qq - raheem

[ArchivalUser]

A 55-year-old man presents with abdominal pain and diarrhea for the past 3 months. He has also noticed a weight loss of 10 lb during this period. He denies nausea, vomiting, melena, or hematochezia. He consumes five to six beers each weekend, smokes half a pack of cigarettes a day, but has never used intravenous drugs. The past medical history is significant for osteoarthritis, newly diagnosed diabetes on a trial diet for 2 months, and recurrent duodenal ulcers found on four separate upper endoscopies. He takes diclofenac/misoprostol and famotidine 40 mg bid. Three years ago, he had taken triple antibiotics to treat H. pylori. He also tells you that tumors run in his family. His vital signs are normal. Physical examination is significant for mild epigastric tenderness to deep palpation without radiation. Routine labs ordered show: WBC 8,500/mm3, hemoglobin 13.4 g/dL, hematocrit 40.1%, platelets 256,000/mm3, amylase 155 U/L, sodium 141 mEq/L, potassium 4.2 mEq/L, chloride 106 mEq/L, CO2 23 mm Hg, BUN 15 mg/dL, creatinine 1.0 mg/dL, glucose 188 mg/dL, and calcium 11.2 mg/dL (elevated). What test would you order next?

(A) Serum lipase
(B) Upper endoscopy with biopsy
© Abdominal ultrasound
(D) Fasting serum gastrin level
(E) Liver enzyme studies

[ArchivalUser]

A)

[ArchivalUser]

E Hemochromatosis

[ArchivalUser]

Answer:

(D) Fasting serum gastrin level

Explanation:

This patient's history of "tumors in the family" is consistent with MEN-1 (hyperparathyroidism, gastrinomas, and pituitary tumors). He presents with symptoms of gastrinoma, such as recurrent ulcer refractory to multiple treatments (H. pylori regimen and high-dose H2 blockers) and diarrhea. He also has an incidental hypercalcemia most likely secondary to his underlying diagnosis of MEN-1. The diagnosis of gastrinoma requires the demonstration of fasting hypergastrinemia and an increased basal gastric output.