A 30-year-old male smoker presents to the emergency room complaining of chest pain and hematemesis, having vomited up two cups of blood. He admits to drinking too much that same evening and having vomited repeatedly after drinking shots of vodka with his friends following a sporting event. His chest pain is worse after each episode of vomiting; he has never had a cardiac problem in the past. His past history is important for only for hypertension controlled with hydrochlorothiazide. He denies any previous history of alcohol abuse. On examination he is anxious and diaphoretic. His supine pulse is 90, with a blood pressure of 110/90. Heart and lungs are normal, and he has mild epigastric tenderness. His hemoglobin is 11. Stool is hemoccult positive. EKG and initial cardiac enzymes are normal. You admit the patient to the intensive care unit and consult a gastroenterologist.
What is the most likely outcome of this patients gastrointestinal bleeding?
This patient has a Mallory-Weiss tear, which is the cause of bleeding in approximately 5% of patients with an acute upper GI bleed. Most of these tears heal spontaneously within 24 to 48 hours with supportive therapy. If there is ongoing bleeding, IV vasopressin or injection of a sclerotic agent via endoscopy may be required. Surgical intervention with oversewing of the bleeder is rarely needed. The history is not suggestive of chronic alcoholism which may be associated with esophageal varices and hence a higher risk of recurrent massive bleeding as well as mental status deterioration. Acute appendicitis rarely presents with UGI bleeding.
A 36-year-old man presents for a well-patient examination. He gives a history that, over the past 20 years, he has had three episodes of abdominal pain and hematemesis, the most recent of which occurred several years ago. He was told that an ulcer was seen on a barium upper GI radiograph. You obtain a serum assay for H pylori IgG, which is positive.
What is the most effective regimen to eradicate this organism?
Although acid suppression therapy leads to 80% healing rates after 4 weeks of treatment, acid reduction with omeprazole or ranitidine alone does not eradicate H pylori. Three- or four-drug therapy, including bismuth or (most often) proton pump inhibitor, combined with two antibiotics effective against H pylori, will be necessary to eradicate the organism. Longer duration of therapy (ie, 14 days) leads to a greater healing rate. This regimen will eradicate H pylori in more than 90% of patients. Patients whose H pylori has been eradicated have only a 5% chance of ulcer recurrence (compared to 60%-70% of patients not treated for H pylori). Follow-up tests to prove H pylori eradication are not recommended in the usual patient who becomes asymptomatic. If the peptic ulcer should recur (again, this happens infrequently), either direct testing of a biopsy specimen or a test for urease activity in the stomach is necessary, as the serological studies remain positive for many years. Benzathine penicillin is commonly used to treat syphilis but not Helicobacter.
A 60-year-old woman complains of fever and constant left lower quadrant pain of 2-day duration. She has not had vomiting or rectal bleeding. She has a history of hypertension but is otherwise healthy. She has never had similar abdominal pain, and has had no previous surgeries. Her only regular medication is lisinopril. On examination blood pressure is 150/80, pulse 110, and temperature 38.9°C (102°F). She has normal bowel sounds and left lower quadrant abdominal tenderness with rebound. A complete blood count reveals WBC = 28,000. Serum electrolytes, BUN, creatinine, and liver function tests are normal.
What is the next best step in evaluating this patient’s problem
The most likely diagnosis in this patient is acute diverticulitis. Diverticulitis results from obstruction of a preexisting colon diverticulum. Colonic diverticulosis is very common in Western societies, and over half of Americans older than 60 have diverticula. Diverticulosis is asymptomatic. However, obstruction of a diverticulum can result in a microscopic perforation contained by the mesentery, or frank perforation and development of a peridiverticular abscess. Diverticulitis is classically associated with abdominal pain and fever. The pain is typically located in the left lower quadrant because the sigmoid is the most common region of the colon to be affected by diverticulosis. The marked leukocytosis in this patient combined with rebound tenderness suggests the possibility of a peridiverticular abscess. Diverticulitis can usually be diagnosed by CT scan of the abdomen and pelvis, which can also detect an associated diver-ticular abscess. Abdominal ultrasound is rarely useful in assessing colon pathology. Diverticulitis should be treated with antibiotics that are effective against coliforms and anaerobes. A typical choice is ciprofloxacin and metronidazole. Diverticular abscesses frequently require drainage, which can often be done percutaneously. Surgery is reserved for cases refractory to antibiotics and percutaneous drainage. Because of the increased risk of colon perforation, colonoscopy and barium enema are usually deferred for 4 to 6 weeks in patients with acute diverticulitis.
A 58-year-old man with cirrhosis and ascites caused by chronic hepatitis C is hospitalized because of subtle personality change that develops into frank mental status changes with confusion. The patient’s wife reports that his stools have been darker than usual and that he has been unsteady upon arising the last few days. She also reports that he has been reluctant to take several of his medications recently as he has been reading about natural remedies. On physical examination, the patient is lethargic, disoriented, and uncooperative. He is afebrile, has clear lungs, normal heart, distended abdomen with shifting dullness, and no meningeal or focal neurologic findings. There is mild hyperreflexia and a nonrhythmic flapping tremor of the wrists. Stool is heme positive. CT scan of the head is normal. What is the best initial therapy to address this patient’s mental status changes?
This patient has hepatic encephalopathy. Precipitating factors include azotemia, acute liver decompensation, use of sedatives or opioids, GI hemorrhage, hypokalemia, constipation, infection, a high-protein diet, and recent placement of a portosystemic shunt (TIPS). The most effective medical treatment is lactulose, a nonabsorbable disaccharide. Antibiotics such as neomycin, metronidazole, and rifaximin can also reduce symptoms. The other listed medications have not been shown to be effective in treating patients with hepatic encephalopathy. Quetiapine is used for psychosis and depression, lorazepam is useful in alcohol withdrawal and anxiety, haloperidol in psychosis, and omeprazole in peptic ulcer disease.
A 65-year-old woman with a complex medical history (including diabetes, hypertension, coronary artery disease, gastroesophageal reflux disease, and ongoing use of alcohol and tobacco) presents with increasing midsternal chest discomfort predominantly when swallowing solid food. Recently, even liquids are becoming problematic. She has not noted blood in her stool or melena, weight loss, or change in her energy level.
What is the most likely cause of her dysphagia?
Peptic strictures due to chronic, persistent acid reflux cause 80% of esophageal strictures. Diagnostic esophagogastroduodenoscopy followed by dilation is necessary to relieve the dysphagia; the procedure may need to be repeated from time to time as symptoms recur. A patient with esophageal cancer is likely to have weight loss. Patients with achalasia often regurgitate undigested food; achalasia is less common than peptic stricture. A Zenker diverticulum is an outpouching in the posterior wall of the hypopharynx, which allows food retention, causing halitosis, recurrent aspiration, and pneumonia. While patients with polymyositis often have dysphagia, they would typically display weakness of the proximal muscles in addition to dysphagia.
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