A 47-year-old web designer has a 14-year history of ulcerative colitis. He recently moved to your area and presents to your office for continued management of his ulcerative colitis. He has been asymptomatic for the past two years and off all medications for one year with no rectal bleeding, diarrhea, abdominal pain, tenesmus, or fever. Before that he had very active colitis requiring steroids and immunosuppressants. He brings records from his previous physician that include his last three colonoscopy and pathology reports. The reports from 6 and 12 years ago documented active colitis with friable mucosa from the mid-transverse colon to the rectum, superficial ulcerations, crypt abscesses and crypt distortion, and acute and chronic inflammation. The most recent report, from almost three years ago, was fairly unremarkable endoscopically. Numerous random biopsies had been obtained. They showed mucosal changes on histology also consistent with a history of ulcerative colitis, but there was no evidence of active disease. What do you recommend?

Correct Answer: D

Rationale: The patient has not had active disease for several years and remains well despite being off medications for the past year. Steroids are indicated for active disease only, and steroids do not prevent recurrence. Ulcerative colitis is a chronic disease with recurrence expected. An argument can be made for azulfidine or mesalamine; 5-ASA agents have been documented to decrease flares and appear to decrease the risk of dysplasia and eventual colon cancer. Patients with ulcerative colitis for more than eight years should undergo colonoscopy every two years with random biopsies taken every $10 \mathrm{~cm}$ to rule out dysplasia; then more frequently after 20 years of disease. Definitive evidence of dysplasia requires referral for colectomy to avoid the extremely high risk of colon cancer. Presence of occult blood in the stool will not change endoscopic management because this patient needs to be on a regular screening protocol regardless of heme-occult status.

Correct Answer: C

Rationale: This young woman has a poor prognosis for recovery using the King's College criteria, and will likely need a liver transplant. She should be intubated immediately for airway protection, given N-acetylcysteine, and transferred to a transplant center. Lactulose has no efficacy in acute liver failure.

Correct Answer: C

Rationale: Abdominal pain, typically epigastric and burning in nature, is the hallmark symptom of a peptic ulcer due to irritation of the ulcerated mucosa by gastric acid.

Correct Answer: A

Rationale: Spicy foods can irritate the gastric mucosa and exacerbate PUD symptoms, making avoidance the most appropriate advice.

Correct Answer: B

Rationale: Managing and preventing shock is critical in a bleeding ulcer due to the risk of hypovolemia from significant blood loss.