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NBME 22 Answers

nbme22/Block 1/Question#44 (43.6 difficulty score)
A 52-year-old man with a history of alcoholic ...
Superior rectalπŸ”

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submitted by cathartic_medstu(28),
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uipreSor irosdhmehro ,oodbl rrfeIion isdemhhoorr rst.obohm asyAlw rbeeermm t.tah


submitted by bobson150(14),
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Teh dgownri of ihts soeqiutn suenfcdo .me isTh si kasnig hchiw" fo ethse ssvseel si teh hhig eseprrus esytms" hit?rg oS het ghhi reesurps psieuorr rcleat si sagiucn eansriedc ussrpree otin eth fnroreii lrect?a

welpdedelp  Superior rectal comes from the inferior mesenteric vein which comes from the splenic vein --> portal veins Thus, this dude had cirrhosis so it would "back-up" into the superior rectal vein. FA 2018: p360 +13  
nc1992  Superior rectal not superior mesenteric. Took me a minute +  
hyperfukus  ugh am i ever gonna get these right EVER +5  
titanesxvi  why not the inferior mesenteric, since the superior rectal drains there +2  
thomasburton  @titanesxvi think it is because question says direct which is why superior rectal +2  
lilyo  thomasburton, so are they asking what vessels do internal hemorrhoids directly drain into? The order is Superior rectal vein--> Inferior mesenteric vein--> portal vein. +  
thomasburton  Yes exactly, so they do eventually reach IMV but not 'directly' +  
pg32  Also worded poorly because the varicosities are connections between the superior rectal and the middle/inferior rectal veins of the systemic circulation. So the blood could be in both the superior rectal vein and the middle/inferior rectal vein as that is what a varicosity is. +2  
snripper  You just gotta know indirect vs. direct hemorrhoids. In this case, it's an indirect hemorrhoid (superior rectal vein) because of the rectal bleeding. +  
jesusisking  @titanesxvi DrDoom explained it pretty well below: "Defining tributary: Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them)" +  

submitted by lilyo(72),
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I hda eth aesm qnsuoiet ridnaggre ths.i I nwok that xaleertn hdhrrosmoei yrarel lebde dna nlrtenai hesiodhromr nrpetse as sianpesl elbegndi os ni ym dimn I enwk I wsa igenb kdsea touba alnnirte hsrehrm.iood ,rwHoeve peorrius -;cte-lr&tag oeirirnf nisetmecer e-n&t;-vig oatlpr ,nive nca yennoa etll me ywh eth nwersa asw priusoer cletra nda otn niefirro ntmceesre?i

dubywow  Because the wording sucks. It's a confusing way to word the question. I too was confused what direct tributaries was referring to and chose Inferior mesenteric because I suck and also because this question sucks. Really its asking where are the hemorrhoids? They are on/from the superior rectals even though those veins feed to Inferior mesenteric. +3  
drdoom  Defining tributary: Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them). +5  

submitted by surfacegomd(2),

The qx asks for the direct tributaries following the vein that is producing the hemorrhoids, in this case internal hemorrhoids because they are painless.

(Amboss) Internal hemorrhoidal plexus -> superior rectal vein -> inferior mesenteric vein -> splenic vein -> portal vein -> ICV