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underwent an endoscopy. On preparation forthe patient's discharge, you have a long discussion with your patient about the course of events. In counseling this patient on his future risks and course of therapy, you should advise him that:A. The risk of rebleeding is between 50%-80% andmedical therapy is indicatedB. The risk of rebleeding is between 50% and 80% and surgical therapy is indicatedC. The risk of rebleeding is between 50% and 80%, but no therapy is indicated given the nature of the problemD. There is no concern for rebleedingE. There is no concern for rebleeding, he is an imminent candidate for transplantExplanation:The correct answer is A.There is overwhelming data to support the treatment strategy of some sort of medical therapy (beta blockade, sclerotherapy, banding) for all patients with an episode of variceal bleeding. The risk of rebleeding is high and approaches 80% in most series at 1-year. There is excellent data showing the efficacy of portal-systemic surgical shunts (side-to-side caval, end-to-side caval, distal splenorenal, TIPS) in secondary prevention. Medical therapy is indicated in all patients and all patients should be offered the option of a surgical shunt. The largest drawback to these procedures is their resultant incidence of encephalopathy. The risk or rebleeding is between 50% -80% and surgical therapy is indicated (choice B)is incorrect because there are nonsurgical options available. These options include beta blockade, sclerotherapy, and banding.It is incorrect to say that the risk of rebleeding is between 50% and 80% but notherapy is indicated given the nature of the problem (choice C). As stated above, therapy options include beta blockade, sclerotherapy, banding, and hopefully a liver transplant.There is a 50% and 80% chance of rebleeding, therefore, there is no concern for rebleeding (choice D)is incorrect.
Liver transplant (choice E)is of coursecurative and its 5-year survival rate of approximately 70% is superior to cirrhotics with Child class C disease who are treated by other modalities. This answer is incorrect because it starts with "there is no concern for rebleeding," which is incorrect.A 69-year-old man is brought to the clinic from his convalescent home, because of decreased mental status. He has a history of Alzheimer's disease, depression, hypertension, coronary artery disease, and glaucoma. There is a “do not resuscitate” (DNR) order on the chart signed by the patient's wife. His temperature is 37.0 C (98. 6 F), blood pressure is 110/70 mm Hg, and respirations are 16/min. Physical examination shows a distended abdomen without focal tenderness or peritoneal signs and hard stool in the rectal vault. The patient is alert and oriented only to person. An electrocardiogram reveals normal sinus rhythm with a few premature ventricular contractions (PVC). Laboratory studies are normal. A plain x-ray of the chest reveals multiple pulmonary nodules. A plain x-ray of the abdomen demonstrates a distended ascending and transverse colon measuring 20 cm with copious stool present.