A 62-year-old woman presents with nausea, vomiting, and epigastric pain. She has a history of chronic pancreatitis and consumes three to four glasses of wine per day. She endorses a 9.1-kg (20-lb) weight loss over the last 4 months and reports increased flatulence and “floating stools.” Physical examination reveals nonspecific abdominal pain to deep palpation in the epigastric region in addition to the finding seen in the photo below.
Which of the following is the most appropriate imaging modality for this patient?
Abdominal CT scan. The patient in this question is presenting with signs and symptoms suspicious for pancreatic cancer. The patient’s history of chronic pancreatitis, scleral icterus, and weight loss is consistent with pancreatic cancer. Several of the patient’s symptoms can be explained by chronic pancreatitis, but the jaundice that is present makes pancreatic cancer the likely diagnosis. CT scan of the abdomen is the best imaging modality for patients with suspected pancreatic cancer. (A) Abdominal upright x-rays are helpful in chronic pancreatitis for detecting calcifications. They are not useful in diagnosing pancreatic cancer. (B) ERCP is useful in cases where CT scan is unable to reveal a tumor within the pancreas. However, this is not the initial imaging modality of choice. (D) Abdominal MRI is a good option for patients with pancreatic duct obstruction who are unable to undergo ERCP. However, CT scan is still the best, and most sensitive, imaging modality for detecting pancreatic cancer.
A 67-year-old woman presents for routine medical screening. Her only complaints are mild constipation and periodic headaches, but she reports that she has had these symptoms for several years. She denies fevers, chills, night sweats, or weight loss. She drinks one glass of wine per day. Physical examination including vital signs is unremarkable and complete blood count (CBC) is within normal limits. Fecal occult blood test (FOBT) is negative. As part of routine medical screening, she receives a colonoscopy that reveals several diverticula in the sigmoid colon. The patient is concerned and would like to know how to best manage this condition.
Which of the following recommendations should be offered to this patient?
Increase in dietary fiber. This patient is presenting with uncomplicated diverticulosis. As people age, diverticula (sac-like protrusions at weak areas in the wall of the colon) are more likely to form.
Uncomplicated, asymptomatic diverticulosis is most common, but diverticulosis can also present with abdominal pain and worsening constipation. Due to the elevated colonic pressure generated in constipation, diverticula can protrude more readily through weak areas in the colonic wall. The most effect management of uncomplicated diverticulosis is dietary modifications, specifically increasing the daily intake of fiber in one’s diet. This creates the formation of bulky stools that minimize the occurrence of diverticula. Laxatives are also helpful in reducing constipation, thereby minimizing the colonic pressure that favors the formation of diverticula. (A) Antibiotics are important in the treatment of diverticulitis; however, diverticulitis is accompanied by fever, leukocytosis, and abdominal pain on physical examination. (C) Refraining from alcohol consumption is beneficial on many levels, but has not been shown to have an effect on diverticular disease. (D) Elective surgery is too extreme of an option given the patient’s lack of symptoms. Surgical intervention is recommended in the setting of complications (bleeding, perforation, etc.).
A 62-year-old woman with a history of hepatitis C infection presents with confusion that has worsened over the past week. Further history reveals that the patient has been vomiting bright red blood recently. The patient was an IV drug user several years previously but endorses no current drug or alcohol use. Physical examination is significant for a confused and disoriented female. Abdominal examination reveals shifting dullness in addition to the finding below (Figure below). When the patient extends her arms out in front of her, a jerking movement of the limbs is observed.
Laboratory results reveal the following:
Which of the following is the most appropriate treatment at this time?
Lactulose. This patient is presenting with signs and symptoms of cirrhosis (ascites, spider angiomata) and hepatic encephalopathy (altered mental status and asterixis). In hepatic encephalopathy, the liver is unable to convert ammonia into urea and it therefore accumulates, in addition to other toxins the liver is unable to clear. It is often precipitated by illness or gastrointestinal bleed (as in this patient with hematemesis). Increased ammonia levels can assist in making the diagnosis, but the diagnosis is ultimately clinical and can cause confusion in the correct setting of end-stage liver disease (ESLD). Treatment involves treating the precipitant and decreasing serum ammonia levels (however, even if one uses ammonia to help with diagnosis, it is not necessary to follow ammonia levels; rather, one should follow clinical improvement). Lactulose, a nonabsorbable disaccharide, is used because bacteria in the gut metabolize it into acidic compounds (lactic acid, acetic acid) that permit the absorbable ammonia to be converted into the nonabsorbable ammonium, thereby enabling excretion from the body. (A) Furosemide would improve the ascites and volume status in a cirrhotic patient, but is not helpful in the management of hepatic encephalopathy. (B) Thiamine is useful in the treatment of Wernicke encephalopathy, another form of encephalopathy characterized by altered mental status, ataxia, and nystagmus and is associated with thiamine deficiency. Of note, asterixis is not present in Wernicke encephalopathy. (D) Morphine is a narcotic that would be challenging for a cirrhotic patient to metabolize.
A 62-year-old man presents with 3 days of abdominal pain and vomiting. He has not had a bowel movement in 4 days and has not passed gas for the past 3 days. He has a temperature of 38.6°C, blood pressure of 118/80 mmHg, heart rate of 110 beats per minute, and a respiratory rate of 22 breaths per minute. Physical examination reveals a distended abdomen that is diffusely tender to palpation without guarding or rebound. Bowel sounds are difficult to appreciate. Laboratory results reveal the following.
What is the best next step in the diagnostic workup for this patient?
Abdominal x-ray. The patient in this question is presenting with signs and symptoms concerning for a small-bowel obstruction (SBO). The typical constellation of symptoms includes abdominal pain, vomiting, obstipation, abdominal distention, and diffuse tenderness. A mild leukocytosis and elevated amylase is often found in an SBO. The best initial test is an abdominal x-ray because it often reveals dilated bowel loops and several air–fluid levels. Treatment involves supportive care, bowel rest, and decompression with a nasogastric tube. Surgery is reserved for those patients who fail to improve with the aforementioned treatments and/or develop findings consistent with strangulation. (A, B, D) These options are not the best initial test in diagnosing an SBO.
A 34-year-old woman with a history of bipolar disorder presents with abdominal pain and diarrhea for the past week. She reports nonbloody watery stools at a frequency of 20 to 25 times per day. She is unable to sleep due to the diarrhea and is hopeful that she can receive treatment for her disorder. She has had several visits in the past 5 years for similar complaints. A physical examination including vital signs is unremarkable. A thorough chart review was performed and it was found that she had a lower GI endoscopy at a previous visit that demonstrated brownish black discoloration of the colonic wall with pale lymph follicles.
Which is the most likely diagnosis in this patient?
Laxative abuse. The patient in this question is presenting with signs and symptoms consistent with factitious diarrhea secondary to laxative abuse. The description, frequency, and nocturnal presence of her diarrhea are suggestive of the diagnosis. Furthermore, she has had multiple visits in the past for similar symptoms. The diagnosis is ultimately confirmed with biopsy that shows dark brown discoloration of the colon with pale lymph follicles. (A) IBS is not associated with nocturnal diarrhea. (B, C) Celiac disease and ulcerative colitis do not present with colonic brown discoloration with interspersed pale lymph follicles.
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