A 25-year-old dental technician has noticed a 10-pound weight loss despite increased appetite, generalized weakness, and constipation with infrequent but unusually voluminous and malodorous stools. On physical examination, he is thin, pale, and appears tired. His abdomen is protuberant but soft. Labs reveal a microcytic anemia. Which of the following is least likely to be helpful?

Correct Answer: D

Rationale: This young man with weight loss, malodorous, bulky stools, increased appetite, and iron deficiency anemia has celiac disease as the most likely diagnosis. Patients occasionally may feel constipated; however, the stools are unusually bulky and consistently malodorous. The disease is diagnosed by biopsy of the small bowel by upper endoscopy (Answer A). Elevated anti-endomysial antibodies are highly suggestive. Fat malabsorption can be rigorously established by fecal fat collection. The differential diagnosis includes chronic pancreatitis, which is best evaluated by CT scan. A colonoscopy is helpful to evaluate iron deficiency anemia to rule out colonic tumors or other causes of occult blood loss or to assess for inflammatory bowel disease. However, in this patient with malabsorption, increased appetite, and young age, sprue is more likely to explain the constipation and iron deficiency anemia. He does not have abdominal pain, blood in the stools, or diarrhea, the most common symptoms of inflammatory bowel disease. Colonoscopy will be less useful.

Correct Answer: B

Rationale: Hepatomegaly, portal vein thrombosis, or new ascites in someone with chronic hepatitis B is hepatocellular carcinoma until proven otherwise. Replication flares do not typically present with pain or hepatomegaly.

Correct Answer: A

Rationale: Helicobacter pylori infection is the most common cause of PUD, as it damages the protective mucosal lining of the stomach and duodenum, leading to ulcer formation.

Correct Answer: B

Rationale: Sucralfate forms a protective coating over ulcers, shielding them from acid and pepsin, thus aiding healing.

Correct Answer: D

Rationale: High dairy intake is not a typical cause of PUD; NSAIDs, H. pylori, and alcohol are well-established contributors to mucosal damage.