Nokea
A 36-year-old woman complains of reflux symptoms and intermittent diarrhea. The diagnosis of gastrinoma is suspected so a fasting serum gastrin is obtained and found to be 280 pg/mL (normal <115 pg/mL). An abdominal CT is negative. What would you do now?
- A. Refer her for an exploratory laparotomy
- B. Measure serum gastrin in response to secretin infusion
- C. Treat her for H. pylori
- D. Obtain a dedicated small bowel series
Correct Answer: B
Rationale: The correct answer is B: Measure serum gastrin in response to secretin infusion. This step is necessary to confirm the diagnosis of gastrinoma. Secretin stimulation test is used to differentiate between Zollinger-Ellison syndrome (gastrinoma) and other causes of hypergastrinemia. If serum gastrin levels remain elevated after secretin infusion, it supports the diagnosis of gastrinoma.
Choice A: Refer her for an exploratory laparotomy - This is an invasive procedure and should not be the first step in the investigation of gastrinoma.
Choice C: Treat her for H. pylori - This is not indicated in the management of suspected gastrinoma. H. pylori infection is not a likely cause of the symptoms described.
Choice D: Obtain a dedicated small bowel series - This test is not typically used in the initial evaluation of gastrinoma. The secretin stimulation test is the preferred method for confirming the diagnosis.
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The client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications by the nurse. Which instruction should the nurse include?
- A. Increase your intake of spicy foods.
- B. Avoid lying down immediately after eating.
- C. Consume a high-fat diet.
- D. Drink caffeinated beverages with meals.
Correct Answer: B
Rationale: The correct answer is B: Avoid lying down immediately after eating. This instruction helps prevent acid reflux by allowing gravity to aid in digestion. Lying down can cause stomach acid to flow back up the esophagus, exacerbating GERD symptoms. Increasing intake of spicy foods (A) can irritate the esophagus, consuming a high-fat diet (C) can delay stomach emptying and worsen symptoms, and drinking caffeinated beverages with meals (D) can relax the lower esophageal sphincter, leading to more reflux.
A 56-year-old woman with rheumatoid arthritis has severe joint pain and swelling in her hands. She has a history of peptic ulcer disease five years ago but presently has no GI symptoms. You elect to start her on an NSAID. Which of the following is correct?
- A. Proton-pump inhibitors and H2-blockers are equally effective in prophylaxis against NSAID-related GI toxicity.
- B. Misoprostol is superior to an H2-blocker in prophylaxis against NSAID-related GI toxicity.
- C. Sucralfate is not the drug of choice for prophylaxis in this patient.
- D. H. pylori infection can alter the risk for an NSAID-induced ulcer.
Correct Answer: B
Rationale: Step 1: Misoprostol is a prostaglandin analog that helps protect the gastric mucosa by increasing mucus production. This mechanism of action makes it effective in preventing NSAID-related GI toxicity.
Step 2: H2-blockers (Choice A) and PPIs are not as effective as misoprostol in preventing NSAID-related GI toxicity.
Step 3: Sucralfate (Choice C) is not as effective as misoprostol in preventing NSAID-related GI toxicity due to its different mechanism of action.
Step 4: H. pylori infection (Choice D) can increase the risk of NSAID-induced ulcers but is not directly related to the prophylactic treatment with misoprostol.
A 60-year-old woman presents with pruritus, jaundice, and xanthomas. Laboratory tests reveal elevated cholesterol and alkaline phosphatase levels. What is the most likely diagnosis?
- A. Primary biliary cirrhosis
- B. Primary sclerosing cholangitis
- C. Gallstones
- D. Pancreatic cancer
Correct Answer: A
Rationale: The most likely diagnosis is A: Primary biliary cirrhosis.
Rationale:
1. Pruritus, jaundice, and xanthomas are classic symptoms of cholestatic liver disease.
2. Elevated cholesterol and alkaline phosphatase levels are characteristic of primary biliary cirrhosis.
3. Primary biliary cirrhosis is an autoimmune disease affecting small bile ducts, leading to liver damage.
4. Primary sclerosing cholangitis (B) presents with similar symptoms but typically affects larger bile ducts.
5. Gallstones (C) could cause jaundice but would not explain the elevated cholesterol levels.
6. Pancreatic cancer (D) may present with jaundice but is less likely given the specific lab findings.
A 68-year-old man with a history of diabetes, hypertension, and coronary artery disease (s/p coronary artery bypass graft two years ago) presents to the emergency room with fevers and left-sided abdominal pain. His physical examination reveals a temperature of 101.5°F, pulse 96, and blood pressure of 135/80. His abdomen is soft with moderate left lower quadrant tenderness. There is no rebound or guarding. Bowel sounds are present. A CT scan is done which reveals inflammation around an area of the left colon. The next step in his workup/management should be
- A. Antibiotic therapy with ciprofloxacin and metronidazole
- B. Referral for urgent colonoscopy
- C. Referral to a surgeon for immediate hemicolectomy
- D. Barium enema
Correct Answer: A
Rationale: The correct answer is A: Antibiotic therapy with ciprofloxacin and metronidazole. This patient likely has diverticulitis given his age, comorbidities, symptoms, and imaging findings. Antibiotic therapy is the initial management for uncomplicated diverticulitis to cover for common pathogens. Surgical intervention is not indicated in the absence of complications like perforation or abscess. Urgent colonoscopy or barium enema are contraindicated during an acute episode of diverticulitis due to the risk of perforation. Antibiotic therapy aims to resolve the infection and prevent complications.
The patient described in the preceding question has a positive H. pylori antibody blood test. She is compliant with the medical regimen you prescribe. Although her symptoms initially respond, she returns to see you six months later with the same symptoms. Which of the following statements is correct?
- A. She is at low risk for reinfection with H. pylori
- B. A positive serum IgG indicates that eradication of H. pylori was successful
- C. The urease breath test is an ideal test to document failure of eradication
- D. Dyspepsia typically worsens with H. pylori eradication
Correct Answer: C
Rationale: The correct answer is C because the urease breath test is the ideal test to document failure of H. pylori eradication. This test directly measures the presence of the H. pylori bacterium in the stomach by detecting the enzyme urease produced by the bacterium. If the patient still has symptoms after treatment, a positive urease breath test would indicate that the bacterium is still present, leading to treatment failure.
Choice A is incorrect because a positive antibody test does not indicate low risk for reinfection. Choice B is incorrect because a positive serum IgG may persist even after successful eradication. Choice D is incorrect because dyspepsia can improve after successful H. pylori eradication rather than worsen.