A 31-year-old woman comes to the office after 3 months of continuous burning upper abdominal pain that is only partially relieved by over-the-counter ranitidine or antacids. She also has experienced recent-onset constipation and excess urination. The patient reports no weight loss or decreased appetite. Her menstrual periods are regular. The patient's father has a history of "many stomach ulcers and multiple kidney stones." Her temperature is 37.1 C (98.8 F), blood pressure is 130/85 mm Hg, pulse is 78/min, and respirations are 14/min. Abdominal examination shows normal bowel sounds, tenderness in the epigastric region, and no palpable masses. Her stools are positive for occult blood. Laboratory results are as follows: Additional evaluation is most likely to reveal which of the following?

Question

A 31-year-old woman comes to the office after 3 months of continuous burning upper abdominal pain that is only partially relieved by over-the-counter ranitidine or antacids.  She also has experienced recent-onset constipation and excess urination.  The patient reports no weight loss or decreased appetite.  Her menstrual periods are regular.  The patient's father has a history of "many stomach ulcers and multiple kidney stones."  Her temperature is 37.1 C (98.8 F), blood pressure is 130/85 mm Hg, pulse is 78/min, and respirations are 14/min.  Abdominal examination shows normal bowel sounds, tenderness in the epigastric region, and no palpable masses.  Her stools are positive for occult blood.  Laboratory results are as follows:  Additional evaluation is most likely to reveal which of the following?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d3cb_8561_bc81_e1b5f0d27eed_MD0003_00 This patient most likely has type 1 multiple endocrine neoplasia syndrome (MEN1), an autosomal dominant condition characterized by 3 primary tumor types ("the 3 Ps"): Parathyroid adenomas/hyperplasia. Constipation, polyuria, and possibly abdominal pain in the setting of a calcium level of 11.4 mg/dL suggest symptomatic hypercalcemia, likely from primary hyperparathyroidism (PHPT). PHPT is present in >90% of patients with MEN1, usually occurs by age 40, and results from multiglandular parathyroid adenomas or parathyroid hyperplasia. Gastrointestinal/pancreatic endocrine tumors (eg, gastrinomas). Burning upper abdominal pain that is only partially responsive to ranitidine and antacids and associated with occult gastrointestinal bleeding is concerning for Zollinger-Ellison syndrome, characterized by severe and refractory peptic ulcer disease due to gastrin-producing tumors (gastrinomas). Pituitary adenomas. The patient's father probably also had MEN1 given his history of kidney stones (likely due to hypercalcemia) and recurrent peptic ulcers. (Choice A) Primary adrenal insufficiency presents with fatigue and weight loss. Typical clinical findings include hypotension, hyperpigmentation, and hyperkalemia. (Choice B) Glucagonoma is a less common tumor in MEN1 and is characterized by hyperglycemia, necrolytic migratory erythema, weight loss, and anemia. Glucagonoma (Choice C) Medullary thyroid cancer is a component of MEN2 and typically presents as a thyroid nodule. (Choice D) Gastric cancer can cause abdominal pain with gastrointestinal ulceration and bleeding. However, it is commonly associated with weight loss, early satiety, and dysphagia; would be rare at this patient's age; and is less likely to explain hypercalcemia. (Choice E) Milk-alkali syndrome is characterized by hypercalcemia, renal insufficiency, and metabolic alkalosis. This patient has a normal serum creatinine and bicarbonate. (Choice G) Sarcoidosis causes hypercalcemia due to increased conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D. However, whereas pulmonary symptoms are common, gastrointestinal manifestations (eg, epigastric pain) are rare. Sarcoidosis also would not explain this patient's family history of recurrent kidney stones and peptic ulcers. (Choice H) A toxic thyroid adenoma could cause hypercalcemia due to increased bone turnover. However, this patient has no other manifestations of thyrotoxicosis (eg, weight loss, tachycardia). Educational objective: Type 1 multiple endocrine neoplasia is characterized by primary hyperparathyroidism, pituitary tumors, and gastrointestinal/pancreatic endocrine tumors (eg, gastrinomas). Common complications include symptomatic hypercalcemia and recurrent peptic ulcer. References: Multiple endocrine neoplasia type 1. (http://www.ncbi.nlm.nih.gov/pubmed/17014705)

A 31-Year-Old Woman Comes to the Office After 3 Months