A 50-year-old woman presents complaining of pruritus. She reports that for the last eight months she has been itching, particularly around her trunk. Her medical history is notable only for hypertension and obesity. Her current medications include hydrochlorothiazide, estrogen, and progesterone. Her labs are notable for an alkaline phosphatase of 487 U/L, an alanine aminotransferase (ALT) of 46 U/L, and an aspartate aminotransferase of 52 U/L. Her total bilirubin is 2.5 mg/dL with a direct bilirubin of 1.6 mg/dL. Which of the following statements is correct?

Correct Answer: A

Rationale: This woman presents with an elevated alkaline phosphatase, mildly elevated transaminases, and an elevated bilirubin level. The alkaline phosphatase elevation is out of proportion to the other tests, suggesting a biliary process. Primary biliary cirrhosis (PBC) would present as such. Antimitochondrial antibodies are seen in most cases of PBC. Ceruloplasmin is usually low in Wilson's disease which can present with elevation of the transaminases and neuropsychiatric disturbances in young patients. Likewise estrogen administration, fatty liver, and autoimmune hepatitis should present with primary elevations of the transaminases rather than the alkaline phosphatase.

Correct Answer: C

Rationale: Black, tarry stools (melena) result from digested blood due to upper GI bleeding, a common sign of a bleeding peptic ulcer.

Correct Answer: A

Rationale: Misoprostol, a prostaglandin analog, protects the stomach lining by increasing mucus and bicarbonate secretion.

Correct Answer: B

Rationale: Giving antacids 1-3 hours after meals maximizes their acid-neutralizing effect when acid levels peak post-digestion.

Correct Answer: B

Rationale: Black, tarry stools indicate GI bleeding, requiring immediate physician notification for assessment and intervention.