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NBME 22 Answers

nbme22/Block 4/Question#28 (41.0 difficulty score)
A 48-year-old man comes to the emergency ...
Splenic vein🔍

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submitted by aesalmon(81),
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nehW in tbodu sit oblyrpab het ieclSnp ineV lyap(" ds"do - nGja)ol

jurrutia  Also, what is causing the splenomegaly? Cross out gastroduodenal A/V, gastric A/V, and pancreatoduodenal A/V since they have nothing to do with the spleen. All that's left is the splenic vessels, and you know it's a vein... +  

submitted by k_tron_3000(31),
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Jsut a narodm ftcaido (as arf sa I n,ok)w ni tesptani twhi ctiisaetpnra eht stom lilyke vlesse ofr boihosmsrt is het snpceil ievn ued ot sceol moia“nact ste”i iwth eth ar.npscea Tihs wlduo aslo ucsae prticso-ngeasl sevia,rc nepialginx the miigvont of odolb.

meningitis  Also explains the splenomegaly. If you have thrombosed splenic vein, the blood will pool in the spleen, can also cause expansion of red pulp of spleen. +10  
pg32  I picked splenic vein because of this ^^ association. However, why is the patient vomiting blood if there isn't a backup of blood into the left gastric/esophageal veinous system? +1  
savethewhales  The splenic vein drains the fundus of the stomach. So, splenic vein thrombosis can cause gastric fundal varices, which explains his bloody vomit. +3  
medschooler1  how do you rule out arteries? +  
ac3  @medschooler1 Just my guess, but when answering this I assumed that splenomegaly meant splenic congestion with blood which can only happen if its outflow tract (splenic vein) is blocked. +4  

submitted by mattnatomy(41),
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tMso mmoonc ceuas of sencipl vine htssboomir si ircochn cpiaaenirstt, ucdsea yb ueepsrivno namonaimlft.i

oeurc:S 5wi/pbv/.:nhhu45ci2w0s.p/4m.tewtodlgnm/b1n.0

hyperfukus  great link! helps answer other qs too thank you :) +  

submitted by almondbreeze(81),

UW: the short gastric vv drain blood from the gastric funds into the splenic vein, pancreatic inflammation (e.g. pancreatitis, pancreatic ca.) can cause a blood clot w/i the splenic vein, which can increase pressure in the short gastric veins and lead to gastric varies only in the funds

almondbreeze  b/c pancreatic causes can form blood clot in splenic v, b/c splenic v runs behind pancreas +  

submitted by dysdiadochokinesia(2),

Chronic alcohol-related hematemesis is associated with 2 possible sources: gastric varices or esophageal varices.

Gastric varices -> L. gastric vein or R. gastric vein (draining the gastric fundus into splenic vein)

Esophageal varices -> L. gastric vein

L. gastric vein can be ruled out because splenomegaly wouldn't be present in a L. gastric vein thrombosis, making the splenic vein the correct answer.

submitted by makinallkindzofgainz(221),

Isolated gastric fundal varices are seen in splenic vein thrombosis.

Thrombosis increases pressure in the short gastric veins --> gastric varices only in the fundus

  • Seen in pancreatic inflammation (ex. pancreatitis, pancreatic cancer), which can cause a blood clot within the splenic vein, backing up blood into the short gastric veins (gastrocaval shunt - drained by the inferior phrenic vein) when ruptured causes gastric bleeding, hemoptysis (seen in stem), and melena