NBME 22 Answers : Block 1 : #44 = A 52-year-old man with a history of alcoholic ...

NBME 22 Answers

nbme22/Block 1/Question#44

A 52-year-old man with a history of alcoholic ...

Superior rectal

+2 upvote downvote
submitted by cathartic_medstu(13),

Superior hemorrhoids blood, Inferior hemorrhoids thrombos. Always remember that.

-Goljan

+1 upvote downvote
submitted by bobson150(4),

The wording of this question confused me. This is asking "which of these vessels is the high pressure system" right? So the high pressure superior rectal is causing increased pressure into the inferior rectal?

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 +9

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 +1

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. +

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: https://i.imgur.com/2zDxPbW.png Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them)" +

+0 upvote downvote
submitted by lilyo(18),

I had the same question regarding this. I know that external hemorrhoids rarely bleed and internal hemorrhoids present as painless bleeding so in my mind I knew I was being asked about internal hemorrhoids. However, superior rectal--> inferior mesenteric vein--> portal vein, can anyone tell me why the answer was superior rectal and not inferior mesenteric?

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. +1

drdoom Defining tributary: https://i.imgur.com/2zDxPbW.png Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them). +1