A 47-year-old, darkly pigmented man with a known history of alcohol abuse begins vomiting large quantities of blood and is brought by ambulance to the emergency department.
Q 1
In the emergency department, the man is found to have a temperature of 36.7 C (98.1 F), blood pressure of 65/40 mm Hg and dropping rapidly, a weak pulse of 130/min, and respirations of 29/min. These vital signs suggest that which of the following is developing?
/ A. Congestive heart failure
/ B. Meningitis
/ C. Pneumonia
/ D. Septicemia
/ E. Shock
Q 2
A blood sample is drawn and an IV Iine is started. While the patient is being cross-matched, the physical examination is continued. The patient's sclerae are noted to be icteric and his nail beds and palms have a yellowish hue. A caput medusa
is noted. Which of the following is the most accurate description of a caput medusa?
/ A. Ecchymoses over the mastoid process
/ B. Paradoxical increase in venous distension and pressure during inspiration
/ C. Reflex movement of the eyes in the opposite direction to that in which the head is moved
/ D. Small bony masses found on the terminal phalanges
/ E. Varicose veins radiating from the area of the umbilicus
Q 3
Caput medusa specifically suggests which of the following diagnoses?
/ A. BIadder infection
/ B. Duodenal ulcer
/ C. Gastric ulcer
/ D. Pancreatitis
/ E. Portal hypertension
Q 4
Which of the following is the most common cause of this patient's disorder in the United States?
/ A. Hepatic cirrhosis
/ B. Hepatic vein thrombosis
/ C. Hepatocellular carcinoma
/ D. Metastatic disease to the liver
/ E. Portal vein thrombosis
Q 5
Endoscopic studies demonstrate that this patient has bleeding esophageal varices, and the bleeding is successfully stopped with
sclerotherapy. What percentage of patients with bleeding esophageal varices have another episode of variceal bleeding at a subsequent
time?
/ A. 5%
/ B. 25%
/ C. 40%
/ D. 70%
/ E. 95%
Q 6
Following blood transfusions and sclerotherapy, the patient initially feels reasonably well and is able to converse with medical personneI. Over
the next 12 hours, while he does not begin to rebleed, his mental status deteriorates. Arterial blood levels of which of the following would be
most helpful in confirming the likely diagnosis?
/ A. Ammonia
/ B. Angiotensin l
/ C. Calcitonin
/ D. Carbon monoxide
/ E. Ceruloplasmin
Gastrointestinal Bleeding case 5 answers
A1
The correct answer is E. The patient's low and dropping blood pressure, tachycardia, high respiratory rate, and slightly below normal body temperature are all consistent with impending shock. At this point, the other conditions listed in the choices have not yet been ruled out, but clinically, the patient should begin to be immediately treated for the shock, even if the therapeutic workup for underlying conditions must be temporarily deferred
A2
The correct answer is E. Medusa was a goddess with snakes instead of hair on her head. The caput medusa (Medusa's head) is an old term still in fairly common use for numerous varicose veins radiating over the abdomen from the area of the umbilicus.
Choice A describes Battle's sign, which is suggestive of basal skull fracture.
Choice B describes Kussmaul's sign, which is seen in constrictive pericarditis.
Choice C describes the doll's eye sign, which is looked for in the evaluation of comatose patients and suggests functional integrity of the brainstem tegmental pathways and cranial nerves involved in eye movement.
Choice D describes Heberden's nodules, which are seen in osteoarthritis.
A3
The correct answer is E. The caput medusa develops when severe portal hypertension induces dilation of the anastomotic channels between the portal venous system and the systemic venous system, some of which involve the superficial veins near the umbilicus. The other answers are distracters.
A4
The correct answer is A. The overwhelmingly most common cause of portal hypertension in the United States is hepatic cirrhosis, which is usually due to either alcoholism or hepatitis viral infection. In this patient's case, the diagnosis of cirrhosis is further clinically substantiated by his jaundice, as evidenced by his sclera, nail beds, and palms. (Look in these areas on individuals in whom dark skin pigmentation may mask the jaundice generally.) The other entities listed are occasional causes of portal hypertension.
A5
The correct answer is D. Patients who have had one episode of bleeding from esophageal varices have an approximately 70% chance of developing a second incident of bleeding, and one third of these episodes of rebleeding is fatal.
A6
The correct answer is A. Hepatic encephalopathy is seen in end-stage cirrhosis patients, and can either present or worsen in the presence of gastrointestinal bleeding. The blood in the upper gastrointestinal tract behaves essentially as a high protein load, and increases the absorption of ammonia and nitrogen, which cannot be appropriately metabolized by the liver. GI bleeding may also predispose for inadequate renal function secondary to hypotension.
Angiotensin I (choice B) is part of the renin-angiotensin-aldosterone system for blood pressure and sodium ion control.
Calcitonin (choice C) is a hormone secreted by the thyroid, which may be increased in medullary carcinoma of the thyroid.
Carbon monoxide (choice D) increases in the blood in smokers.
Ceruloplasmin (choice E) is a copper-carrying protein monitored in patients with Wilson disease.
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