A 56-year-old woman with rheumatoid arthritis has severe joint pain and swelling in her hands. She has a history of peptic ulcer disease five years ago but presently has no GI symptoms. You elect to start her on an NSAID. Which of the following is correct?

Correct Answer: B

Rationale: The correct answer is B: Misoprostol is superior to an H2-blocker in prophylaxis against NSAID-related GI toxicity. Misoprostol is a prostaglandin analog that helps protect the stomach lining, reducing the risk of NSAID-induced ulcers. H2 blockers only reduce acid production and do not address the underlying mechanism of NSAID-induced injury. Sucralfate does not provide as effective prophylaxis as misoprostol. H. pylori infection can increase the risk of NSAID-induced ulcers; eradication of H. pylori can reduce this risk.

Correct Answer: D

Rationale: The correct answer is D: Obtain serologic studies for antibodies to Trypanosoma cruzi. This patient's presentation is consistent with Chagas disease, caused by Trypanosoma cruzi. The patient is from Brazil, where Chagas disease is endemic. The dilated esophagus and lower esophageal sphincter tapering are classic findings of megaesophagus, a complication of Chagas disease. Serologic studies for antibodies to Trypanosoma cruzi are necessary for definitive diagnosis. Choice A: Refer for partial esophagectomy - Not appropriate as surgery is not indicated without confirming the diagnosis. Choice B: Thick and thin smears of peripheral blood looking for parasites - Not appropriate as Chagas disease is diagnosed through serologic testing, not blood smears. Choice C: Therapeutic trial of a proton pump inhibitor - Not appropriate as the patient's symptoms are likely due to Chagas disease, not gastroesophageal reflux disease.

Correct Answer: A

Rationale: The correct answer is A: Endoscopic retrograde cholangiopancreatography (ERCP) should be performed urgently. ERCP is not indicated in the acute setting of pancreatitis unless there is evidence of biliary obstruction or cholangitis. The priority in this case would be to manage the acute pancreatitis and potential pancreatic necrosis. Antibiotic therapy (Choice B) may be considered in cases of infected necrosis. A CT-guided needle aspirate (Choice C) may be helpful for diagnosing infected necrosis but is not typically done urgently. Surgical debridement (Choice D) is indicated if there is evidence of infected pancreatic necrosis on culture results, but this should be done after appropriate medical management.

Correct Answer: D

Rationale: The correct answer is D: Perianal fistula formation. Ulcerative colitis primarily affects the colon and rectum, leading to inflammation and ulceration of the intestinal lining. Perianal fistula formation is more commonly associated with Crohn's disease, not ulcerative colitis. Rationale: A: Arthritis - Extraintestinal manifestation commonly seen in ulcerative colitis due to immune system involvement. B: Sclerosing cholangitis - Liver complication associated with ulcerative colitis. C: Autoimmune hemolytic anemia - Blood disorder linked to ulcerative colitis due to immune system dysregulation. D: Perianal fistula formation - More characteristic of Crohn's disease, not ulcerative colitis.

Correct Answer: D

Rationale: The correct answer is D because hepatitis A infection can have a relapsing course. This is due to the natural course of the infection, where patients can initially recover but then experience a recurrence of symptoms. This is different from hepatitis B or C, which typically do not have a relapsing course. A is incorrect because in alcoholic hepatitis, the AST/ALT ratio is usually greater than 2. B is incorrect because Alpha-1 Antitrypsin deficiency is associated with liver and lung diseases, not arteriovenous malformations of the brain. C is incorrect because although serum A1AT levels are used to diagnose A1AT deficiency, they are not solely diagnostic as genetic testing is also required for confirmation.