A 52-year-old woman presents for her annual physical examination. Her past medical history is significant for hypertension and diabetes mellitus type 2. She endorses smoking two packs of cigarettes per day for the past 18 years. Her vital signs are stable and her physical examination is unremarkable. She receives a colonoscopy that demonstrates multiple diverticular outpouchings. The patient is very concerned and has plenty of questions about the conditions.
Which of the following recommendations should be offered to this patient in the setting of her newly diagnosed condition?
Increase daily fiber intake. This patient has multiple diverticula on colonoscopy. Her diverticulosis is currently asymptomatic, but symptomatic diverticulosis can present with abdominal pain, constipation, and painless rectal bleeding. The only recommendation at this stage of the patient’s diverticular disease is dietary modification, specifically to increase her daily fiber intake. This generates bulky stools that decrease the likelihood of developing more diverticula. (A) Smoking cessation should always be recommended to any patient. However, research has not shown that this improves diverticulosis. (B) Antibiotics are the treatment of choice in diverticulitis that is uncomplicated; however, diverticulitis is associated with fever and leukocytosis, neither of which this patient has. (C) Surgery is recommended in complications of diverticular disease, including bleeding or perforation. This patient has asymptomatic diverticulosis and should not be offered surgery.
A 43-year-old woman presents with jaundice, right upper quadrant pain, and bothersome pruritus for the past 6 months. Her past medical history is significant for asthma and she only takes inhaled albuterol as needed. Laboratory testing reveals positive anti-mitochondrial antibodies and the patient is diagnosed with primary biliary cirrhosis.
Which of the following is the best initial treatment for this patient?
Ursodeoxycholic acid. This patient has been diagnosed with primary biliary cirrhosis (PBC) as indicated by positive anti-mitochondrial antibodies, jaundice, right upper quadrant pain, and pruritus. PBC is a chronic autoimmune disease of the liver that is associated with intrahepatic duct destruction and cholestasis. The initial drug of choice is ursodeoxycholic acid because it not only reduces cholestasis and improves symptoms but it also has been shown to slow disease progression and therefore increases the time before a liver transplant is needed. (A) Liver transplantation is the only curative treatment in PBC; however, this is only an option once the disease has evolved to a cirrhotic state. (B, C) Neither high-dose steroids nor biliary stent placement has been shown to be effective in the treatment of PBC mainly because biliary stents do not affect intrahepatic bile ducts that are involved in the disease.
A 37-year-old man presents with abdominal pain, mild nausea, and “dark stools.” The patient reports that over the past 6 months he has noticed abdominal pain that is only alleviated by eating. He has gained 6.8 kg (15 lb) during this time period. The patient denies alcohol or illicit drug use, but does report headaches for which he takes over-thecounter acetaminophen. Physical examination is unremarkable; however, fecal occult blood test (FOBT) is positive.
Which of the following is the most likely diagnosis?
Peptic ulcer disease. This patient is presenting with melena (dark tarry stools) and abdominal pain. Given the patient’s history of alleviation of the abdominal pain with food, it is likely that his symptoms and GI bleeding are secondary to peptic ulcer disease (PUD), specifically duodenal ulcers. Duodenal ulcers are associated with weight gain and gastric ulcers are associated with weight loss. Furthermore, duodenal ulcers and gastric ulcers are both most commonly caused by H. pylori infections, but duodenal ulcers are almost entirely (greater than 95%) to be linked to H. pylori. Of note, PUD is the most common cause of upper GI bleeding. Diagnosis requires upper endoscopy. (B) Diverticulosis is usually asymptomatic; however, if it is associated with GI bleeding, it is typically bright red bleeding. (C) Colon cancer should always be considered, but this is a young patient and he does not present with weight loss. Similar to diverticulosis, colon cancer would present with bright red blood per rectum, unless it is a slow, right-sided GI bleed, which can be maroon colored or melenotic. (D) Mesenteric ischemia is accompanied by abdominal pain that is worse with eating. However, this patient’s abdominal pain improves with eating (making duodenal peptic ulcer disease the most likely diagnosis).
A 47-year-old man with a history of chronic viral hepatitis C infection is brought in by his partner for vomiting blood over the past 2 hours. He is unarousable on physical examination and he has a temperature of 36.8°C, blood pressure of 124/90 mmHg, heart rate of 96 beats per minute, and a respiratory rate of 18 breaths per minute. While being examined, the patient begins to vomit a large amount of blood.
In addition to normal saline administration, which of the following is the best next step in management of this patient?
Endotracheal intubation. The patient in this question is presenting with unrelenting hematemesis, and given his history of chronic hepatitis C infection, the bleeding is likely secondary to esophageal variceal hemorrhage. This patient is hemodynamically unstable and is continuing to vomit blood. In this situation, the ABCs take precedence; since he has an elevated risk of aspiration from a depressed level of consciousness and ongoing hematemesis, the critical next step to perform (in addition to ample fluid administration) is endotracheal intubation to secure his airway (which is already compromised). (A) An upper GI endoscopy is definitely warranted in this case to locate and stop the variceal bleeding; however, this should only be performed after the patient is stabilized. (B) Abdominal CT scan is not indicated with GI bleeding. (D) Octreotide (a somatostatin analog) is an inhibitory hormone that leads to vasoconstriction of portal circulation and therefore would be beneficial in this patient. However, stabilization and securing an airway takes precedence in management.
A 27-year-old woman presents with abdominal pain, bloody diarrhea, and nausea for the past 6 weeks. She has lost 4.5 kg (10 lb) over this time period. She has an insignificant past medical history and denies alcohol or illicit drug use. She has a temperature of 38.7°C, blood pressure of 80/48 mmHg, heart rate of 124 beats per minute, and a respiratory rate of 18 breaths per minute. Physical examination demonstrates abdominal distention and tenderness to palpation in all four quadrants. The patient has diminished bowel sounds. Rectal examination is performed and gross blood mixed with mucous is appreciated. The patient’s leukocyte count is severely elevated at 28,000/mm3 .
Which of the following is the initial test of choice in the diagnostic workup of this patient’s suspected condition?
Abdominal x-ray. This patient is demonstrating signs and symptoms consistent with inflammatory bowel disease, likely ulcerative colitis (abdominal pain, bloody diarrhea, nausea). She is hemodynamically unstable and has hypotension, tachycardia, leukocytosis, and fever. This presentation is suspicious for toxic megacolon, which is associated with a high mortality rate. To diagnose toxic megacolon, there must be hemodynamic instability, leukocytosis and/or anemia, and signs of colonic distention on abdominal x-ray (colon must be dilated >6 cm). (A, C, D) These are not helpful in diagnosing toxic megacolon. In fact, colonoscopy can be harmful due to its risk for colonic perforation.
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