A 65-year-old man is admitted with rectal bleeding. He noticed a significant amount of blood in the toilet after going to the bathroom this morning and had some mild cramping just before that bowel movement. His past medical history is positive for coronary artery disease (has had stents placed and is on aspirin and clopidogrel) and osteoarthritis for which he has been taking ibuprofen. He denies weight loss and has no previous history of bleeding. On examination he is slightly diaphoretic. Vital signs are BP 124/72 and pulse 88 with the patient supine, BP 94/52 and pulse 110 with the patient standing. Abdomen is nontender and nondistended. NG aspirate is negative for occult blood. After establishing two large-bore intravenous lines, administering an IV fluid bolus and otherwise stabilizing the patient, what will be the most important study to perform?
This patient has ischemic colitis. It typically occurs in people older than 50. Risk factors include atherosclerotic disease, including peripheral vascular disease and coronary artery disease. Episodes of bleeding can be preceded by abdominal pain and watery diarrhea. Colonoscopy will reveal inflammatory changes (sometimes patchy) from the splenic flexure to the sigmoid colon with sparing of the rectum. Nonsteroidal induced colitis is also a possibility and could be evaluated by colonoscopy. Given the history of red blood per rectum, upper endoscopy would not be the first choice of examination. An air-contrast barium enema could be obtained if colonoscopy were unavailable, in order to evaluate for colitis and to rule out a carcinoma. Plain x-rays of the abdomen occasionally show thumbprinting from edematous mucosal folds but are less sensitive than colonoscopy. A CT of the abdomen would be unrevealing in a case of ischemic colitis and would be unlikely to detect a small carcinoma if present.
A 60-year-old woman with depression and poorly controlled type 2 diabetes mellitus complains of episodic vomiting over the last 3 months. She has constant nausea and early satiety. She vomits once or twice almost every day. In addition, she reports several months of mild abdominal discomfort localized to the upper abdomen. The pain sometimes awakens her at night. She has lost 5 lb of weight. Her diabetes has been poorly controlled (glycosylated hemoglobin recently was 9.5). Current medications are glyburide, metformin, and amitriptyline.
Her physical examination is normal except for mild abdominal distention and evidence of a peripheral sensory neuropathy. Complete blood count, serum electrolytes, BUN, creatinine, and liver function tests are all normal. Gallbladder sonogram is negative for gallstones. Upper GI series and CT scan of the abdomen are normal.
What is the best next step in the evaluation of this patient’s symptoms?
Delayed gastric emptying (gastroparesis) is a common cause of recurrent vomiting, nausea, early satiety, and weight loss in poorly controlled diabetics. Abdominal discomfort is often nonspecific, but may be localized to the upper abdomen and often awakens the patient at night. Drugs with anticholinergic properties may aggravate the problem. The best diagnostic test is a scintigraphic gastric emptying study, which will show delay in gastric emptying. Treatment includes withdrawal of aggravating drugs such as opiates and anticholinergics, good diabetes control, and drug therapy with metoclopramide or erythromycin. The patient’s symptoms are not those of esophageal disease (dysphagia, odynophagia), so a barium esophagram would not be useful. Her symptoms also do not suggest colonic pathology; in the absence of iron deficiency, colonoscopy would not be indicated. You would not order a liver biopsy in a patient with normal liver enzymes and CT scan of the abdomen. Small bowel biopsy would be indicated if her symptoms suggested intestinal malabsorption.
A 56-year-old woman becomes the chief financial officer of a large company and, several months thereafter, develops upper abdominal pain that she ascribes to stress. She takes an over-the-counter antacid with temporary benefit. She uses no other medications. One night she awakens with nausea and vomits a large volume of coffee grounds-like material; she becomes weak and diaphoretic. Upon hospitalization, she is found to have an actively bleeding duodenal ulcer. Which of the following statements is true?
Duodenal ulcer is more common in men than women, but H pylori is present in 70% of patients (men and women) who have a duodenal ulcer not associated with NSAID ingestion. In gastric ulcer disease, the incidence of H pylori is 30% to 60%. Helicobacter pylori is more common in developing countries but is often seen in the United States. It is more common in patients with low socioeconomic status, in particular those with unsanitary living conditions, which suggests that H pylori is transmitted by fecal-oral or oral-oral routes. In patients with duodenal ulcer, organisms consistent with H pylori are frequently seen on biopsy. Before the discovery of H pylori, most duodenal ulcers would reoccur. Adenocarcinoma of the duodenum is a rare cause of upper gastrointestinal bleeding.
A 40-year-old woman complains of mid-abdominal pain that began several hours ago. She has vomited once, and the ride to the hospital was very uncomfortable for her. She has felt hot but has not checked her temperature. She denies any diarrhea or blood in her stools. She has a history of diabetes and hypertension and is on metformin, lisinopril, and hydro-chlorothiazide. She denies trauma or dysuria, and she is currently on her menstrual period. Her surgical history is positive only for a laparoscopic cholecystectomy and tubal ligation. On examination she has a temperature of 38.3°C (101°F), a pulse of 96, clear lungs, normal heart, some right flank tenderness, decreased bowel sounds with voluntary guarding diffusely, and more exquisite tenderness in the right lower quadrant. Her white blood cell count is 16,000 with a left shift. A urinalysis and a pregnancy test are both negative.
What would be the next best step?
This patient has classic signs and symptoms of acute appendicitis. Appropriate historical and laboratory data leading to this suspicion will lead to the correct diagnosis only 75% of the time in the hands of experienced clinicians. Other potential diagnoses would be mesenteric lymphadenitis, pelvic inflammatory disease, a ruptured graafian follicle, or corpus luteum or gastroenteritis. Abdominal CT is readily available in most emergency departments and is highly accurate (95%). Simple abdominal x-rays are not usually helpful in this situation. Abdominal ultrasound requires the patient to have fasted for 6 hours and to have a full bladder to obtain satisfactory images, and while it can be used to detect appendicitis, it depends on the experience of the technician/radiologist. While surgery will be consulted once the diagnosis is confirmed, they should not be called at this point.
A 70-year-old man presents with a complaint of fatigue. There is no history of alcohol abuse or liver disease; the patient is taking no medications. Scleral icterus is noted on physical examination; the liver and spleen are nonpalpable. The patient has a normocytic, normochromic anemia. Urinalysis shows bilirubinuria with absent urine urobilinogen. Serum bilirubin is 12 mg/dL, AST and ALT are normal, and alkaline phosphatase is 300 U/L (three times normal). Which of the following is the best next step in evaluation?
Patients with jaundice should be characterized as having unconjugated (indirect reacting) or conjugated (direct) hyperbilirubinemia. Causes of unconjugated hyperbilirubinemia include hemolysis, ineffective erythropoiesis, or enzyme deficiencies (the commonest in adults being Gilbert syndrome). The patient, however, has conjugated hyperbilirubinemia, which almost always indicates significant liver dysfunction, either hepatocellular or cholestatic (obstructive); this patient’s predominant elevation of alkaline phosphatase suggests a cholestatic pattern. Normal transaminases rule out hepatocellular damage (such as viral or alcoholic hepatitis). Instead, a disease of bile ducts or a cause of impaired bile excretion should be considered. Ultrasound or CT scan will evaluate the patient for an obstructing cancer or stone disease versus intrahepatic cholestasis. Ferritin values would evaluate for hemochromatosis, but this disease typically causes transaminase elevation and hepatomegaly. Primary biliary cirrhosis (PBC, evaluated by the antimitochondrial antibody test) might be considered if imaging studies show a nondilated biliary system (suggesting intrahepatic cholestasis), but PBC is usually seen in middle-aged women.
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