A 50-year-old woman presents with nocturnal pruritus, an elevated alkaline phosphatase of 284 U/L, and normal bilirubin and aminotransferases. She is on no medications and has a normal physical examination. Ultrasound of the liver reveals no ductal abnormalities and no gallstones. What should be the next step?

Correct Answer: D

Rationale: This presentation is typical of primary biliary cirrhosis. Viral hepatitis does not present with only alkaline phosphatase elevation. With a normal ultrasound, no pain, and no jaundice, common bile duct stone is unlikely. A CT scan will not add any more information in this setting. Antimitochondrial antibodies are positive in over $90 \%$ of patients with primary biliary cirrhosis.

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.

Correct Answer: B

Rationale: Caffeinated beverages stimulate acid production, worsening PUD symptoms, and should be avoided.