A patient with dyspepsia has a positive serologic test for Helicobacter pylori and is concerned that he could have an ulcer. Which of the following statements about H. pylori and ulcer disease would be most accurate?
Answer(s): C
Duodenal ulcers are usually associated with hypersecretion of acid, whereas gastric ulcers may be related to breakdown of the mucosal protective mechanisms or to malignancy. Type I gastric ulcers are the most common. They are usually associated with altered mucosal defense and not hypersecretion of acid. Type II gastric ulcers are caused by a duodenal ulcer and the resulting pyloric obstruction. Type III gastric ulcers are found proximal to the pylorus and are associated with hypersecretion and duodenal ulcers. H. pylori is found in 95% of duodenal and 80% of gastric ulcer patients. However, only 10% of people who carry the bacteria actually manifest ulcer disease. Serologic testing does not determine the presence of an active infection. Active infections can be determined by endoscopic biopsy sampling or the use of urease breath testing. All currently recommended regimens to eradicate H. pylori utilize both antibiotics and acid suppression.
Which of the following patients is most likely to have symptoms of the carcinoid syndrome?
Answer(s): E
Carcinoid syndrome is seen in less than 10% of patients with metastatic carcinoid disease. It is seen in patients with elevated serotonin levels, which is metabolized by the liver. Thus, only patients with massive hepatic metastasis or with tumors that bypass the hepatic filter--such as a retroperitoneal tumor--show symptoms. 5-Hydroxyindoleacetic acid (5-HIAA) levels can be tested in the urine to give the diagnosis (urinary vanillylmandelic acid [VMA] is indicative of a pheochromocytoma). An apple core lesion on the colon is most likely to be a large adenocarcinoma, which would not be associated with carcinoid symptoms. Common symptoms of carcinoid syndrome include flushing, diarrhea, right heart failure, and asthma.Weight loss and liver failure are uncommon symptoms.
Apatient undergoes a gastrectomy following a gunshot injury. How would you counsel him about postgastrectomy syndromes?
Most patients have a change in their digestive habits after gastrectomy. These symptoms are actually related to the vagotomy done with the operation. The majority of patients learn to manage their symptoms with only a small amount requiring surgical intervention. Dumping syndrome is associated with abdominal pain, nausea, vomiting, dizziness, and palpitations related to the quick hyperosmolar emptying into the small intestine. These symptoms can be managed by eating small, low carbohydrate meals throughout the day. Postvagotomy diarrhea is related to the rapid transit of unconjugated bile salts and is effectively treated with cholestyramine. Proton pump inhibitors are not a useful therapy for alkaline reflux.
A 19-year-old female presents to the ED complaining of swelling in her left lower extremity. She reports that she had arthroscopy of the right knee about a week ago for a torn meniscus. The swelling started last night and is uncomfortable.Which of the following statements most accurately describes the situation?
This patient has developed a DVT of her left leg. This is a complication following surgery that can be prevented in part by the use of subcutaneous heparin and sequential compression devices. Coumadin is not used as a prophylaxis, but rather as a treatment modality. Risk factors for developing DVTs include female gender, obesity, orthopedic surgery, use of oral contraceptives, smoking, and long periods of being sedentary. Her knee should be aspirated if she has a red, hot, or swollen joint; as these symptoms are not mentioned and the DVT is in the leg opposite to the surgically treated joint, aspiration is not necessary at this time.
A 72-year-old woman undergoes a sigmoid colectomy for diverticulitis. Postoperatively, she develops a wound infection for which she is transferred to the ICU for 2 days because of hypotension. Which of the following would have had the most effect on reducing her risk of developing complications?
Answer(s): A
Wound infection is a complication of surgery that can lead to a great deal of morbidity and longer hospital stay. Prevention of wound infection includes perioperative antibiotics, which should be at their peak tissue concentration at the time of skin incision. This means they should be given at least 30 minutes prior to incision. Patients who have other infections, such as urinary tract infections, are at increased risk for wound infection. Bowel surgery exposes the wound to the normal intestinal flora, the most common being Bacteroides. Washing hands is an essential part of preventing spread of infectious pathogens between patients. Using gloves is not a substitute for good hand hygiene. Once a wound is infected, it must be opened and drained. Antibiotic therapy alone is not adequate.
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