastroduodenoscopy (EGD) is the best test for evaluation of the
proximal gastrointestinal tract. Because of high-quality images, disorders of color such as Barrett
metaplasia and mucosal irregularities are easily demonstrated. Sensitivity of endoscopy is superior to
that of barium radiography for mucosal lesions. Because the endoscope has an instrumentation
channel, biopsy specimens are easily obtained, and dilation of strictures can also be performed. The
sensitivity of radiography compared with endoscopy for detecting reflux esophagitis reportedly ranges
from 22%–95%, with higher grades of esophagitis (i.e., ulceration or stricture) exhibiting greater
detection rates. Conversely, the sensitivity of barium radiography for detecting esophageal strictures is
greater than that of endoscopy, especially when the study is done in conjunction with barium-soaked
bread or a 13-mm barium tablet. Barium studies also provide an assessment of esophageal function and
morphology that may be undetected on endoscopy. The major shortcoming of barium radiography is
that it rarely obviates the need for endoscopy. Barium radiography does not require sedation, which in
some populations at risk for conscious sedation is an important consideration.

20. ‫שאלה‬
17
•
‫בן‬ ‫גבר‬
50
‫מס‬ ‫צרבת‬ ‫בשל‬ ‫נבדק‬
'
‫שנים‬
.
‫העולים‬ ‫אדומים‬ ‫לשונות‬ ‫נראו‬ ‫בגסטרוסקופיה‬
‫מהקרדיה‬
‫פרוקסימלית‬
‫לאורך‬
2.5
‫סמ‬
'
.
‫מדגימות‬ ‫ביופסיות‬
Columnar Metaplasia
.
‫הבאות‬ ‫מההצהרות‬ ‫איזו‬
‫נכונה‬ ‫איננה‬
:
‫א‬
-
‫של‬ ‫המצאות‬
high-grade dysplasia
‫נוספת‬ ‫התערבות‬ ‫מחייבת‬
‫ב‬
-
‫ב‬ ‫הנרחב‬ ‫השימוש‬ ‫למרות‬ ‫האחרונים‬ ‫בעשורים‬ ‫עלתה‬ ‫זה‬ ‫מסוג‬ ‫ממצאים‬ ‫של‬ ‫ההיארעות‬
-
PPI
‫ג‬
-
PPI
‫קרוב‬ ‫יגרמו‬ ‫גבוה‬ ‫במינון‬
‫לודאי‬
‫האנדוסקופי‬ ‫הממצא‬ ‫של‬ ‫לנסיגה‬
‫ד‬
-
‫ושט‬ ‫לסרטן‬ ‫מוגבר‬ ‫סיכון‬ ‫יש‬ ‫זה‬ ‫לחולה‬
‫ה‬
-
‫אנטי‬ ‫ניתוח‬
-
‫רפלוקס‬
‫הממצאים‬ ‫לנסיגת‬ ‫גורם‬ ‫אינו‬
‫תשובה‬
:
‫פרק‬
347
Barrett metaplasia is the most serious complication of GERD. It has a strong association with the subsequent
development of esophageal adenocarcinoma. The incidence of these lesions has increased, not decreased, in the era of
potent acid suppression. Barrett metaplasia is endoscopically recognized by tongues of reddish mucosa extending
proximally from the gastroesophageal junction or histopathologically identified by the finding of specialized columnar
metaplasia. Barrett metaplasia can progress to adenocarcinoma through the intermediate stages of low- and high-
grade dysplasia. Due to this risk, areas of Barrett metaplasia and especially any included areas of mucosal irregularity
should be extensively biopsied. No high-level evidence confirms that aggressive antisecretory therapy or antireflux
surgery causes regression of Barrett esophagus or prevents adenocarcinoma. Although the management of Barrett
esophagus remains controversial, the finding of dysplasia in Barrett esophagus, particularly high-grade dysplasia,
mandates further intervention. In addition to the high rate of progression to adenocarcinoma, there is also a high
prevalence of unrecognized coexisting cancer with high-grade dysplasia. Nonetheless, treatment remains controversial.
Esophagectomy, intensive endoscopic surveillance, and mucosal ablation have all been advocated. Currently,
esophagectomy is the gold standard treatment for high-grade dysplasia in an otherwise healthy patient with minimal
surgical risk. However, esophagectomy has a mortality ranging from 3%–10%, along with substantial morbidity. As a
result of these factors and the increasing evidence of the effectiveness of endoscopic therapy with purpose-built
radiofrequency ablation devices, many now favor this therapy as a preferable management strategy.

21. ‫שאלה‬
18
•
‫ותבחין‬ ‫תריסריון‬ ‫כיב‬ ‫עם‬ ‫לחולה‬ ‫ביותר‬ ‫הטוב‬ ‫הראשוני‬ ‫הטיפול‬ ‫מהו‬
‫אוריאז‬
‫חיובי‬
:
‫א‬
-
Lansoprazole + clarithromycin + metronidazole
‫ל‬
-
14
‫ימים‬
‫ב‬
-
Pantoprazole +amoxicillin
‫ל‬
-
21
‫ימים‬
‫ג‬
-
Pantoprazole + clarithromycin
‫ל‬
-
21
‫ימים‬
‫ד‬
-
Omeprazole + bismuth + tetracycline + metronidazole
‫ל‬
-
14
‫ימים‬
‫ה‬
-
Omeprazole + metronidazole + clarithromycin
‫ל‬
-
7
‫ימים‬
‫תשובה‬
:
‫פרק‬
348
Documented eradication of H pylori in patients with peptic ulcer disease (PUD) is associated with
a dramatic decrease in ulcer recurrence to <10%–20% as compared to 59% in gastric ulcer
patients and 67% in duodenal ulcer patients when the organism is not eliminated. Eradication of
the organism may lead to diminished recurrent ulcer bleeding. The effect of its eradication on
ulcer perforation is unclear. Extensive effort has been made in determining who of the many
individuals with H pylori infection should be treated. The common conclusion arrived at by
multiple consensus conferences around the world is that H pylori should be eradicated in patients
with documented PUD. This holds true independent of time of presentation (first episode or not),
severity of symptoms, presence of confounding factors such as ingestion of NSAIDs, or whether
the ulcer is in remission. Multiple drugs have been evaluated in the therapy of H pylori. No single
agent is effective in eradicating the organism. Combination therapy for 14 days provides the
greatest efficacy, although regimens based on sequential administration of antibiotics also appear
promising.
‫המשך‬
‫בשיקופית‬
‫הבאה‬

22. • A shorter administration course (7–10 days), although attractive, has not proved as successful as
the 14-day regimens. Suggested treatment regimens for H pylori are outlined in Table VIII-10.
Choice of a particular regimen will be influenced by several factors, including efficacy, patient
tolerance, existing antibiotic resistance, and cost of the drugs. The aim for initial eradication rates
should be 85%–90%. Dual therapy (proton pump inhibitor [PPI] plus amoxicillin, PPI plus
clarithromycin, ranitidine bismuth citrate [Tritec] plus clarithromycin) is not recommended in view
of studies demonstrating eradication rates of <80%–85%. Addition of acid suppression assists in
providing early symptom relief and enhances bacterial eradication. Triple therapy, although
effective, has several drawbacks, including the potential for poor patient compliance and drug-
induced side effects. Compliance is being addressed by simplifying the regimens so that patients
can take the medications twice a day. Simpler (dual therapy) and shorter regimens (7 and 10 days)
are not as effective as triple therapy for 14 days. Two anti–H pylori regimens are available in
prepackaged formulation: Prevpac (lansoprazole, clarithromycin, and amoxicillin) and Helidac
(bismuth subsalicylate, tetracycline, and metronidazole). The contents of the Prevpac are to be
taken twice per day for 14 days, whereas Helidac constituents are taken four times per day with an
antisecretory agent (PPI or H2 blocker), also taken for at least 14 days. Clarithromycin-based triple
therapy should be avoided in settings where H pylori resistance to this agent exceeds 15%–20%.
Quadruple therapy should be reserved for patients with failure to eradicate H pylori after an
effective initial course

23. ‫שאלה‬
19
•
‫ממער‬ ‫יתר‬ ‫ספיגת‬ ‫עם‬ ‫קשורה‬ ‫הבאות‬ ‫מהמחלות‬ ‫איזה‬
'
‫למער‬ ‫העיכול‬
'
‫הפורטלית‬
:
‫א‬
-
‫צליאק‬ ‫מחלת‬
‫ב‬
-
‫מחלת‬
‫קרוהן‬
‫ג‬
-
‫ממאירה‬ ‫אנמיה‬
Pernicious anemia
‫ד‬
-
‫מחלת‬
Whipple
‫ה‬
-
‫מחלת‬
Wilson
‫תשובה‬
:
‫פרק‬
349
Almost all GI malabsorption clinical problems are associated with diminished intestinal absorption of
one or more dietary nutrients and are often referred to as the malabsorption syndrome. Most
malabsorption syndromes are associated with steatorrhea, an increase in stool fat excretion to >6% of
dietary fat intake. The only clinical conditions in which absorption is increased are hemochromatosis
and Wilson disease, in which absorption of iron and copper, respectively, is elevated. Celiac disease may
cause significant malabsorption of multiple nutrients, with diarrhea, steatorrhea, weight loss, and the
consequences of nutrient depletion (i.e., anemia and metabolic bone disease) or depletion of a single
nutrient (e.g., iron or folate deficiency, osteomalacia, edema from protein loss). Malabsorption of bile
salts and vitamins is common in Crohn disease due to ileal involvement. The magnitude of
malabsorption is dependent on the extent of disease. Whipple disease is a chronic multisystemic
disease associated with diarrhea, steatorrhea, weight loss, arthralgia, and CNS and cardiac problems; it
is caused by the bacteriumTropheryma whipplei.
•

24. ‫שאלה‬
20
•
‫בן‬ ‫גבר‬
40
‫של‬ ‫קוליטיס‬ ‫עם‬
‫קרוהן‬
‫מס‬
'
‫שנים‬
,
‫ב‬ ‫מטופל‬
-
Remicade
‫ושרוי‬
‫ברמיסיה‬
‫מזה‬ ‫המעי‬ ‫מחלת‬ ‫של‬
‫שנתיים‬
.
‫בצורת‬ ‫היה‬ ‫בתחילה‬ ‫אשר‬ ‫הימנית‬ ‫השוק‬ ‫בקדמת‬ ‫עורי‬ ‫ממצא‬ ‫הופיע‬ ‫האחרונים‬ ‫בשבועיים‬
‫פוסטולה‬
‫מס‬ ‫תוך‬ ‫אך‬
'
‫כ‬ ‫בקוטר‬ ‫עמוק‬ ‫ככיב‬ ‫נראה‬ ‫ימים‬
-
2
‫סמ‬
'
.
‫מס‬ ‫לאחר‬ ‫הופיע‬ ‫יותר‬ ‫קטן‬ ‫אך‬ ‫דומה‬ ‫ממצא‬
'
‫גם‬ ‫ימים‬
‫השנייה‬ ‫השוק‬ ‫בקדמת‬
.
‫היותר‬ ‫הסבירה‬ ‫האבחנה‬ ‫מהי‬
:
‫א‬
-
‫מחלת‬
‫קרוהן‬
‫מטסטטית‬
‫ב‬
-
‫אריתמה‬
-
‫נודוזום‬
‫ג‬
-
‫פיודרמה‬
‫גנגרנוזום‬
‫ד‬
-
‫תגובה‬
‫דמויית‬
‫הביולוגי‬ ‫לטיפול‬ ‫פסוריאזיס‬
‫ה‬
-
‫מהתשובות‬ ‫אחת‬ ‫לא‬ ‫אף‬
‫תשובה‬
:
‫פרק‬
351
There are a number of dermatologic manifestations of inflammatory bowel disease (IBD), and each type
of IBD has a particular predilection for different dermatologic conditions. This patient has pyoderma
gangrenosum. Pyoderma gangrenosum can occur in up to 12% of patients with ulcerative colitis and is
characterized by a lesion that begins as a pustule and progresses concentrically to surrounding normal
skin. The lesions ulcerate with violaceous, heaped margins and surrounding erythema. They are
typically found on the lower extremities. Often the lesions are difficult to treat and respond poorly to
colectomy; similarly, pyoderma gangrenosum is not prevented by colectomy. Treatment commonly
includes intravenous antibiotics, glucocorticoids, dapsone, infliximab, and other immunomodulatory
agents. Erythema nodosum is more common in Crohn disease and attacks correlate with bowel
symptoms. The lesions are typically multiple, red hot, tender nodules measuring 1–5 cm and are found
on the lower legs and arms. Psoriasis is more common in ulcerative colitis. Finally, pyoderma vegetans is
a rare disorder in intertriginous areas reported to be a manifestation of IBD in the skin.

25. ‫שאלה‬
21
•
‫של‬ ‫ידוע‬ ‫סיבוך‬ ‫הוא‬ ‫מהבאים‬ ‫איזה‬
Methotrexate
-‫א‬
‫היסטופלזמוזיס‬
‫ב‬
-
‫חריפה‬ ‫לבלב‬ ‫דלקת‬
‫ג‬
-
Primary sclerosing cholangitis
‫ד‬
-
Pneumonitis
‫ה‬
-
‫שחפת‬
‫תשובה‬
:
‫פרק‬
295
Methotrexate, azathioprine, cyclosporine, tacrolimus, and anti–tumor necrosis factor
(TNF) antibody are reasonable options for patients with Crohn disease, depending on
the extent of macroscopic disease. Pneumonitis is a rare but serious complication
of methotrexate therapy. Primary sclerosing cholangitis is an extraintestinal
manifestation of IBD. Pancreatitis is an uncommon complication of azathioprine, and
IBD patients treated with azathioprine are at fourfold increased risk of developing a
lymphoma. Anti-TNF antibody therapy is associated with an increased risk of
tuberculosis, disseminated histoplasmosis, and a number of other infections.

26. ‫שאלה‬
22
•
‫רגיש‬ ‫מעי‬ ‫של‬ ‫אבחנה‬ ‫מתן‬ ‫לפני‬ ‫נוסף‬ ‫בבירור‬ ‫צורך‬ ‫אין‬ ‫הבאים‬ ‫מהחולים‬ ‫באיזה‬
–
IBS
‫א‬
-
‫בת‬ ‫אישה‬
70
‫מס‬ ‫עוויתי‬ ‫בטן‬ ‫כאב‬ ‫של‬ ‫סיפור‬ ‫עם‬
'
‫ושלשול‬ ‫הבטן‬ ‫תפיחות‬ ‫מלווה‬ ‫חודשים‬
‫ב‬
-
‫בת‬ ‫אישה‬
28
‫עוויתי‬ ‫בטן‬ ‫כאב‬ ‫עם‬
,
‫הבטן‬ ‫תפיחות‬
,
‫במשך‬ ‫שלשול‬
6
‫אותה‬ ‫מעיר‬ ‫גם‬ ‫וכעת‬ ‫ומחמיר‬ ‫שהולך‬ ‫חודשים‬
‫משינה‬
‫ג‬
-
‫בת‬ ‫אישה‬
28
‫עוויתי‬ ‫אופי‬ ‫בעל‬ ‫תחתונה‬ ‫בטן‬ ‫מכאב‬ ‫משנה‬ ‫למעלה‬ ‫סובלת‬
,
‫יציאה‬ ‫לאחר‬ ‫מוקל‬
,
‫רכה‬ ‫יציאה‬
4
‫פעמים‬
‫במשקל‬ ‫ירידה‬ ‫ללא‬ ‫הבקר‬ ‫בשעות‬ ‫בעקר‬ ‫ביום‬
‫ד‬
-
‫בת‬ ‫נערה‬
18
‫מחמירה‬ ‫שתדירותו‬ ‫חודשיים‬ ‫במשך‬ ‫שלשול‬ ‫עם‬
,
‫השלשול‬ ‫טרי‬ ‫דם‬ ‫פעם‬ ‫ומידי‬ ‫מתמשך‬ ‫בטן‬ ‫כאב‬
‫ה‬
-
‫בת‬ ‫אישה‬
32
‫הבטן‬ ‫תפיחות‬ ‫שנה‬ ‫חצי‬ ‫של‬ ‫סיפור‬ ‫עם‬
,
‫של‬ ‫וירידה‬ ‫ושלשול‬ ‫עוויתי‬ ‫בטן‬ ‫כאב‬
5
‫קג‬
'
‫במשקל‬
‫תשובה‬
:
‫פרק‬
352
Irritable bowel syndrome (IBS) is characterized by the following: recurrence of lower abdominal pain
with altered bowel habits over a period of time without progressive deterioration, onset of symptoms
during periods of stress or emotional upset, absence of other systemic symptoms such as fever and
weight loss, and small-volume stool without evidence of blood. Warning signs that the symptoms may
be due to something other than IBS include presentation for the first time in old age, progressive course
from the time of onset, persistent diarrhea after a 48-hour fast, and presence of nocturnal diarrhea or
steatorrheal stools. Each patient, except for patient C, has “warning” symptoms that should prompt
further evaluation.

27. ‫שאלה‬
23
•
‫בן‬ ‫גבר‬
65
‫במשך‬ ‫תחתונה‬ ‫שמאלית‬ ‫בטן‬ ‫כאב‬ ‫של‬ ‫סיפור‬ ‫עם‬ ‫המיון‬ ‫בחדר‬ ‫מופיע‬
4
‫וחום‬ ‫ימים‬
.
‫תקינה‬ ‫היציאה‬
.
‫בבדיקה‬
‫הבטן‬ ‫של‬ ‫תחתון‬ ‫שמאלי‬ ‫ברביע‬ ‫בינונית‬ ‫רגישות‬ ‫מצאת‬ ‫פיזיקלית‬
.
‫בדם‬ ‫הלויקוציטים‬ ‫ספירת‬
–
12000
.
‫לדימות‬ ‫באשר‬ ‫נכון‬ ‫מה‬
‫זה‬ ‫במקרה‬
:
‫א‬
-
‫מים‬ ‫פלסי‬ ‫שנראה‬ ‫גבוהה‬ ‫סבירות‬
-
‫סקירה‬ ‫בטן‬ ‫בצילום‬ ‫אויר‬
‫ב‬
-
‫שב‬ ‫גבוהה‬ ‫סבירות‬
-
CT
‫הגס‬ ‫המעי‬ ‫דופן‬ ‫עיבוי‬ ‫יודגם‬
‫באיזור‬
‫הסיגמה‬
‫ג‬
-
US
‫אבחנתי‬ ‫כלי‬ ‫הוא‬ ‫התחתונה‬ ‫הבטן‬ ‫של‬
‫מצויין‬
‫זה‬ ‫במקרה‬
‫ד‬
-
‫שב‬ ‫גבוהה‬ ‫סבירות‬
-
CT
‫של‬ ‫תמונה‬ ‫נראה‬
Thumb-printing
‫בסיגמה‬
‫ה‬
-
‫בביצוע‬ ‫צורך‬ ‫כלל‬ ‫אין‬
CT
‫המחלה‬ ‫של‬ ‫זה‬ ‫בשלב‬ ‫בטן‬
‫תשובה‬
:
‫פרק‬
353
The patient presents with classic signs of diverticulitis with fever, abdominal pain that is usually left lower quadrant,
anorexia or obstipation, and leukocytosis. This most commonly occurs in older individuals. Patients may present with
acute abdomen due to perforation, although this occurs in <25% of cases. Plain radiographs of the abdomen are
seldom helpful but may show the presence of an air-fluid level in the left lower quadrant indicating a giant diverticulum
with impending perforation. CT with oral contrast is the diagnostic modality of choice with the following findings:
sigmoid diverticula, thickened colonic wall >4 mm, and inflammation within the pericolic space with or without the
collection of contrast material or fluid. In 16% of patients, an abdominal abscess may be present. Symptoms of IBS may
mimic those of diverticulitis. Therefore, suspected diverticulitis that does not meet CT criteria or is not associated with
a leukocytosis or fever is not diverticular disease. Other conditions that can mimic diverticular disease include an
ovarian cyst, endometriosis, acute appendicitis, and pelvic inflammatory disease. Although the benefit of colonoscopy
in the evaluation of patients with diverticular disease has been called into question, its use is still considered important
in the exclusion of colorectal cancer. The parallel epidemiology of colorectal cancer and diverticular disease provides
enough concern for an endoscopic evaluation before operative management. Therefore, a colonoscopy should be
performed ~6 weeks after an attack of diverticular disease. Although diverticular disease may result in hematochezia,
these are generally not temporally linked to diverticulitis.

28. ‫שאלה‬
24
•
‫לבלב‬ ‫דלקת‬ ‫של‬ ‫ראשון‬ ‫לאירוע‬ ‫הגורם‬ ‫את‬ ‫לזהות‬ ‫מנת‬ ‫על‬ ‫לבצע‬ ‫שיש‬ ‫ביותר‬ ‫הטובה‬ ‫הראשונה‬ ‫הבדיקה‬ ‫מהי‬
‫חריפה‬
‫א‬
-
‫בסרום‬ ‫אלכוהול‬ ‫רמות‬
‫ב‬
-
‫בסרום‬ ‫טריגליצרידים‬ ‫רמות‬
‫ג‬
-
‫עליונה‬ ‫בטן‬ ‫סונר‬
‫ד‬
-
‫מידת‬
‫העליה‬
‫של‬
‫ליפזה‬
‫בסרום‬
‫ה‬
-
‫מיפוי‬
HIDA
‫תשובה‬
:
‫פרק‬
371
The most common cause of acute pancreatitis in the United States is gallstones causing common bile
duct obstruction. Although bile duct obstruction may be demonstrated on technetium HIDA scan, right
upper quadrant ultrasound is preferred for ease, demonstration of gallstones in the gallbladder, and
demonstration of obstructed bile duct. Alcohol is the second most common cause, followed by
complications of ERCP. Hypertriglyceridemia accounts for 1%–4% of cases with triglyceride levels usually
>1000 mg/dL. Other potential common causes include trauma, surgery, drugs such as valproic acid, anti-
HIV medications, estrogens, and sphincter of Oddi dysfunction. Additionally, a number of rare causes
have been described. The most judicious first step in evaluation is to test for gallstones and pursue more
rare causes after the most common cause has been ruled out.

29. ‫שאלה‬
25
•
‫מה‬
‫נכון‬ ‫לא‬
‫בצואה‬ ‫סמוי‬ ‫דם‬ ‫לבדיקת‬ ‫באשר‬
:
‫א‬
-
‫בכ‬
-
50%
‫שלילית‬ ‫היא‬ ‫בצואה‬ ‫סמוי‬ ‫דם‬ ‫בדיקת‬ ‫גס‬ ‫מעי‬ ‫סרטן‬ ‫עם‬ ‫מהחולים‬
‫ב‬
-
‫הוא‬ ‫חיובית‬ ‫סמוי‬ ‫דם‬ ‫בדיקת‬ ‫עם‬ ‫חולים‬ ‫בקרב‬ ‫ממאיר‬ ‫גידול‬ ‫למצוא‬ ‫הסיכוי‬
<
10%
‫ג‬
-
‫גס‬ ‫מעי‬ ‫מסרטן‬ ‫התמותה‬ ‫את‬ ‫מורידה‬ ‫לשנה‬ ‫אחת‬ ‫בצואה‬ ‫סמוי‬ ‫דם‬ ‫בדיקת‬ ‫ביצוע‬
‫ד‬
-
‫הוא‬ ‫חיובית‬ ‫סמוי‬ ‫דם‬ ‫בדיקת‬ ‫עם‬ ‫חולה‬ ‫אצל‬ ‫הגס‬ ‫במעי‬ ‫פוליפים‬ ‫למצוא‬ ‫הסיכוי‬
>
50%
‫ה‬
-
‫העיכול‬ ‫מערכת‬ ‫בבירור‬ ‫הצורך‬ ‫את‬ ‫מייתרת‬ ‫אינה‬ ‫ברזל‬ ‫מחוסר‬ ‫אנמיה‬ ‫עם‬ ‫אדם‬ ‫אצל‬ ‫שלילית‬ ‫סמוי‬ ‫דם‬ ‫בדיקת‬
‫תשובה‬
:
‫פרק‬
110
SCREENING
Unfortunately, even when performed optimally, the fecal occult blood test has major limitations as a screening
technique. About 50% of patients with documented colorectal cancers have a negative fecal occult blood test,
consistent with the intermittent bleeding pattern of these tumors. When random cohorts of asymptomatic persons
have been tested, 2–4% have fecal occult blood-positive stools. Colorectal cancers have been found in <10% of these
“test-positive” cases, with benign polyps being detected in an additional 20–30%. Thus, a colorectal neoplasm will not
be found in most asymptomatic individuals with occult blood in their stool. Nonetheless, persons found to have fecal
occult blood-positive stool routinely undergo further medical evaluation, including sigmoidoscopy and/or
colonoscopy—procedures that are not only uncomfortable and expensive but also associated with a small risk for
significant complications. The added cost of these studies would appear justifiable if the small number of patients
found to have occult neoplasms because of fecal occult blood screening could be shown to have an improved prognosis
and prolonged survival. Prospectively controlled trials have shown a statistically significant reduction in mortality rate
from colorectal cancer for individuals undergoing annual stool guaiac screening. However, this benefit only emerged
after >13 years of follow-up and was extremely expensive to achieve, because all positive tests (most of which were
falsely positive) were followed by colonoscopy. Moreover, these colonoscopic examinations quite likely provided the
opportunity for cancer prevention through the removal of potentially premalignant adenomatous polyps because the
eventual development of cancer was reduced by 20% in the cohort undergoing annual screening.

30. ‫שאלה‬
26
•
‫מה‬
‫מהמשפטים‬
‫לינץ‬ ‫לתסמונת‬ ‫באשר‬ ‫נכון‬ ‫הבאים‬
'
–
Lynch
‫א‬
-
‫פוליפים‬ ‫עשרות‬ ‫של‬ ‫בהופעה‬ ‫המוקדמים‬ ‫בשלביה‬ ‫מאופיינת‬ ‫התסמונת‬
‫אדנומטוטיים‬
‫צעיר‬ ‫בגיל‬
‫ב‬
-
‫ביותר‬ ‫השכיחות‬ ‫המוטציות‬
(
90%
)
‫ב‬ ‫הן‬
-
MLH1
‫ו‬
-
MSH2
‫ג‬
-
‫הממאיר‬ ‫השינוי‬
‫באדנומות‬
‫לינץ‬ ‫תסמונת‬ ‫עם‬ ‫חולים‬ ‫בקרב‬
'
‫מאשר‬ ‫יותר‬ ‫לאט‬ ‫קורה‬
‫באדנומות‬
‫ספורדיות‬
‫ד‬
-
‫לינץ‬ ‫תסמונת‬ ‫של‬ ‫התורשה‬
'
‫היא‬
‫אוטוזומלית‬
‫רצסיבית‬
‫ה‬
-
‫לינץ‬ ‫תסמונת‬ ‫עם‬ ‫חולים‬ ‫בקרב‬ ‫לבלב‬ ‫סרטן‬ ‫של‬ ‫השכיחות‬
'
‫גבוהה‬
‫מהאוכלוסיה‬
‫הכללית‬
‫תשובה‬
:
‫פרק‬
101
,
Familial cancer syndromes
‫תמונה‬ ‫כולל‬
101e-3
In contrast to patients with FAP, patients with hereditary nonpolyposis colon cancer (HNPCC, or Lynch’s
syndrome) do not develop multiple polyposis, but instead develop only one or a small number of
adenomas that rapidly progress to cancer. Most HNPCC cases are due to mutations in one of four DNA
mismatch repair genes, which are components of a repair system that is normally responsible for
correcting errors in freshly replicated DNA. Germline mutations in MSH2 and MLH1 account for more
than 90% of HNPCC cases, whereas mutations in MSH6 and PMS2 are much less frequent. When a
somatic mutation inactivates the remaining wild-type allele of a mismatch repair gene, the cell develops
a hypermutable phenotype characterized by profound genomic instability, especially for the short
repeated sequences called microsatellites. This microsatellite instability (MSI) favors the development
of cancer by increasing the rate of mutations in many genes, including oncogenes and tumor-suppressor
genes. These genes can thus be considered caretakers. Interestingly, CIN can also be found in colon
cancer, but MSI and CIN appear to be mutually exclusive, suggesting that they represent alternative
mechanisms for the generation of a mutator phenotype in this cancer. Other cancer types rarely exhibit
MSI, but most exhibit CIN.

31. ‫שאלה‬
27
•
‫המרה‬ ‫בכיס‬ ‫אבנים‬ ‫לגבי‬ ‫נכון‬ ‫מה‬
‫א‬
-
‫הוא‬ ‫מקרי‬ ‫באורח‬ ‫שהתגלו‬ ‫המרה‬ ‫בכיס‬ ‫אבנים‬ ‫עם‬ ‫הקשורים‬ ‫תסמינים‬ ‫לפתח‬ ‫הסיכוי‬
20-40%
‫של‬ ‫במעקב‬
25
‫שנים‬
‫ב‬
-
‫בחולים‬ ‫המרה‬ ‫כיס‬ ‫לכריתת‬ ‫הוריה‬ ‫יש‬ ‫ולכן‬ ‫סכרת‬ ‫עם‬ ‫חולים‬ ‫בקרב‬ ‫יתר‬ ‫שכיחים‬ ‫מרה‬ ‫כיס‬ ‫מאבני‬ ‫הסיבוכים‬
‫סכרתיים‬
‫תסמינים‬ ‫ללא‬
‫ג‬
-
‫יותר‬ ‫גבוה‬ ‫האבנים‬ ‫אובחנו‬ ‫בו‬ ‫שהגיל‬ ‫ככל‬ ‫עולה‬ ‫מרה‬ ‫כיס‬ ‫מאבני‬ ‫לתסמינים‬ ‫הסיכוי‬
‫ד‬
-
‫לסיבוכים‬ ‫הסיכון‬
(
‫מרה‬ ‫כיס‬ ‫דלקת‬
,
‫כולנגיטיס‬
‫ופנקריאטיטיטיס‬
)
‫הוא‬ ‫המרה‬ ‫בכיס‬ ‫אבנים‬ ‫עם‬ ‫אנשים‬ ‫בקרב‬
1-3%
‫בשנה‬
‫ה‬
-
‫נכונות‬ ‫התשובות‬ ‫כל‬
‫תשובה‬
:
‫פרק‬
369
,
Diseases of the gall bladder – Natural history
Gallstone disease discovered in an asymptomatic patient or in a patient whose symptoms are not referable to
cholelithiasis is a common clinical problem. Sixty to 80% of persons with asymptomatic gallstones remain asymptomatic
over follow-up periods of up to 25 years. The probability of developing symptoms within5 years after diagnosis is 2–4%
per year and decreases in the years thereafter to 1–2%. The yearly incidence of complications is about 0.1–0.3%.
Patients remaining asymptomatic for 15 years were found to be unlikely to develop symptoms during further follow-up,
and most patients who did develop complications from their gallstones experienced prior warning symptoms. Similar
conclusions apply to diabetic patients with silent gallstones. Decision analysis has suggested that (1) the cumulative risk
of death due to gallstone disease while on expectant management is small, and (2) prophylactic cholecystectomy is not
warranted.
Complications requiring cholecystectomy are much more common in gallstone patients who have developed symptoms
of biliary pain. Patients found to have gallstones at a young age are more likely to develop symptoms from cholelithiasis
than are patients >60 years at the time of initial diagnosis. Patients with diabetes mellitus and gallstones may be
somewhat more susceptible to septic complications, but the magnitude of risk of septic biliary complications in diabetic
patients is incompletely defined.

32. ‫שאלה‬
28
•
‫תזמין‬ ‫הבאים‬ ‫מהמקרים‬ ‫באיזה‬
/
‫בדיקת‬ ‫י‬
ERCP
‫דחופה‬
‫א‬
-
‫בן‬ ‫גבר‬
60
‫יומיים‬ ‫מזה‬ ‫עליונה‬ ‫ימנית‬ ‫בטן‬ ‫כאב‬ ‫עם‬
,
‫חום‬
,
‫ניכרת‬ ‫רגישות‬
‫בהיפוכונדריום‬
‫ימני‬
.
‫המעבדה‬ ‫בבדיקות‬
‫לויקוציטוזיס‬
,
‫תקינים‬ ‫ובילירובין‬ ‫כבד‬ ‫אנזימי‬
.
‫בסונר‬
–
‫מרה‬ ‫דרכי‬ ‫הרחבת‬ ‫אין‬
.
‫ואבנים‬ ‫מעובה‬ ‫דופן‬ ‫עם‬ ‫מרה‬ ‫כיס‬
‫בתוכו‬
‫ב‬
-
‫בן‬ ‫גבר‬
60
‫יומיים‬ ‫מזה‬ ‫עליונה‬ ‫ימנית‬ ‫בטן‬ ‫כאב‬ ‫עם‬
,
‫חום‬
‫ספטי‬
,
‫במעבדה‬
-
‫לויקוציטוזיס‬
,
‫טרנסאמינזות‬
‫פי‬
10
‫מהנורמה‬
,
‫פוספטזה‬
‫פי‬ ‫בסיסית‬
1.5
‫מהנורמה‬
,
‫בילירובין‬
6
‫ישיר‬ ‫רובו‬
.
‫בסונר‬
–
‫המרה‬ ‫בכיס‬ ‫אבנים‬
,
‫המרה‬ ‫צינור‬
‫בקוטר‬ ‫המשותף‬
10
‫ממ‬
'
‫בתוכו‬ ‫אבנים‬ ‫ללא‬
‫ג‬
-
‫בן‬ ‫גבר‬
60
‫עליונה‬ ‫בטן‬ ‫כאב‬ ‫עם‬
4
‫שבועות‬
,
‫תיאבון‬ ‫חוסר‬
,
‫של‬ ‫במשקל‬ ‫ירידה‬
5
‫קג‬
'
.
‫במעבדה‬
–
‫פוספטזה‬
‫בסיסית‬
‫פי‬
5
‫מהנורמה‬
,
‫ללא‬
‫לויקוציטוזיס‬
‫ובסונר‬
–
‫בקוטר‬ ‫המשותף‬ ‫המרה‬ ‫צינור‬
11
‫ממ‬
,'
‫כבדיות‬ ‫תוך‬ ‫מרה‬ ‫דרכי‬ ‫הרחבת‬
‫אבנים‬ ‫ללא‬ ‫תפוח‬ ‫מרה‬ ‫וכיס‬
‫ד‬
-
‫בן‬ ‫חולה‬
45
‫קשה‬ ‫גרד‬ ‫מלווה‬ ‫שבועיים‬ ‫לפני‬ ‫שהופיעה‬ ‫צהבת‬ ‫עם‬ ‫רבות‬ ‫שנים‬ ‫כיבית‬ ‫קוליטיס‬ ‫של‬ ‫רקע‬ ‫עם‬
,
‫חום‬ ‫ללא‬
‫כאבים‬ ‫או‬
.
‫במעבדה‬
–
‫פוספטזה‬
‫בסיסית‬
350
,
‫טרנסאמינזות‬
‫פי‬
1.5
‫מהנורמה‬
,
‫בילירובין‬
3.2
.
‫ממצאים‬ ‫ללא‬ ‫בסונר‬
‫בכבד‬ ‫או‬ ‫המרה‬ ‫בדרכי‬
‫ה‬
-
‫בן‬ ‫גבר‬
60
‫חריפה‬ ‫לבלב‬ ‫דלקת‬ ‫של‬ ‫תמונה‬ ‫עם‬
.
‫במעבדה‬
–
‫פי‬ ‫קלה‬ ‫עליה‬
1.5
‫הכבד‬ ‫אנזימי‬ ‫בכל‬
,
‫תקין‬ ‫בילירובין‬
.
‫בסונר‬
–
‫מוגדרת‬ ‫לא‬ ‫סדירות‬ ‫אי‬ ‫הלבלב‬ ‫ובראש‬ ‫חריגים‬ ‫ממצאים‬ ‫ללא‬ ‫מרה‬ ‫וכיס‬ ‫מרה‬ ‫דרכי‬
,
‫גוש‬ ‫ספק‬
‫תשובה‬
:
‫פרק‬
370
Studies Pertaining to Pancreatic Structure
Both EUS and MRCP have largely replaced ERCP in the diagnostic evaluation of pancreatic disease. As
these techniques become more refined, especially with the administration of secretin, they may well be
the diagnostic tests of choice to evaluate the pancreatic duct. ERCP is still needed for treatment of bile
duct and pancreatic duct lesions. ERCP is primarily of therapeutic value after CT, EUS, or MRCP has
detected abnormalities requiring invasive endoscopic treatment. ERCP can also be helpful at
clarification of equivocal findings discovered with other imaging techniques

33. ‫שאלה‬
29
•
‫בן‬ ‫חולה‬
80
‫מס‬ ‫בטן‬ ‫כאב‬ ‫של‬ ‫סיפור‬ ‫עם‬ ‫המיון‬ ‫לחדר‬ ‫מגיע‬
'
‫בתפקוד‬ ‫וירידה‬ ‫ימים‬
.
‫פרקינסון‬ ‫מחלת‬ ‫ברקע‬
,
‫דיסק‬ ‫פריצת‬ ‫האחרונים‬ ‫ובשבועות‬
L4-5
‫מטופל‬
‫בנרקוטיקה‬
‫נמוך‬ ‫במינון‬
.
‫דופק‬ ‫בבדיקה‬
90
‫לדקה‬
,
‫דם‬ ‫לחץ‬
‫תקין‬
,
‫נשימות‬
15
‫לדקה‬
,
‫הבטן‬ ‫של‬ ‫בולטת‬ ‫תפיחות‬
,
‫טימפניות‬
‫דיפוזית‬
,
‫בינונית‬ ‫דיפוזית‬ ‫רגישות‬
‫ירודה‬ ‫ופריסטלטיקה‬
.
‫בדיקה‬
‫רקטלית‬
‫תקינה‬
(
‫צואה‬ ‫וללא‬
.)
‫כל‬ ‫של‬ ‫ניכרת‬ ‫הרחבה‬ ‫נראית‬ ‫סקירה‬ ‫בטן‬ ‫בצילום‬
‫האנוס‬ ‫עד‬ ‫הגס‬ ‫המעי‬
,
‫לחסימה‬ ‫עדות‬ ‫ללא‬
.
‫תקינים‬ ‫אלקטרוליטים‬
.
‫החדרת‬ ‫לאחר‬
rectal tube
‫למס‬ ‫הקלה‬
'
‫בלבד‬ ‫שעות‬
.
‫הצעד‬ ‫מה‬
‫המיידי‬
‫זה‬ ‫לחולה‬ ‫ביותר‬ ‫הטוב‬ ‫הבא‬
‫א‬
-
‫הכנה‬ ‫ללא‬ ‫דחופה‬ ‫קולונוסקופיה‬
(
‫הזמן‬ ‫קוצר‬ ‫בשל‬
)
‫ב‬
-
CT
‫הבטן‬ ‫של‬
‫ג‬
-
‫לצורך‬ ‫לכירורגים‬ ‫להפנות‬
‫צאקוסטומיה‬
‫דחופה‬
‫ד‬
-
‫אישפוז‬
‫נוזלים‬ ‫עירוי‬ ‫עם‬
,
‫ומעקב‬ ‫התרופתי‬ ‫הטיפול‬ ‫כל‬ ‫הפסקת‬
‫ה‬
-
‫מתן‬
Neostigmine
‫הוריד‬ ‫דרך‬
‫תשובה‬
:
‫פרק‬
355
–
Acute intestinal obstruction – Treatment
‫ו‬
-
345
Colonic Obstruction and Pseudoobstruction
Acute colonic pseudoobstruction is a form of colonic ileus that is usually attributable to electrolyte
disorders, narcotic and anticholinergic medications, immobility (as after surgery), and retroperitoneal
hemorrhage or mass. Multiple causative factors are often present
‫המשך‬
‫בשיקופית‬
‫הבאה‬

34. COLONIC PSEUDO-OBSTRUCTION (OGILVIE’S DISEASE)
Neostigmine is an acetylcholinsterase inhibitor that
increases cholinergic (parasympathetic) activity, which
can stimulate colonic motility. Some studies have shown
it to be moderately effective in alleviating acute colonic
pseudo-obstruction. It is the most common therapeutic
approach and can be used once it is certain that there is
no mechanical obstruction. Cardiac monitoring is
required, and atropine should be immediately available.
Intravenous administration induces defecation and flatus
within 10 min in the majority of patients who will
respond.

35. ‫שאלה‬
30
•
‫מקבוצת‬ ‫בתרופות‬ ‫טיפול‬ ‫עם‬ ‫קשורה‬ ‫אינה‬ ‫הבאות‬ ‫מהתופעות‬ ‫איזו‬
Anti-TNF
‫א‬
-
psoriasiform skin lesions
-‫ב‬
‫לימפומה‬
Non-Hodgkin
‫ג‬
-
‫מלנומה‬
‫ד‬
-
‫ריאקטיבציה‬
‫שלצרבת‬
‫ה‬
-
‫ריאקטיבציה‬
‫של‬
‫הפיטיטיס‬
C
‫תשובה‬
:
‫פרק‬
351
Side Effects of Anti-TNF Therapies
Side Effects of Anti-TNF TherapiesDEVELOPMENT OF ANTIBODIES
The development of antibodies to infliximab (ATIs) is associated with an increased risk of infusion reactions and a decreased
response to treatment. Current practice does not include giving on-demand or episodic infusions in contrast to periodic (every 8
week) infusions because patients are most likely to develop ATIs. ATIs are generally present when the quality of response or the
response duration to infliximab infusion decreases. Decreasing the dosing intervals or increasing the dosage to 10 mg/kg may
restore the efficacy. There are commercial assays for both infliximab and adalimumab antibodies and trough levels to determine
optimal dosing. If a patient has high ATIs and a low trough level of infliximab, it is best to switch to another anti-TNF therapy. Most
acute infusion reactions and serum sickness can be managed with glucocorticoids and antihistamines. Some reactions can be
serious and would necessitate a change in therapy, especially if a patient has ATIs.
NON-HODGKIN’S LYMPHOMA (NHL)
The baseline risk of NHL in CD patients is 2:10,000, which is slightly higher than in the general population. Azathioprine and/or 6-
MP therapy increases the risk to about 4:10,000. The highest risk for thiopurine-associated NHL is in patients over 65 years old,
with a moderate risk in those between the ages of 50 and 65. Anti-TNF therapy increases the risk to approximately 6:10,000.
‫המשך‬
‫בשיקופית‬
‫הבאה‬

36. HEPATOSPLENIC T CELL LYMPHOMA (HSTCL)
HSTCL is a nearly universally fatal lymphoma in patients with
or without CD. In patients with CD, events reported to the
Food and Drug Administration Adverse Event Reporting
System (FDA AERS) and search of PubMed and Embase
published case reports demonstrate a total of 37 unique
cases. Eighty-six percent of the patients were male, with a
median age of 26 years. Patients had CD for a mean of 10
years before the diagnosis of HSTCL. Thirty-six cases had used
either 6-MP or azathioprine, and 28 cases had used infliximab.
Of these 28 cases, 27 had also used 6-MP or azathioprine. The
other case had a history of both infliximab and adalimumab
exposure.
‫המשך‬
‫בשיקופית‬
‫הבאה‬

37. SKIN LESIONS
New-onset psoriasiform skin lesions develop in nearly 5% of IBD patients
treated with anti-TNF therapy. Most often, these can be treated topically, and
rarely, anti-TNF therapy must be decreased, switched, or stopped. The risk of
melanoma is increased almost twofold with anti-TNF and not thiopurine use.
The risk of nonmelanoma skin cancer is increased with thiopurines and
biologics, especially with 1 year of follow-up or greater. Patients on these
medications should have a skin check at least once a year.
INFECTIONS
All of the anti-TNF drugs are associated with an increased risk of infections,
particularly reactivation of latent tuberculosis and opportunistic fungal
infections including disseminated histoplasmosis and coccidioidomycosis. It is
recommended that patients have a purified protein derivative (PPD) or a
QuantiFERON-TB gold test as well as a chest x-ray before initiation of anti-TNF
therapy. Patients over 65 have a higher rate of infections and death on
infliximab or adalimumab than those younger than 65 years of age.