A 34-year-old man presents with substernal discomfort. The symptoms are worse after meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing, pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the patient has gained 20 lb in the past 2 years. Which of the following is the most appropriate initial approach?
In the absence of alarm symptoms (such as dysphagia, odynophagia, weight loss, or gastrointestinal bleeding), a therapeutic trial of acid reduction therapy is reasonable. Mild to moderate GERD symptoms often respond to H2 blockers. More severe disease, including erosive esophagitis, usually requires proton pump inhibitor therapy for 8 weeks to ensure healing. If the patient has recurrent symptoms or symptomatic GERD for over 5 years, endoscopy is indicated to rule out Barrett esophagus (intestinal metaplasia of the lower esophagus). Barrett esophagus is a premalignant condition, and most patients receive surveillance EGD every 2 to 3 years, although evidence of mortality benefit from this approach is not available. In the absence of alarm symptoms, a therapeutic trial is generally favored over more expensive diagnostic studies (endoscopy, CT scan). Classic symptoms of GERD do not mandate an evaluation for coronary artery disease unless other features suggest this diagnosis.
A 48-year-old woman presents with a 2-month history of change in bowel habit and 10-lb weight loss despite preservation of appetite. She notices increased abdominal gas, particularly after fatty meals. The stools are malodorous and occur two to three times per day; no rectal bleeding is noticed. The symptoms are less prominent when she follows a clear liquid diet.
Which of the following is the most likely histological abnormality associated with this patient’s symptoms?
The patient’s history suggests malabsorption. Weight loss despite increased appetite goes with either a hypermetabolic state (such as hyperthyroidism) or nutrient malabsorption. The gastrointestinal symptoms support the diagnosis of malabsorption. Patients may notice greasy malodorous stools, increase in stool frequency, stools that are tenacious and difficult to flush, as well as changes in bowel habit according to the fat content of the diet. In the United States, celiac sprue (gluten-sensitive enteropathy) and chronic pancreatic insufficiency are the commonest causes of malabsorption. The histological pattern described in option c is associated with celiac sprue. IgA antiendomysial antibodies and antibodies against tissue transglutaminase provide supporting evidence. Signet ring cells are seen with gastric cancer. This lesion causes weight loss through anorexia or early satiety but would not cause malabsorption. Colonic mucosal inflammation and crypt abscesses are associated with ulcerative colitis; since this disease affects only the colon, small bowel absorption is not affected. Helicobacter pylori (which appears as curved gram-negative rods on gastric biopsy) is not associated with malabsorption. Periportal inflammation is seen in chronic hepatitis but does not cause malabsorption.
An otherwise healthy 40-year-old woman sees you because of recurrent abdominal pain. In the past month she has had four episodes of colicky epigastric pain. Each of these episodes has lasted about 30 minutes and has occurred within an hour of eating. Two of the episodes have been associated with sweating and vomiting. None of the episodes have been associated with fever or shortness of breath. She has not lost weight. She does not drink alcohol or take any prescription or over-the-counter medications. Other than three previous uneventful vaginal deliveries, she has never been hospitalized.
Her examination is negative except for mild obesity (BMI = 32). A complete blood count and multichannel chemistry profile that includes liver function tests are normal. A gallbladder sonogram reveals multiple gallstones.
What is the next best step in the treatment of this patient?
Cholelithiasis (gallstone disease) is very common. Risk factors for the development of gallstones include advancing age, female gender, obesity, prior pregnancies, Native American or Hispanic ancestry, and rapid weight loss. Many patients are asymptomatic, but some develop biliary colic. About half of symptomatic patients will have recurrent episodes, and 1% to 2% will develop complications annually. The treatment of choice is cholecystectomy, which can usually be performed laparoscopically. This woman’s symptoms are classic for biliary colic; acid reducers such as omeprazole would not be useful. Although ursodeoxycholic acid can dissolve gallstones, they usually recur, and this drug is no longer considered appropriate therapy unless surgery is contraindicated. Weight reduction does not dissolve gallstones, and rapid weight loss can precipitate symptoms. In order to prevent complications, symptomatic patients with low operative risk are usually managed with surgery rather than with observation. Asymptomatic gallstone disease is followed and treated surgically if symptoms develop.
A 56-year-old chronic alcoholic has a 1-year history of ascites. He is admitted with a 2-day history of diffuse abdominal pain and fever. Examination reveals scleral icterus, spider angiomas, a distended abdomen with shifting dullness, and diffuse abdominal tenderness. Paracentesis reveals slightly cloudy ascitic fluid with an ascitic fluid PMN cell count of 1000/µL.
Which of the following statements about treatment is true?
Spontaneous bacterial peritonitis is the occurrence of bacterial infection in preexisting ascitic fluid without bowel wall perforation. It is almost always caused by a single species; isolation of multiple species would suggest a bowel wall perforation. The typical patient has preexisting cirrhosis and ascites, and presents with fever and abdominal pain. Acute deterioration of liver function and hepatic encephalopathy are common. An ascitic fluid PMN cell count of greater than 250/µL confirms the diagnosis, even if the culture is negative. Standard antibiotic therapy is a fluoroquinolone or third-generation cephalosporin for 7 to 10 days. Response to therapy can be judged clinically, and repeated paracentesis is not usually necessary. The addition of albumin to antibiotic therapy has been shown to improve survival. Recurrence rates are high, and long-term prophylactic therapy with a fluoroquinolone is recommended.
A 60-year-old man with known hepatitis C and a previous liver biopsy showing cirrhosis requests evaluation for possible liver transplantation. He has never received treatment for hepatitis C. Though previously a heavy user of alcohol, he has been abstinent for over 2 years. He has had two episodes of bleeding esophageal varices. He was hospitalized 6 months ago with acute hepatic encephalopathy. He has a 1-year history of ascites that has required repeated paracentesis despite treatment with diuretics. Medications are spironolactone 200 mg daily and lactulose 30 cc three times daily
On examination he appears thin, with obvious scleral icterus, spider angiomas, palmar erythema, gynecomastia, a large amount of ascitic fluid, and small testicles. There is no asterixis.
Recent laboratory testing revealed the following:
What is the best next step in the management of this patient’s liver failure?
Cirrhosis caused by hepatitis C is the most common cause for liver transplantation in the United States. A previous history of alcoholism is not a contraindication to transplantation, although most transplant centers require abstinence from alcohol for 6 months before transplantation is considered. Three-year survival rate after transplantation in most centers now exceeds 80%. The model for end-stage liver disease (MELD) scoring system is used in the United States to allocate cadaveric livers to potential donors. Patients with complications of cirrhosis (esophageal variceal bleeding, hepatic encephalopathy, and uncontrolled ascites) or who have significantly elevated bilirubin, INR, and serum creatinine are usually made eligible for transplantation. Repeat liver biopsy would be unnecessary and potentially risky due to the patient’s coagulopathy. Patients with end-stage cirrhosis from hepatitis C do not benefit from interferon and ribavirin therapy. Hospice care is inappropriate until the patient is evaluated by a transplant center.
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