A 46-year-old man with a history of cirrhosis is brought in by his wife because he has been acting strangely. On examination, he is disoriented, ataxic, and has slurred speech. He is also hyperreflexic. His white blood cell count is normal. His hematocrit is 34%. Coagulation times are elevated. His ammonia level is normal. Which of the following statements regarding his management is correct?

Correct Answer: A

Rationale: The correct answer is A: He should be treated with a low-protein diet and lactulose. This patient is presenting with hepatic encephalopathy, as evidenced by his altered mental status, ataxia, slurred speech, hyperreflexia, and normal ammonia level. The management of hepatic encephalopathy involves reducing the production of ammonia in the gut. Lactulose is a non-absorbable disaccharide that helps trap ammonia in the gut and promote its excretion in the feces. A low-protein diet is also recommended to decrease ammonia production. Option B is incorrect because lorazepam is not the drug of choice for managing hepatic encephalopathy; it can worsen the condition. Option C is incorrect because gentamicin is not indicated in this scenario. Option D is incorrect because acetaminophen should be avoided in patients with liver disease due to the risk of hepatotoxicity; nonsteroidal anti-inflammatory drugs

Correct Answer: C

Rationale: Rationale: C is false because eradication of H. pylori does not completely prevent adenocarcinoma of the stomach, although it reduces the risk. A is true as H. pylori can invade epithelium. B is true as it can stimulate acid secretion. D is true as H. pylori produces urease. Thus, C is the only false statement.

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.

Correct Answer: B

Rationale: The correct answer is B: 81 mg of aspirin per day decreases the benefit of using a COX II inhibitor. Aspirin, a non-selective COX inhibitor, can interfere with the action of selective COX II inhibitors by competing for the same binding site on the COX enzyme. This competition can limit the effectiveness of the COX II inhibitor in reducing inflammation and pain. This is particularly important in patients with a history of chronic iron deficiency anemia who may require NSAIDs for pain management. Option A is incorrect because a dedicated small bowel series may not necessarily be positive for identifying the source of blood loss in this patient. Option C is incorrect as a provocative arteriogram with heparin infusion is an invasive procedure and not typically indicated as a first-line investigation for blood loss in patients with iron deficiency anemia. Option D is incorrect as hormonal therapy is not typically used to decrease blood loss from arteriovenous malformations.

Correct Answer: B

Rationale: The correct answer is B: Ischemic colitis affects the watershed areas of the colon, namely, the splenic flexure, right colon, and rectum. This is because these areas have relatively poor collateral blood supply, making them more susceptible to ischemia. Ischemic colitis typically presents with abdominal pain, bloody diarrhea, and tends to affect elderly patients with cardiovascular risk factors. Choice A is incorrect as most cases of ischemic colitis can be managed conservatively without the need for colonic resection. Choice C is incorrect as ischemic colitis can occur in individuals of any age group, although it is more common in the elderly. Choice D is incorrect because colonoscopic intervention is not always necessary for the diagnosis and management of ischemic colitis.