A 53-year-old man with a history of peptic ulcer disease and hypertension presents with hematemesis. A nasogastric tube is placed and a large amount of coffee ground material is lavaged. The patient has a temperature of 37°C, blood pressure of 88/42 mmHg, heart rate of 112 beats per minute, respiratory rate of 20 breaths per minute, and oxygen saturation of 97% on room air. Physical examination reveals delayed capillary refill.
Which of the following is the best next step in management of this patient?
Administration of fluids. This is a common question on the Internal Medicine shelf examination that emphasizes the importance of airway, breathing, and circulation (ABCs) in the management of patients (regardless of the underlying disorder). This patient presents with hypotension and delayed capillary refill, indicating that there is compromise of his circulation. The best next step in management of circulatory compromise (in this case from an upper GI bleed) is fluid resuscitation. After the patient is hemodynamically stable, treatment for the actual underlying condition can be initiated. (A, C, D) All these answer choices address the underlying cause of the upper GI bleeding (likely peptic ulcer bleeding); however, the patient must be stabilized before these modalities are pursued.
A 57-year-old woman with a history of hypertension and diabetes mellitus type 2 presents with dysphagia to both solids and liquids. She reports that starting 5 months ago she had difficulty swallowing solids only, but it has progressed to difficulty swallowing liquids as well. She endorses a 5.44-kg (12-lb) weight loss as well as heartburn during this time frame. Physical examination is unremarkable. A barium swallow study is ordered (Figure below) and manometry confirms the diagnosis.
Endoscopic evaluation. The patient in this question is presenting with signs and symptoms (dysphagia to solids and liquids, weight loss, heartburn) consistent with a diagnosis of achalasia, which is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the LES. If there is dysphagia to both solids and liquids, then it is likely a motility problem whereas if the dysphagia started to solids and progressed to liquids, then it is likely mechanical obstruction. The result is a loss of peristalsis in the distal esophagus and loss of appropriate LES relaxation during swallowing. Although diagnosis is suspected clinically, a barium swallow is the first step in management and demonstrates a “bird-beak” at the gastroesophageal junction. Manometry will further confirm the diagnosis with elevated resting LES pressure and incomplete LES relaxation after swallowing. It is absolutely critical that esophageal cancer is ruled out first, though it can produce identical symptoms to achalasia (pseudoachalasia). Therefore, endoscopy must be performed to rule out esophageal cancer at the gastroesophageal junction before proceeding with treatment. (A) Good surgical candidates are generally recommended for surgical myotomy as the definitive treatment for achalasia. (B) Poor surgical candidates can proceed with medical therapy, such as calcium channel blockers and botulinum toxin injection. (D) A proton pump inhibitor might improve the patient’s heartburn, but will not resolve the dysphagia.
A 49-year-old morbidly obese man with a 40 pack-year history of smoking presents with worsening heartburn. The patient reports that he has had heartburn for 3 years, but it has worsened over the past 3 months. Over-the-counter medications do not ameliorate his symptoms anymore. Upper endoscopy is performed and a hiatal hernia is diagnosed. The patient adamantly refuses any medical or surgical intervention.
Which of the following is he at risk for developing?
Adenocarcinoma of the esophagus. The patient in this question is presenting with signs and symptoms of gastroesophageal reflux disease (GERD). His chronic GERD is likely the result of the hiatal hernia. Chronic GERD causes the normal squamous epithelium in the lower end of the esophagus to be replaced with columnar epithelium (Barrett esophagus). Barrett esophagus is a major risk factor for developing esophageal cancer, specifically the adenocarcinoma type. (A) SCC of the esophagus tends to occur in the upper two-thirds of the esophagus with risk factors including smoking, alcohol, hot food and beverages, vitamin deficiencies, and viral infections. Barrett esophagus is not a risk factor for SCC of the esophagus. (C) Esophageal perforation is typically iatrogenic, usually due to medical instrumentation. (D) Mallory–Weiss tears cause bleeding in the mucosa at the gastroesophageal junction and are usually caused by severe alcoholism and retching.
A 61-year-old man presents with abdominal pain, vomiting, jaundice, and a weight loss of 9.1 kg (20 lb) over the last 4 months. His abdominal pain is localized to the right upper quadrant and radiates to the back. The patient has a temperature of 37°C, blood pressure of 120/80 mmHg, heart rate of 106 beats per minute, and a respiratory rate of 22 breaths per minute. Physical examination reveals a 6-cm palpable mass below the right costal margin. Ultrasound confirms an enlarged gallbladder. Laboratory results reveal the following.
Which of the following is the best next step in the diagnostic workup of this patient?
Abdominal CT scan. The patient in this question is presenting with an enlarged palpable gallbladder (Courvoisier sign) and signs, symptoms, and laboratory values consistent with biliary obstruction (elevated direct bilirubin, elevated alkaline phosphatase, and jaundice). These clinical and laboratory findings support the most likely diagnosis as pancreatic cancer (specifically carcinoma of the head of the pancreas). The best imaging modality with suspected pancreatic carcinoma is the abdominal CT scan. (B) Laparoscopy is not indicated with pancreatic cancer. (C) ERCP might eventually be warranted, but is not the best initial test. (D) Abdominal films are helpful in patients with suspected cholelithiasis (gallstones) or to detect calcifications from chronic pancreatitis.
A 42-year-old woman presents with unrelenting abdominal pain for the past 2 days. The pain is epigastric in location and occasionally radiates to her back. She has vomited numerous times and cannot tolerate food or liquids. She has no significant past medical history, but does endorse drinking two bottles of wine per day for the last 5 years. She has a temperature of 37°C, blood pressure of 98/64 mmHg, heart rate of 110 beats per minute, and a respiratory rate of 20 breaths per minute. Physical examination reveals epigastric tenderness to deep palpation without guarding or rebound. Amylase and lipase levels are elevated more than four times that of the upper limit of normal.
Which of the following complications is NOT associated with this condition?
Mesenteric ischemia. The patient in this question is presenting with classical symptoms of acute pancreatitis (nausea, vomiting, epigastric pain radiating to the back), in addition to laboratory values consistent with acute pancreatitis (elevated amylase and lipase). Alcohol use and gallstones are the most common causes of acute pancreatitis (this patient endorses a history of alcoholism). This question tests the student’s ability to recall the complications associated with acute pancreatitis. Complications typically seen with acute pancreatitis include pleural effusion, renal failure, ileus, and respiratory distress. Mesenteric ischemia is not associated with acute pancreatitis.
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