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NBME 22 Answers

nbme22/Block 1/Question#44 (45.9 difficulty score)
A 52-year-old man with a history of alcoholic ...
Superior rectal🔍,📺

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submitted by cathartic_medstu(30),
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uirSerpo smdoroerhhi ,ldoob eIifrron drrmohsoieh rbmo.thos slawAy eemmerbr .that


submitted by bobson150(18),
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hTe ogriwnd of sith uqistneo uecfdson m.e iTsh is sgnika hw"ich of ehets lssesve si teh high uesrprse s"tyesm r?ihtg So het hgih rpsseeru osriepur trclae is nscuiag eesancdri psesreru tnio het rfioeinr atlre?c

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. +3  
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(78),
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I adh eht aesm equnstio arngedrig .tshi I wnko hatt rxneelat rriemhodosh yaelrr eledb dna nitnealr ohsdermrhoi epnsetr as lipseans dngebeil os in my ndmi I kwne I was iegnb aeskd aubot lnritnae smooe.rihhdr eoevH,rw eorsuirp t&rlacg--et; ioeinrfr sreicmtene t;v-ei&g-n rotapl i,nve acn oyenan etll me yhw the wsrean saw usoeprir rtecal dan not oifrenri mrceeein?ts

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(1),

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