Question 1

A 38-year-old woman comes to the office for follow-up after recent hospitalization.  The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis.  She had intermittent, burning, epigastric pain over the past several months prior to hospitalization.  At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy.  The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena.  She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains.  The patient does not use tobacco, alcohol, or illicit drugs and has no allergies.  Family history is notable for gastric cancer in her father.  Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min.  Cardiopulmonary examination is normal.  The abdomen is nondistended, soft, and nontender.  Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy. The patient returns to the office a month after completing the prescribed treatment.  She reports that she initially felt better but has had intermittent recurrence of the abdominal pain.  She also has had occasional nausea but no vomiting, hematemesis, hematochezia, or melena.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf48_7562_8f63_cd99967b0e8c_MD0005_00 This patient has persistent symptoms of peptic ulcer disease (PUD), despite completing appropriate treatment, which is concerning for treatment failure. Given increasing antibiotic resistance, Helicobacter pylori eradication should be confirmed for patients with the following: persistent symptoms H pylori-associated ulcer on endoscopy evidence of an H pylori-associated malignancy (eg, mucosa-associated lymphoid tissue lymphoma). Common methods for determining bacterial eradication include urea breath testing and fecal antigen testing. Testing should occur >4 weeks after the completion of therapy. If testing confirms eradication but symptoms remain, other etiologies should also be considered. In patients who do not clear the infection after first-line therapy, second-line options such as quadruple therapy or sequential therapy involving distinct antibiotics should be used. (Choice B) With the advent of effective antibiotic and acid suppression therapy for PUD, surgery is performed mostly for complications such as perforation or refractory hemorrhage. Surgery should not be considered for treatment failure of antibiotic therapy until patients have failed multiple attempts at eradication. (Choice C) Empiric re-treatment without testing for eradication is inappropriate given both the ease of evaluation and the need to consider alternate diagnoses in the setting of persistent symptoms despite elimination of H pylori. (Choice D) Repeat upper endoscopy can help establish whether H pylori has been eradicated; however, given the availability of other less invasive options (eg, urea breath test), it should be reserved for patients with indeterminate indirect testing or with other additional indications for endoscopy. (Choice E) Simply switching to a different proton pump inhibitor is an insufficient strategy given the risk of treatment failure and antibiotic resistance. Educational objective: Patients with persistent symptoms of peptic ulcer disease, evidence of Helicobacter pylori-associated ulcers, or H pylori-associated malignancy should undergo an evaluation to determine bacterial eradication. The preferred options include urea breath testing and fecal antigen testing. References: A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication. (http://www.ncbi.nlm.nih.gov/pubmed/24587620)

Question 2

A 48-year-old woman comes to the office after abnormal serum liver chemistry results were found during a life insurance medical evaluation. She has no chronic medical issues and takes no medications. The patient says she has felt excessively tired lately, which she attributes to menopause. She has had no hot flashes, changes in sleep pattern, anorexia, or weight loss. The patient does not use tobacco, alcohol, or illicit drugs. She works in an accounting firm. Her father died at age 62 from an unknown liver disease. Vital signs are within normal limits. BMI is 30 kg/m². She has small bilateral xanthelasmata but no scleral icterus. The thyroid is not enlarged. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender with no hepatosplenomegaly. She has no skin rash. Current laboratory results are as follows: Abdominal ultrasonography reveals a normal-sized liver and no gallstones. Intrahepatic and common bile ducts are normal. This patient is at greatest risk for which of the following due to nutritional complications of her current condition?

Accepted Answer

Explanation: Metabolic bone disease, such as osteopenia and osteoporosis, is a frequent complication of primary biliary cholangitis (PBC). Its cause is unknown, although its increased prevalence among patients with PBC may in part be due to its predisposition to affect female patients who are frequently postmenopausal and already at risk. As PBC progresses, cholestasis may cause toxic accumulations of substances that inhibit bone turnover. Vitamin D levels are typically normal in these patients, with the exception of those with extremely advanced disease (due to severe protracted cholestasis causing fat malabsorption). Therefore, it is important to screen regularly for osteoporosis (eg, using bone densitometry) in such patients. Calcium and vitamin D supplements are generally recommended, and bisphosphonates (eg, alendronate) are indicated for those with established osteoporosis. Osteomalacia (decreased bone mineralization) can sometimes be seen with PBC and is typically associated with vitamin D deficiency. (Choices A, B, C, and D) In the United States, most water-soluble vitamin (eg, vitamin B) deficiencies are rare and usually seen in patients with chronic alcoholism, severely restrictive diets (eg, anorexia nervosa), or malabsorptive disorders (eg, celiac disease, short gut syndrome). Patients with PBC do not have a significantly increased risk for these deficiencies. Clinical manifestations of select vitamin B deficiencies include the following: Angular cheilosis and stomatitis - nonspecific but can be seen in riboflavin (vitamin B₂) deficiency. Wet Beriberi (eg, dilated cardiomyopathy, polyneuropathy) and Wernicke-Korsakoff syndrome (ie, neurocognitive impairment, oculomotor dysfunction, ataxia, encephalopathy, amnesia) - can be seen with thiamine (vitamin B₁) deficiency. Pellagra (ie, photosensitive dermatitis, diarrhea, dementia) - can be seen with niacin (vitamin B₃) deficiency. Educational objective: Primary biliary cholangitis is associated with an increased risk for osteopenia and osteoporosis, and warrants screening with bone densitometry.

Question 3

A 48-year-old woman comes to the office after abnormal serum liver chemistry results were found during a life insurance medical evaluation. She has no chronic medical issues and takes no medications. The patient says she has felt excessively tired lately, which she attributes to menopause. She has had no hot flashes, changes in sleep pattern, anorexia, or weight loss. The patient does not use tobacco, alcohol, or illicit drugs. She works in an accounting firm. Her father died at age 62 from an unknown liver disease. Vital signs are within normal limits. BMI is 30 kg/m². She has small bilateral xanthelasmata but no scleral icterus. The thyroid is not enlarged. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender with no hepatosplenomegaly. She has no skin rash. Current laboratory results are as follows: Abdominal ultrasonography reveals a normal-sized liver and no gallstones. Intrahepatic and common bile ducts are normal. Which of the following is most likely to help establish the diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_bf4d_0947_8f63_c55c4dd6e738_MD0005_00 Primary biliary cholangitis (PBC, formerly known as primary biliary cirrhosis) is a progressive autoimmune disease characterized by fibrosis and obliteration of the intrahepatic bile ducts, potentially leading to cirrhosis. PBC is most common in women of Northern European heritage with typical onset at age 30-65, with the risk increased in family members. Patients are often asymptomatic at the time of diagnosis, with abnormalities noted on liver function tests done for other reasons. Fatigue and pruritus are the most common symptoms, but patients can also develop jaundice, steatorrhea, hyperpigmentation, and hyperlipidemia with xanthelasma (cholesterol-rich skin deposits, usually around the eyelids). Patients may also have other autoimmune disorders (eg, CREST syndrome, type 1 diabetes mellitus). xanthelasma PBC is characterized by significant elevations in alkaline phosphatase (reflecting cholestasis); mild elevations in bilirubin and hepatic transaminases (eg, aspartate aminotransferase) may also be seen. Antimitochondrial antibodies are highly sensitive (~95%) and specific for PBC. Liver biopsy can confirm the diagnosis and provide staging information, but is not necessary in patients with typical clinical and laboratory findings. (Choice A) Alpha-1 antitrypsin deficiency typically causes cirrhosis (with significant elevations in hepatic transaminases) and emphysema. This patient has no pulmonary manifestations, and the xanthelasma and predominant elevation in alkaline phosphatase are more consistent with PBC. (Choice B) Anti-smooth-muscle antibodies are associated with type 1 autoimmune hepatitis, which typically causes elevation of hepatic transaminases. Alkaline phosphatase is usually normal or only mildly elevated. (Choice D) Wilson disease is caused by abnormal transport and metabolism of copper, and leads to low serum ceruloplasmin levels. It typically presents before age 35 with hepatomegaly and elevation in transaminases, and patients frequently have neuropsychiatric symptoms (eg, depression, movement disorders). (Choice E) Serum ferritin and transferrin saturation are useful in evaluation of hemochromatosis, which is a common cause of chronic liver disease. However, hemochromatosis is more common in men, causes predominant elevations in transaminases, and often has additional findings including hyperpigmentation, diabetes mellitus, arthropathy, and cardiomyopathy. Educational objective: Primary biliary cholangitis is a progressive autoimmune disease characterized by fibrosis and obliteration of the intrahepatic bile ducts. Fatigue and pruritus are the most common symptoms. Most patients have significant elevations in alkaline phosphatase, and antimitochondrial antibodies are highly sensitive and specific. References: The diagnosis of primary biliary cholangitis. (http://www.ncbi.nlm.nih.gov/pubmed/24424173)

Question 4

A 2-week-old girl is brought to the office because she looks "a bit yellow."  She was born at 40 weeks gestation by normal spontaneous vaginal delivery to a mother whose blood type is AB+.  Apgar scores were 9 (-1 color) and 9 (-1 color) at 1 and 5 minutes, respectively.  Birth weight, length, and head circumference were at the 50th percentile.  She was discharged home on the second day of life and has been breastfeeding every 2-3 hours for 15 minutes on each side.  The infant has 6 wet diapers and 5-6 yellow seedy stools per day.  She has regained her birth weight and has normal vital signs.  Physical examination shows an active, crying infant with moist mucous membranes and jaundice of the face, neck, and chest.  The remainder of the examination is normal.  Total bilirubin is 10 mg/dL and direct bilirubin is 0.6 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: The American Academy of Pediatrics recommends that infants with breast milk jaundice continue breastfeeding exclusively. Formula (Choice C) is not required if the mother's breast milk supply is adequate and the neonate is gaining weight and has a normal examination. Cessation of breastfeeding can accelerate the decline in serum bilirubin levels but has no clinical benefits as kernicterus from breast milk jaundice is very rare. Rather, discontinuing breastfeeding prevents the infant from receiving the benefits of breast milk, including maternal antibodies, mother-infant bonding, and immunity. Interrupting breastfeeding with bottles, especially during the first month, can decrease the mother's milk supply and the newborn's ability to latch and suck at the breast. All efforts should be made to promote and support breastfeeding. Parents should be reassured that the prognosis is good with spontaneous resolution by age 3 months. (Choice B) Oral rehydration solutions are used to treat dehydration. They are less nutritious than breast milk and are not indicated in this adequately hydrated neonate. (Choice D) The level of hyperbilirubinemia in this 2-week-old infant does not warrant phototherapy, but phototherapy can be considered if the level continues to rise. (Choice E) Conjugated hyperbilirubinemia is always pathologic and requires additional workup. If the direct bilirubin is elevated (>20% of total bilirubin), ultrasound of the hepatobiliary tree should be performed to evaluate for biliary atresia. Educational objective: Treatment of breast milk jaundice includes frequent follow-up and monitoring of the infant's hyperbilirubinemia. Exclusive breastfeeding should be continued and encouraged as the jaundice should resolve spontaneously by age 3 months. References: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. (http://www.ncbi.nlm.nih.gov/pubmed/15231951) Hyperbilirubinemia in the newborn infant > or =35 weeks' gestation: an update with clarifications. (http://www.ncbi.nlm.nih.gov/pubmed/19786452) Neonatal jaundice and human milk. (http://www.ncbi.nlm.nih.gov/pubmed/21942599)

Question 5

A 52-year-old woman undergoes laparoscopic cholecystectomy due to recurrent episodes of biliary colic. During the surgery, a blunt trocar is inserted near the umbilicus under direct vision (ie, open technique), and pneumoperitoneum is achieved via insufflation of the abdomen with carbon dioxide. Three additional trocars are inserted, and the cholecystectomy is completed uneventfully. After a period of observation in the postanesthesia care unit, the patient is discharged home. Three days later, the patient returns to the emergency department due to persistent abdominal pain and nausea. She takes acetaminophen and hydrocodone every 6 hours. Temperature is 38 C (100.4 F), blood pressure is 120/68 mm Hg, and pulse is 104/min. Physical examination shows intact port incisions with no erythema or discharge. There is mild generalized tenderness of the abdomen with some guarding. Bowel sounds are diminished. The remainder of the examination is normal. Laboratory testing shows leukocytes at 16,000/mm³; serum electrolytes and bilirubin are normal. Abdominal x-ray reveals generalized distension of the small and large bowel, stool in the distal colon, and intraperitoneal free air. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient who underwent laparoscopic surgery now has findings concerning for early intraabdominal infection, including persistent abdominal pain, fever, abdominal guarding, ileus (eg, diminished bowel sounds, small- and large-bowel distension), and leukocytosis. The best next step is abdominal CT scan with oral contrast to evaluate for possible unrecognized bowel injury (eg, bowel puncture when intraabdominal access is obtained, thermal injury when electrosurgical instruments are used). Bowel injuries that are recognized intraoperatively are immediately repaired. Some injuries, however, go unrecognizedand may not be diagnosed until patients seek care later with symptoms arising from the spillage of gastrointestinal contents, which may cause varying degrees of inflammation. Postoperative patients with frank peritonitis do not require abdominal imaging prior to surgical reexploration (although, in practice, imaging is often obtained en route to the operating room). Patients (such as this one) with concerning findings but without frank peritonitis (eg, some guarding but no rigidity or rebound tenderness) should undergo abdominal CT scan to evaluate for bowel injury. The use of oral contrast, given by nasogastric tube if necessary, assists with detecting the site of leakage (eg, extraluminal contrast extravasation). Intraperitoneal free air, as seen on this patient's x-ray, is normally present for days following procedural pneumoperitoneum and is therefore not specific for bowel perforation. (Choice A) Rectal enemas can help treat constipation (eg, from opioid use), which may cause abdominal pain and diminished bowel sounds. However, x-ray often reveals a large amount of feces throughout the entire colon (vs just the distal colon), and fever and leukocytosis are not expected. (Choices B and E) This patient has postoperative ileus (eg, decreased bowel sounds, generalized bowel distension). Although postoperative ileus is often benign with a self-limited course (for which reassurance or supportive care may be appropriate), this patient's additional findings of fever and leukocytosis are concerning for intraabdominal infection (eg, unrecognized bowel injury) and demand further workup (eg, CT scan). (Choice D) Early findings in patients with unrecognized biliary injury, a feared complication of laparoscopic cholecystectomy, may include nausea, persistent abdominal pain, and low-grade fever; however, serum bilirubin is often elevated (vs normal). Abdominal CT scan (vs endoscopic retrograde cholangiopancreatography) is typically used to make the diagnosis of biliary injury, which often requires surgical repair. Educational objective: Bowel injury is a potential complication of laparoscopic surgery that may go unrecognized intraoperatively. Concerning postoperative findings include fever, leukocytosis, abdominal pain/guarding, and ileus. Abdominal CT scan with oral contrast can help detect the site of leakage. References: Delayed manifestations of laparoscopic bowel injury. (http://www.ncbi.nlm.nih.gov/pubmed/25975332) Laparoscopic entry techniques. (http://www.ncbi.nlm.nih.gov/pubmed/30657163)

Question 6

A 76-year-old man is brought from the nursing home to the emergency department for evaluation of rectal discomfort that has worsened over the past 3 days.  The patient also had an episode of a small amount of rectal bleeding.  His other medical problems include chronic constipation, benign prostatic hypertrophy, and chronic obstructive pulmonary disease.  His temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, pulse is 100/min, and respirations are 20/min.  Examination of the anal area shows a thick, protruding, rectal mucosal mass with bluish discoloration, concentric rings, and friability.  He appears to be in moderate distress due to rectal discomfort.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf4e_de0c_8f63_77bd278ea92a_MD0005_00 This patient's presentation suggests complete rectal prolapse with strangulation and gangrene. Rectal prolapse is due to a mucosal or full-thickness layer of rectal tissue sliding through the anal orifice. Risk factors for rectal prolapse include prior pelvic surgery, pelvic floor dysfunction or anatomical defects, conditions causing increased intra-abdominal pressure (eg, chronic straining with constipation, benign prostatic hypertrophy), or women >age 40 with prior vaginal deliveries. Patients usually develop difficulty with defecation, diarrhea/fecal incontinence, discomfort (not significant pain) in the anal area, rectal bleeding, and a protruding rectal mass. Symptoms may occur intermittently. Significant rectal pain suggests a different underlying disorder. Diagnosis is made clinically by physical examination showing a mass extending through the anus with concentric rings of rectal mucosa. Management depends on the extent of prolapse and symptoms: Medical management is usually sufficient for patients without a full thickness rectal prolapse. Uncomplicated prolapsed rectal mucosa can be reduced by gentle digital pressure. Additional therapies include adequate fluid and fiber intake, pelvic floor exercises, and possible biofeedback for fecal incontinence (Choice B). Surgery (intra-abdominal or perineal approach) is preferred for patients who have complete rectal prolapse (such as this patient) or prolapse with fecal incontinence and/or constipation. Untreated complete rectal prolapse can lead to strangulation and gangrene of the rectal mucosa. The prognosis is generally good with prompt and appropriate care. (Choice A) This patient needs prompt treatment and possible emergency surgical intervention in the form of a rectosigmoidectomy. Outpatient medical management is not recommended at this point. (Choice E) Anoscopy is required for diagnosing a prolapsed internal hemorrhoid, which can present as inflamed veins in the left lateral and right anterior/posterior walls of the anal canal. Grade IV internal hemorrhoids can prolapse and usually cannot be reduced. However, internal hemorrhoids do not typically cause a full thickness rectal prolapse with concentric mucosal rings as seen in this patient. Educational objective: Rectal prolapse is due to a mucosal or full-thickness layer of rectal tissue sliding through the anal orifice. Complete rectal prolapse should be promptly evaluated for signs of incarceration and gangrene. Surgery (intra-abdominal or perineal approach) is preferred for patients with complete rectal prolapse or prolapse with fecal incontinence and/or constipation. References: Anorectal conditions: rectal prolapse (http://www.ncbi.nlm.nih.gov/pubmed/24742085) Rectal prolapse (http://www.ncbi.nlm.nih.gov/pubmed/23177071)

Question 7

A 40-year-old woman comes to the office to discuss nutrition. She says, "I have been overweight since the birth of my third child 10 years ago, and none of the diets I have tried ever seem to help." The patient reduced her food intake by 100-200 kcal/day on a restricted-fat diet 4 weeks ago, but her weight has not changed. She says, "I want to make sure I am doing the right thing. I tried to read about diets on the internet but I don't know what to believe." Medical history is notable for hypothyroidism, treated with a stable dose of levothyroxine. She does not smoke and drinks alcohol on social occasions only. Family history is significant for breast cancer and coronary artery disease in her mother and colon cancer in her father. Vital signs are normal. BMI is 32 kg/m². The thyroid is normal to palpation. Cardiopulmonary examination is normal. The abdomen is soft and nontender with no hepatomegaly. Deep tendon reflexes are normal and symmetric. Serum TSH is 2.1 µU/mL. Which of the following is the most appropriate nutritional recommendation for this patient?

Accepted Answer

Explanation: 11ec2b69_bf46_c7af_8f63_3dc5054dd849_MD0005_00 Patients who are obese are at increased risk for cardiovascular disease, hypertension, diabetes mellitus, and cancer, but weight loss of 5%-7% from baseline can confer a demonstrable reduction in risk. The following diets have been shown to reduce the risk of cardiovascular disease and are associated with moderate weight reduction in obese patients: Mediterranean diet - high in fruits, vegetables, whole grains, beans, nuts, and seeds with low/moderate intake of fish, poultry, dairy, and red wine. Olive oil is prominently featured and red meat and saturated fats are generally avoided. Dietary Approaches to Stop Hypertension (DASH) diet - high in fruits, vegetables, whole grains, and low-fat dairy, with low/moderate intake of lean meats, nuts, seeds, and legumes. Vegetarian, low-fat, and low-carbohydrate diets can also be helpful in weight loss, although evidence for cardioprotective effects is not as strong as for the Mediterranean and DASH diets. Once this patient determines which approach is preferred, supportive follow-up may be helpful, as weight loss correlates more closely with patient adherence and overall behavior modification (eg, exercise habits, food-eating triggers) than with the specific macronutrient content of the diet chosen (Choice C). (Choice A) Diets high in dietary fiber are associated with a lower risk of cardiovascular disease, cancer (eg, breast, colon), diabetes mellitus, and all-cause mortality. Processed fiber supplements, however, have not shown the same benefit. (Choice B)Most diets used for weight loss (eg, low-fat, DASH, Mediterranean, nonvegan vegetarian) are not associated with increased risk of vitamin D deficiency or fracture. By contrast, patients on strict vegan diets or who undergo surgical procedures for weight reduction often require vitamin D supplementation to prevent fracture. (Choice D) Although the "3,500 kcal rule" predicts that a deficit of 3,500 kcal (eg, 500 kcal/day for a week) will yield a 0.45 kg (1 lb) weight loss, observed weight loss is usually much less due to metabolic and behavioral compensation (eg, reduced activity). Educational objective: Diets (eg, Mediterranean, DASH) high in fruits, vegetables, whole grains, lean meats, and low-fat dairy and low in red/processed meats and saturated fats have been shown to reduce the risk of heart disease, and can induce moderate weight loss in obese patients. References: Nutrition myths and healthy dietary advice in clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/25955738)

Question 8

A 46-year-old female comes with a two-week history of intermittent epigastric abdominal pain and nausea.  The pain gets better after a light meal or a cup of milk.  The symptoms often occur at night.  She has never had these symptoms before.  She is currently not taking any medications.  Endoscopy reveals a small duodenal ulcer in the bulbar area.  The serology test for Helicobacter pylori is positive.  You decide to manage the patient with triple drug therapy.  Which of the following is the most appropriate next step to confirm the eradication of H. pylori infection in this patient?

Accepted Answer

Explanation: Temporary improvement of epigastric pain after a small meal is typical of duodenal ulcers, whereas pain exacerbation after meals tends to occur with gastric ulcers. Worsening symptoms at night is also frequent with duodenal ulcers. H. pylori infection is highly associated with duodenal ulcers, with at least 70% of patients being infected. The combination of proton pump inhibitor omeprazole, clarithromycin, and amoxicillin is the commonly used triple therapy. Confirmation of H. pylori eradication is recommended for patients with a duodenal ulcer. Either a urea breath test or fecal antigen test can be performed to confirm eradication, but neither should be performed until 4 weeks after the completion of therapy. The fecal antigen test is more readily available but may be less accurate than the urea breath test. Intake of antibiotics or bismuth can result in false-negative test results for both the urea breath and fecal antigen tests. Eradication should also be confirmed in patients with persistent dyspepsia, MALT lymphoma, or who have had resection of early gastric cancer. (Choice A) H. pylori serology tests evaluate for the presence of antibodies. However, H. pylori antibodies may be present after the infection has been eradicated and therefore they should not be used to assess for eradication for at least a year. (Choice B) Surveillance endoscopy is generally indicated to confirm the healing of gastric ulcers, which have high risk for malignancy. The risk of malignancy is extremely low with duodenal ulcers and no surveillance endoscopy is needed. Even so, endoscopy would not directly confirm H. pylori eradication. (Choice C) H. pylori bacteria is not typically present in the bloodstream of infected patients, and therefore blood culture should not be used to evaluate for eradication. (Choice D) Urea breath testing can be used at least 4 weeks after the completion of therapy. 1 week is too soon and may result in a false positive test. Educational objective: Confirmation of H. pylori eradication is recommended for patients with ulcers or ongoing dyspepsia. Either urea breath or fecal antigen testing can be used after 4 weeks to confirm H. pylori eradication. H. pylori serology should not be used since it may remain positive a year or more after eradication. References: A rapid lateral flow stool antigen immunoassay and (14)C-urea breath test for the diagnosis and eradication of Helicobacter pylori infection in children. (http://www.ncbi.nlm.nih.gov/pubmed/18722071) Accuracy of a new monoclonal stool antigen test in post-eradication assessment of Helicobacter pylori infection: comparison with the polyclonal stool antigen test and urea breath test. (http://www.ncbi.nlm.nih.gov/pubmed/16023902)

Question 9

A 62-year-old female is being evaluated for vague epigastric discomfort which she has had for the past two months. She denies having nausea, vomiting, diarrhea, flank pain or urinary symptoms, but says she might have lost 2-3 pounds during this time. Her past medical history is significant for hypertension. Her daily medications are hydrochlorothiazide and lisinopril. She does not use tobacco or alcohol. Her family history is significant for breast cancer in her mother at age 72. On physical examination, the patient's blood pressure is 133/87 mmHg and heart rate is 73/min. Her BMI is 22 kg/m². The remainder of the examination is unremarkable. Her laboratory test results are as follows: CT scan of the abdomen shows a 3.6 cm loculated cystic lesion in the head of the pancreas with some wall calcifications. What is the best next step in the management of this patient?

Accepted Answer

Explanation: Cystic lesions in the pancreas are usually found incidentally on abdominal imaging and are classified as pseudocysts, non-neoplastic, or neoplastic. Endoscopic ultrasound (EUS) uses ultrasound guidance of the endoscope for needle biopsy of lesions too small to be identified by CT/MRI or that are encased by vascular structures (making percutaneous biopsy difficult). EUS is most effective for biopsying lymph nodes and lesions in the pancreas, liver, adrenal gland, bile duct, peritoneal fluid, and pleural fluid. (Choice A)ERCP is indicated for evaluation of pathology in the pancreas and biliary tree, and has potential complications including pancreatitis, bleeding, perforation, and hemorrhage. Safer diagnostic modalities such as EUS are more sensitive than ERCP in evaluating pancreatic lesions. ERCP has evolved into a therapeutic procedure for choledocholithiasis, dilated common bile duct, cholangitis, and acute biliary pancreatitis. (Choice C) Serum carcinoembryonic antigen (CEA) elevation may suggest a mucinous pancreatic neoplasm but there is no direct correlation of serum CEA concentration with malignancy. A high fluid CEA concentration from a cystic lesion is also suggestive of a neoplasm. (Choice D) Pancreatic cystic neoplasms account for nearly 50% of pancreatic cysts and can be asymptomatic. Further analysis with biopsy is required to identify malignant potential. Serial CT scans in 3-6 months are used to monitor benign lesions. (Choice E) Surgery is the primary treatment for malignant lesions in the pancreas. Distal pancreatectomy is done for lesions in the tail and body of the pancreas, whereas pancreaticoduodenectomy is indicated for lesions in the head of the pancreas. Educational objective: Endoscopic ultrasound with aspiration is the best test to evaluate a pancreatic cyst to differentiate malignancy from nonmalignant causes. References: ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts (http://www.ncbi.nlm.nih.gov/pubmed/17764489)

Question 10

A 48-year-old woman comes to the office after abnormal serum liver chemistry results were found during a life insurance medical evaluation. She has no chronic medical issues and takes no medications. The patient says she has felt excessively tired lately, which she attributes to menopause. She has had no hot flashes, changes in sleep pattern, anorexia, or weight loss. The patient does not use tobacco, alcohol, or illicit drugs. She works in an accounting firm. Her father died at age 62 from an unknown liver disease. Vital signs are within normal limits. BMI is 30 kg/m². She has small bilateral xanthelasmata but no scleral icterus. The thyroid is not enlarged. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender with no hepatosplenomegaly. She has no skin rash. Current laboratory results are as follows: Abdominal ultrasonography reveals a normal-sized liver and no gallstones. Intrahepatic and common bile ducts are normal. Which of the following may be helpful to slow the progression of this patient's disease?

Accepted Answer

Explanation: Ursodeoxycholic acid can slow the progression of primary biliary cholangitis (PBC) and improve overall and transplantation-free survival. The only curative treatment is liver transplantation. PBC can recur following transplant; however, if it does recur, it tends to have slower progression. (Choices A and B) Small serial studies have shown some benefit with the use of azathioprine and corticosteroids, but controlled trials have not replicated these results. Corticosteroids are the treatment of choice for autoimmune hepatitis and acute alcoholic hepatitis. (Choice C) Methotrexate is often the treatment of choice in autoimmune diseases, including rheumatoid arthritis, and in some malignancies. Despite its autoimmune nature, PBC does not respond to treatment with methotrexate. (Choice D) Therapeutic phlebotomy is used to reduce iron overload in hemochromatosis. It does not have value in the management of PBC. Educational objective: Treatment options for active primary biliary cholangitis include ursodeoxycholic acid to slow progression and liver transplantation for cure. Corticosteroids and immunosuppressive drugs are not useful, despite the apparent autoimmune nature of the disease. References: Primary biliary cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/26364546)

Question 11

A 45-year-old man is brought to the emergency department by his wife due to progressive lethargy, confusion, and abdominal pain.  He has had no hematemesis, melena, or hematochezia.  The patient has a history of alcoholic cirrhosis.  He had a variceal hemorrhage 2 months ago and has been treated previously for hepatic encephalopathy.  The patient takes nadolol, furosemide, spironolactone, and lactulose at home.  There have been no changes in his dietary intake, and he has not used any over-the-counter medicines or herbal supplements.  He still occasionally drinks alcohol but does not use tobacco or illicit drugs.  Temperature is 38 C (100.4 F), blood pressure is 104/60 mm Hg, and pulse is 96/min.  The patient is cachectic and somnolent, and he wakes up with painful stimuli.  He has a flapping tremor of both hands, and the speech is slurred and incomprehensible.  Mucous membranes are dry, and he has scleral icterus.  Several spider angiomata are present on the upper torso.  The lungs are clear to auscultation, and heart sounds are normal with no murmur.  The abdomen is distended and tense with large abdominal wall collaterals.  There is a fluid wave and diffuse tenderness but no rebound tenderness.  Bowel sounds are decreased.  Stool occult blood is negative.  Laboratory results are as follows:

A diagnostic paracentesis is performed, and the ascitic fluid results are as follows:  
Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf51_2801_8f63_532ac53b1ac4_MD0005_00 This patient with cirrhosis, mental status changes, and diffuse abdominal pain likely has spontaneous bacterial peritonitis (SBP). SBP is often thought to occur due to bacterial translocation through the intestine. It is diagnosed through diagnostic paracentesis with either positive cultures or >250 neutrophils/mm³ in the ascitic fluid. This patient has 900 × 50% = 450 neutrophils/mm³ of ascitic fluid. With SBP in the setting of portal hypertension (eg, cirrhosis), the serum-ascites albumin gradient (SAAG) is >1.1 g/dL; in this patient, SAAG = 2.8 − 1.6 = 1.2 g/dL. Antibiotic therapy with a third-generation cephalosporin should be initiated as soon as cultures are obtained, as untreated SBP is associated with high mortality rates. SBP is also often associated with renal dysfunction (possibly exacerbated by decreased effective intravascular volume due to cirrhosis and hypoalbuminemia). IV albumin has been shown to decrease the incidence of renal failure and reduce mortality in patients with SBP. If this patient's renal function does not improve following volume expansion with albumin, treatment for hepatorenal syndrome (eg, octreotide, midodrine) may be indicated. (Choice A) Rifaxamin is a nonabsorbed oral antibiotic used for additional treatment of hepatic encephalopathy caused by bacterial overgrowth and ammonia formation in the gut. This patient's encephalopathy is more likely caused by his acute infection due to SBP, which rifaximin would not treat. (Choice B) Hypertonic (3%) sodium infusions are indicated for severe, symptomatic hyponatremia (eg, seizures). This patient has a mild hyponatremia, which is commonly noted in patients with cirrhosis who have volume overload and which does not require pharmacologic treatment. Fluid restriction would be considered after treatment of SBP and acute renal failure. His mental status deterioration is likely due to SBP. (Choice D) Large-volume paracentesis (LVP) is usually performed in patients with symptomatic ascites due to a large volume of ascitic fluid. However, in patients with SBP, antibiotic therapy takes precedence, and LVP could worsen intravascular volume depletion and exacerbate renal dysfunction. (Choice E) Transjugular intrahepatic portosystemic shunt (TIPS) procedures are performed for refractory ascites and uncontrolled variceal bleeding. Active infection is a contraindication to TIPS placement. TIPS is also associated with portosystemic encephalopathy in up to 35% of patients. Transjugular intrahepatic portosystemic shunt (TIPS) Educational objective: Spontaneous bacterial peritonitis is a serious complication of cirrhosis and is diagnosed when >250 neutrophils/mm³ are found in the peritoneal fluid. Empiric antibiotic therapy must be started immediately while waiting for the culture results, especially if there are other clinical indicators of infection. IV albumin has been associated with improved renal function and decreased mortality. References: Spontaneous bacterial peritonitis: the clinical challenge ofa leaky gut and a cirrhotic liver. (http://www.ncbi.nlm.nih.gov/pubmed/25848460) Review article: potential mechanisms of action of rifaximin in the management of hepatic encephalopathy and other complications of cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/26618922) Treatment and management of ascites and hepatorenal syndrome: an update. (http://www.ncbi.nlm.nih.gov/pubmed/25729433)

Question 12

A 38-year-old woman comes to the office for follow-up after recent hospitalization.  The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis.  She had intermittent, burning, epigastric pain over the past several months prior to hospitalization.  At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy.  The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena.  She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains.  The patient does not use tobacco, alcohol, or illicit drugs and has no allergies.  Family history is notable for gastric cancer in her father.  Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min.  Cardiopulmonary examination is normal.  The abdomen is nondistended, soft, and nontender.  Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf47_d921_8f63_f5d886cb07c4_MD0005_00 Helicobacter pylori infection is an important risk factor for the development of peptic ulcer disease (PUD), gastric cancer, and mucosa-associated lymphoid tissue lymphoma. H pylori may also have a role in the pathogenesis of nonulcer dyspepsia and gastroesophageal reflux disease. It accounts for 70%-80% of duodenal ulcers and approximately 50% of gastric ulcers, and its eradication significantly reduces the risk of recurrence of PUD. Multiple regimens have been proposed for the eradication of H pylori infection, and the preferred initial regimen depends on local antibiotic susceptibility. In regions with limited clarithromycin resistance, an acceptable initial regimen is triple therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin for 14 days. Metronidazole can be substituted for amoxicillin in patients allergic to penicillin. In areas with clarithromycin resistance >15%, initial therapy should consist of 14 days of quadruple therapy with a PPI, bismuth, and 2 antibiotics (or a PPI and 3 antibiotics). (Choice B) The addition of bismuth without antibiotics would not result in the resolution of H pylori infection, and although sucralfate appears to suppress H pylori, it does not have a specific role in its eradication. (Choices C and D) Patients with H pylori infection are at increased risk for ulcer formation in the setting of nonsteroidal anti-inflammatory drugs, and patients should be encouraged to avoid their use until the completion of treatment. However, in the absence of antibiotic therapy the infection will likely persist, placing the patient at continued risk for complications associated with H pylori. In addition, indefinite continuation of PPI therapy is not appropriate for the management of PUD as therapy is often needed for only 2 weeks and is rarely indicated for >12 weeks. (Choice E) Misoprostol is a prostaglandin that inhibits gastric acid secretion and improves mucosal defenses. It has been used to prevent ulcers associated with the use of nonsteroidal anti-inflammatory drugs, but is not routinely used for PUD associated with H pylori. Educational objective: Patients with Helicobacter pylori-associated peptic ulcer disease should receive treatment based on local antibiotic susceptibility. Acceptable first-line regimens include triple drug therapy with a proton pump inhibitor, clarithromycin, and amoxicillin, or quadruple therapy with a proton pump inhibitor, bismuth, and 2 antibiotics (or a PPI and 3 antibiotics). References: Treatment of Helicobacter pylori infection: current status and future concepts. (http://www.ncbi.nlm.nih.gov/pubmed/24833858) Eradication of Helicobacter pylori infection: which regimen first? (http://www.ncbi.nlm.nih.gov/pubmed/24574740)

Question 13

A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain.  The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement.  The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control.  He also has hypertension, which is controlled with a thiazide diuretic.  He walks 5 miles daily.  The patient has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach.  His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min.  He lies flat and motionless on the bed.  His mucous membranes are dry.  Abdominal examination shows marked tenderness on superficial palpation.  The patient does not allow any further palpation of the abdomen.  Electrocardiogram shows sinus tachycardia. 
Which of the following is the best initial test for this patient?

Accepted Answer

Explanation: 11ec2b69_bf49_ade3_8f63_894b03f5a9bb_MD0005_00 This patient's acute abdominal pain with significant tenderness and guarding is highly suggestive of bowel perforation with peritonitis. A perforated peptic ulcer is the most common etiology, and is especially likely in this patient who has a history of "burning" abdominal sensations. In contrast to patients with renal colic, who tend to writhe in pain, patients with peritonitis tend to lie flat and motionless to limit peritoneum irritation. Rupture of a hollow organ allows air into the abdomen (pneumoperitoneum); this air can often be detected by an upright chest x-ray. It is important to keep the patient in an upright position so that air within the peritoneal cavity can be visualized beneath the diaphragm. Pneumoperitoneum identification in a supine patient can be much more difficult. Given this patient's presentation, the presence of pneumoperitoneum on the chest x-ray would likely be diagnostic. If the findings of the chest x-ray are unclear, an abdominal CT scan may be useful (Choice C). (Choice A) An abdominal ultrasound is most helpful in evaluating the acute abdomen when there is concern for gallbladder disease or a ruptured abdominal aortic aneurysm. However, neither is likely in this patient. A ruptured abdominal aortic aneurysm is usually accompanied by profound hypotension. Gallbladder disease can cause acute epigastric pain, but it generally causes recurrent episodes of right upper-quadrant pain. (Choice D) Diagnostic peritoneal lavage is occasionally used to detect hemoperitoneum in patients with blunt abdominal trauma. It would not be useful in the initial evaluation of acute abdominal pain. (Choice E) Lipase is a useful marker for pancreatic disease, especially acute pancreatitis. Lactic acid is a marker for impaired tissue perfusion (seen in acute bowel infarction). Both tests may be informative, but chest and abdominal x-rays should be completed first as they may prompt emergency surgical intervention. This patient's history is more suggestive of peptic ulcer disease with perforation. Educational objective: Peritonitis from hollow viscus perforation should be suspected in patients experiencing sudden-onset abdominal pain with significant tenderness and guarding. Patients with peritonitis tend to lie still to minimize peritoneum irritation. An upright chest x-ray showing pneumoperitoneum can identify perforation. References: Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. (http://www.ncbi.nlm.nih.gov/pubmed/7785629)

Question 14

A 50-year-old male comes in to the emergency department complaining of unremitting pain in an area of his right buttock near the anus.  Although he is uncertain when the discomfort first began, he notes that the pain has increased significantly over the past 24 hours.  He finds he is unable to pass stool because of the pain.  He has not experienced symptoms like this before.  Ten years ago, he was diagnosed with diabetes mellitus.  He is currently on insulin.  He smokes half a pack of cigarettes per day but would like to quit.  He denies drinking alcohol or using recreational drugs.  His temperature is 38.1C (100.6F), blood pressure is 128/86 mm Hg, and pulse is 90/min.  There is a hot, tender, mass located between the anus and the left ischial tuberosity.  The mass fluctuates upon palpation.
What is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: Anal abscesses arise when one or more of the several glands that encircle the anus become blocked and the bacteria within grow unchecked. Patients with anal abscesses typically present with severe, constant pain that may be accompanied by fever or malaise. Physical examination commonly reveals erythematous, indurated skin or a fluctuant mass over the perianal or ischiorectal space. Purulent material may be seen if the abscess has begun to drain spontaneously. It is widely agreed that the most important aspect of treatment is prompt incision and drainage of the abscess (Choice E). Perianal and small ischiorectal abscesses are often drained in the office, but larger ischiorectal abscesses typically require surgical intervention. Increasing the insulin dose (Choice A) or prescribing bupropion (Choice B)are inappropriate because they do not treat the abscess. However, strict control of diabetes is very important in reducing the complications associated with wound healing. Oral antibiotics (Choice C) should also be prescribed to those patients who have diabetes mellitus, immunosuppression, extensive cellulitis, or valvular heart disease. However, antibiotics are an adjunct to and not a substitute for incision and drainage of the abscess. Admission to the hospital for intravenous antibiotics (Choice D) is unnecessary in a patient with localized infection. Educational Objective: Anal abscesses should be treated with prompt incision and drainage. Antibiotics should also be prescribed in those patients who have diabetes mellitus, immunosuppression, extensive cellulitis, or valvular heart disease.

Question 15

A 50-year-old male comes in to the emergency department complaining of unremitting pain in an area of his right buttock near the anus.  Although he is uncertain when the discomfort first began, he notes that the pain has increased significantly over the past 24 hours.  He finds he is unable to pass stool because of the pain.  He has not experienced symptoms like this before.  Ten years ago, he was diagnosed with diabetes mellitus.  He is currently on insulin.  He smokes half a pack of cigarettes per day but would like to quit.  He denies drinking alcohol or using recreational drugs.  His temperature is 38.1C (100.6F), blood pressure is 128/86 mm Hg, and pulse is 90/min.  There is a hot, tender, mass located between the anus and the left ischial tuberosity.  The mass fluctuates upon palpation.
The patient is treated appropriately.  To minimize risk of complications, he is advised to promptly schedule a follow-up visit with his primary care physician.  Patients with anal abscesses are at greatest risk of developing which of the following conditions?

Accepted Answer

Explanation: While an anal abscess is an infection within one or more of the anal spaces, an anal fistula (Choice B) is a tunneling between the anus or rectum and another epithelial lined space (eg, the skin overlying the drainage site). Fifty percent of patients with anal abscesses will go on to develop a chronic fistula from the involved anal gland to the overlying skin. Patients with fistulas typically present with an anal abscess that persists after incision and drainage, or with a pustule-like lesion in the perianal or ischiorectal area that continually drains. Surgical repair is usually necessary to eliminate the fistula while preserving fecal continence. Soft tissue infection (Choice A) is rarely a concern when the initial mass has been properly incised and drained. Fecal impaction (Choice C) could be of concern in a patient with an anal abscess who had been unable to pass stool for a long period before presenting for treatment. It does not commonly occur subsequent to treatment of anal abscess, however. Incontinence (Choice D) and hemorrhoids (Choice E) are not commonly associated with anal abscesses. Educational Objective: Fifty percent of patients with anal abscesses will go on to develop a chronic fistula from the involved anal gland to the overlying skin. Such fistulas require surgical repair.

Question 16

A 33-year-old woman comes to the office due to fatigue over the last 6 months.  She attributes this to her stressful work environment but still wants to be "checked up."  The patient has no significant medical history, and her only medication is an oral contraceptive.  She has had no abdominal pain, back pain, vomiting, diarrhea, or leg swelling.  The patient drinks 1 or 2 glasses of wine on most days of the week but does not use tobacco or illicit drugs.  Vital signs are normal.  Today, her weight is 64 kg (141 lbs), and the patient reports she weighed 68 kg (150 lbs) 3 months ago.  The liver edge is palpable 2 cm below the right costal margin.  Laboratory results are as follows:  Abdominal ultrasound confirms mild hepatomegaly; the pancreas is not well visualized.  Chest x-ray reveals bilateral hilar fullness but no parenchymal opacities.  Which of the following is the most likely cause of the abnormal liver function studies in this patient?

Accepted Answer

Explanation: This patient has an enlarged liver with elevations of alkaline phosphatase and gamma-glutamyl transpeptidase (suggesting liver rather than bone origin of the alkaline phosphatase elevation); her other hepatic markers are essentially normal. This pattern can be seen with infiltrative liver diseases. The patient also has mild hypercalcemia and signs of hilar adenopathy on chest x-ray. Together, these findings are consistent with hepatic sarcoidosis. Liver involvement occurs in 50%-65% of patients with sarcoidosis, although most are asymptomatic or have nonspecific symptoms (eg, weight loss). More severe disease can lead to jaundice, abdominal pain, cirrhosis, and manifestations of portal hypertension. Liver involvement in sarcoidosis is characterized by infiltration with noncaseating granulomas. The lesions are visible on CT scan and MRI, but biopsy is recommended to rule out other granulomatous diseases (eg, tuberculosis) and metastatic malignancy. Initial treatment of symptomatic hepatic sarcoidosis is with systemic glucocorticoids (eg, prednisone). (Choices A and C) Alcoholic liver disease and hepatic steatosis typically display a hepatocellular injury pattern (ie, elevations in transaminases > elevation in alkaline phosphatase). This patient's moderate alcohol intake is unlikely to lead to significant hepatic injury, and steatosis is often identifiable by increased hepatic echogenicity on ultrasound. Furthermore, this patient's hypercalcemia and x-ray findings are more consistent with sarcoidosis. (Choice D) Older formulations of oral contraceptives were associated with a significant risk of hepatic injury, but risk with contemporary contraceptives is low. When contraceptive-induced cholestatic liver disease does occur, bilirubin is typically elevated. (Choice E) Although hepatomegaly with elevated alkaline phosphatase can be seen with pancreatic cancer, this patient has no risk factors for pancreatic cancer (eg, smoking, obesity, chronic pancreatitis) and is relatively young. In addition, many patients with symptomatic pancreatic cancer have jaundice and abdominal pain, mass lesions are usually visible on ultrasound, and bilirubin is commonly (although not always) elevated. Educational objective: An isolated elevation of alkaline phosphatase can be seen in infiltrative liver diseases (eg, granulomatous disease, infection, certain medications). Additional evidence of granulomatous disease, such as bilateral hilar adenopathy in sarcoidosis, may be helpful in making the diagnosis. References: Clinical presentation and protocol for management of hepatic sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/25473783) Hepatic sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/26357609)

Question 17

A 16-year-old boy is brought to the emergency department due to severe abdominal pain.  He was playing soccer an hour ago when he suddenly developed left upper quadrant pain.  The pain is sharp and constant and makes it difficult for him to take deep breaths.  The patient has been otherwise healthy except for several days of fever, sore throat, and fatigue 2 weeks ago.  He takes no daily medications, and immunizations are up to date.  Temperature is 37.2 C (99 F), blood pressure is 86/58 mm Hg, pulse is 122/min, and respirations are 24/min.  Pulse oximetry is 96% on room air.  Physical examination shows an uncomfortable-appearing adolescent.  The lungs are clear to auscultation, and heart sounds are normal.  The abdomen is soft, with left upper quadrant rebound tenderness.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient's sudden, severe left upper quadrant pain and signs of hypovolemic shock (eg, hypotension, tachycardia) 2 weeks after an episode of pharyngitis are most concerning for spontaneous splenic rupture, a life-threatening condition that can occur in the setting of postviral splenomegaly. Viral infections, especially Epstein-Barr virus (ie, infectious mononucleosis) and cytomegalovirus, are among the most common causes of splenomegaly in children and adolescents. Splenomegaly occurs due to lymphocytic infiltration into the spleen; the infiltration disrupts the spleen's fibrous support system and stretches the spleen's capsule, increasing the risk of splenic rupture. Affected patients are advised to refrain from sports for several weeks; however, even when appropriate precautions are taken, rupture can be spontaneous and atraumatic. Management of splenic rupture begins with resuscitation and stabilization of the patient. Hypovolemic shock, as seen in this patient, requires immediate volume resuscitation (eg, crystalloid, blood products). Once the patient is hemodynamically stable (eg, systolic blood pressure >90 mm Hg), a CT scan of the abdomen with intravenous contrast may be performed to assess the severity of splenic injury and determine whether bleeding is ongoing (ie, contrast extravasation) (Choice A). Patients with spontaneous splenic rupture should ideally be managed nonoperatively (eg, observation with serial hemoglobin measurement, embolization) to preserve splenic function. However, patients who remain hemodynamically unstable despite adequate resuscitation (eg, due to severe ongoing hemorrhage) may require exploratory laparotomy and splenectomy (Choice C). (Choice B) Diagnostic peritoneal lavage (DPL) was historically used to evaluate for intraabdominal hemorrhage in certain hemodynamically unstable patients. However, DPL is more invasive and less informative than a CT scan (eg, DPL cannot identify the specific bleeding source or differentiate ongoing vs recent bleeding), and this patient may be stable enough to undergo CT scan following volume resuscitation. Diagnostic peritoneal lavage (Choice D) Monospot testing (ie, heterophile antibodies) can be used to confirm the diagnosis of infectious mononucleosis but would not alter the immediate management of this patient with splenic rupture and subsequent hypovolemic shock. Educational objective: Viral infection (eg, Epstein-Barr virus) can cause splenomegaly, which increases the risk of splenic rupture. Splenic rupture can cause intraabdominal hemorrhage and hypovolemic shock; volume resuscitation is the first step in management. References: Splenic rupture in infectious mononucleosis: a systematic review of published case reports. (http://www.ncbi.nlm.nih.gov/pubmed/26563483) Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/23222107)

Question 18

A 35-year-old Caucasian man is seen in the emergency department for the evaluation of fever, weakness, generalized abdominal pain, and bloody stools. He denies any vomiting but his appetite has been poor. He was diagnosed with ulcerative colitis six months ago and he has been on and off sulfasalazine treatment. His flare-up started four days ago, and rapidly progressed to his having multiple bloody bowel movements and severe abdominal pain. He is a current smoker, but he has been trying to quit. He has not been taking any antibiotics recently and he denies recent travel. His temperature is 100 F (37.8 C), heart rate is 124/min, and blood pressure is 106/72 mmHg. His mucous membranes appear dry. Bowel sounds are hypoactive. There is generalized abdominal tenderness and distension without any rebound tenderness or guarding. The percussion note is tympanitic. Item 1 of 2 Which of the following is the best initial step for managing this patient?

Accepted Answer

Explanation: This patient is clearly in the midst of a severe ulcerative colitis flare as evidenced by his multiple bloody bowel movements and severe abdominal pain, particularly given the history of only sporadic use of sulfasalazine. However, this patient has a somewhat toxic appearance, given his fever and tachycardia. The tympany to percussion elicited on physical exam may be secondary to bowel dilatation. This conglomeration of findings is concerning for possible toxic megacolon, and an abdominal x-ray should be performed to evaluate for colonic dilatation. Findings of peritonitis may be absent in toxic megacolon, so the lack of rebound tenderness or guarding on this patient's exam does not exclude the diagnosis. The transverse colon usually shows the most prominent dilatation among the colonic segments in cases of toxic megacolon, generally measuring at least 6 cm in diameter. Multiple air-fluid levels are commonly seen, along with loss of the normal haustral pattern and possibly mucosal ulcerations. Pneumoperitoneum may be present if the toxic megacolon has progressed to perforation. Patients with inflammatory bowel disease are most at risk of developing toxic megacolon early in the course of their disease, possibly even at initial presentation. (Choice A)Abdominal x-rays typically demonstrate bowel abnormalities better than ultrasound. Furthermore, x-rays tend to be more readily available and less operator-dependent. (Choice C)Full colonoscopy should be avoided in patients with toxic megacolon because there is a significant risk of perforation. (Choice D) Toxic megacolon can occur secondary to amebiasis or bacterial infections such as shigella, salmonella, or campylobacter. However, the patient's underlying inflammatory bowel disease would be the most likely cause of toxic megacolon here, and the results of stool studies would not be available readily enough to affect his acute management anyway. Educational objective: Toxic megacolon should be suspected in patients who have a history of severe colitis, particularly secondary to inflammatory bowel disease, who develop toxic signs and have a distended, tympanitic abdomen. Abdominal plain films are helpful for making the diagnosis. CT scan is best utilized for early detection of complications. References: Toxic megacolon in ulcerative colitis. Early diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/3091613) Toxic megacolon: role of CT in evaluation and detection of complications. (http://www.ncbi.nlm.nih.gov/pubmed/11682295) A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/14638335)

Question 19

A 54-year-old man comes to the emergency department with a 2-week history of exertional dyspnea and nonproductive cough.  He has no known medical problems and does not use any medications.  The patient has a long history of alcohol abuse and currently consumes a half-pint of vodka a day, although he is "trying to cut down."  He smokes a pack of cigarettes a day and does not use illicit drugs.  Temperature is 36.8 C (98.2 F), blood pressure is 123/78 mm Hg, heart rate is 114/min and regular, and oxygen saturation is 96% on room air.  Lung examination shows decreased breath sounds on the right with dullness to percussion.  The patient's abdomen is distended with flank dullness and a positive fluid shift sign.  There is 1+ bilateral pitting lower-extremity edema.  His hands are flushed over the palmar aspects, and small dilated blood vessels are visible over his upper chest.  Laboratory results are as follows:  Chest x-ray demonstrates a large right-sided pleural effusion.  A thoracentesis is performed, and 1.2 L of straw-colored fluid is removed.  The fluid shows a protein concentration of 1.2 g/dL and lactate dehydrogenase concentration of 60 U/L.  Gram stain and cultures are negative.  The patient's symptoms improve after the procedure, and counseling regarding cessation of alcohol and tobacco use is provided.  Which of the following is the best next step in management of this patient's pleural effusion?

Accepted Answer

Explanation: This patient's pleural effusion is consistent with hepatic hydrothorax. Patients with decompensated cirrhosis (evidenced by prolonged INR, lower-extremity edema, and abdominal distension with shifting dullness in the setting of chronic alcohol abuse) can develop pleural effusion due to passage of peritoneal ascites through the diaphragm. The effusion usually occurs on the right side, presumably because the right hemidiaphragm is thinner and more likely to have porous defects than the left hemidiaphragm. In addition, the effusion is typically transudative based on Light criteria, with fluid to serum total protein ratio <0.5, fluid to serum lactate dehydrogenase (LDH) ratio <0.6, and fluid LDH <2/3 the upper limit of normal for serum LDH. Light criteriasodium restriction in combination with loop (eg, furosemide) and potassium-sparing (eg, spironolactone) diuretics. Presence of hepatic hydrothorax signals advanced liver disease and should prompt consideration for liver transplantation. (Choice A) Chemical pleurodesis involves instillation of an irritant (eg, talc) into the pleural space to stimulate inflammation and fibrosis of the visceral and parietal pleural to fuse the 2 layers together. It is often effective in preventing recurrent exudative (eg, malignant) pleural effusion, but is typically ineffective in preventing recurrent transudative pleural effusion such as occurs in hepatic hydrothorax. (Choice C) Placement of an indwelling pleural catheter is a poor treatment option for hepatic hydrothorax because it results in excessive volume and protein loss that cannot be compensated for with intravenous albumin replacement (as is done with periodic therapeutic paracentesis for ascites). (Choice D) Thorascopic repair of diaphragmatic defects may correct hepatic hydrothorax in some patients, but it is highly invasive and should not be considered unless other therapies have failed. (Choice E) Transjugular intrahepatic portosystemic shunt (TIPS) placement creates a fistula between the portal vein and hepatic veins, which decreases hydrostatic pressure in the portal venous system. It is often effective in relieving ascites and hepatic hydrothorax, but it is associated with risks (eg, hepatic encephalopathy, hepatic decompensation) and is not pursued until medication therapy has failed. Educational objective: Hepatic hydrothorax usually presents as a right-sided transudative pleural effusion in patients with decompensated cirrhosis and ascites. The initial treatment is with sodium restriction and diuretics; transjugular intrahepatic portosystemic shunt placement may be pursued in refractory cases. References: Hepatic hydrothorax. (http://www.ncbi.nlm.nih.gov/pubmed/22447255) The Light criteria: the beginning and why they are useful 40 years later. (http://www.ncbi.nlm.nih.gov/pubmed/23411053)

Question 20

A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain.  The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement.  The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control.  He also has hypertension, which is controlled with a thiazide diuretic.  He walks 5 miles daily.  The patient has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach.  His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min.  He lies flat and motionless on the bed.  His mucous membranes are dry.  Abdominal examination shows marked tenderness on superficial palpation.  The patient does not allow any further palpation of the abdomen.  Electrocardiogram shows sinus tachycardia. Further evaluation shows pneumoperitoneum on the upright chest x-ray.  The patient's white blood cell count is 11,300/μL, creatinine is 1.1 mg/dL, and lactic acid level is 2.1 mg/dL.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: Peptic ulcer perforation is a potentially fatal complication of peptic ulcer disease. If left untreated, the patient can have a rapid clinical deterioration leading to death within 12-24 hours. However, early diagnosis and treatment generally lead to excellent prognosis and most patients recover fully. Emergency surgery (open or laparoscopic) is indicated in all patients with perforated peptic ulcer. In preparation for surgery, patients with a perforated viscus should receive fluid resuscitation and broad-spectrum intravenous antibiotics with good coverage for Gram-negative organisms. Intravenous proton-pump inhibitor therapy is also suggested for patients with perforated peptic ulcer. (Choice A) Barium esophagram is indicated for the evaluation of dysphagia (eg, patients with suspected hiatal hernia, achalasia, esophageal webs). It is contraindicated in patients with suspected perforation. (Choice C) Non-contrast chest CT is useful for evaluating disorders of the pulmonary parenchyma or traumatic chest injuries. It would not be recommended in a patient with a known perforated viscus. (Choice D) Octreotide infusion is most commonly used for bleeding esophageal varices. It would not be helpful in the setting of perforation. (Choice E) Upper gastrointestinal endoscopy is used in the evaluation of gastritis and peptic ulcer disease. However, surgery is needed in the setting of perforation. Educational objective: In preparation for expedited surgical intervention, patients with suspected or confirmed peptic ulcer perforation should receive intravenous fluid resuscitation, broad-spectrum intravenous antibiotics, and intravenous proton-pump inhibitor therapy. References: Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. (http://www.ncbi.nlm.nih.gov/pubmed/24338777)

Exam 1: Advanced Clinical Medicine