Hepatic Failure/GI/Endocrine Emergencies

Answer: C

The most recent guidelines from the American

Association for the Study of Liver Diseases and the

U.S. Acute Liver Failure Study Group define ALF as

a coagulopathy, usually an INR of 1.5 or more, with

any degree of encephalopathy in patients without pre-

existing liver disease (Answer C is correct). Although

jaundice, thrombocytopenia, and leukocytosis can occur

in patients with ALF, they are not currently defined as

hallmark signs of the disease that exist in all patients

(Answers A, B, and D are incorrect).

Administration of acetylcysteine is recommended in all

ALF cases when acetaminophen is suspected as a cause,

regardless of the acetaminophen concentration (Answer

B is incorrect). Although oral and intravenous formula-

tions have efficacy for the treatment of acetaminophen

overdose, the intravenous formulation is recommended

when patients have greater than grade I encephalopa-

thy or hypotension or when they cannot tolerate oral

therapy (Answers C and D are incorrect). Intravenous

acetylcysteine is recommended for most patients who

present with liver failure and can be extended beyond

the 21-hour regimen, especially if therapy was initiated

more than 8 hours after ingestion or baseline concen-

trations were greater than 300 mg/dL (Answer A is

correct).

Answer: D

Patients with AP should not be kept NPO (Answer A

is incorrect). Studies that have compared TPN with

enteral feeding in AP have shown that enteral feeding is

associated with reduced mortality and infectious com-

plications. Thus, enteral feeding is recommended over

TPN for AP, if it is tolerated (Answer B is incorrect).

Enteral feeding can be given by either the NJ or the NG

route for AP, though the NG route may increase the risk

of aspiration. Because this patient has several admis-

sions for aspiration and is thus high risk for aspiration, it

is safer to use the NJ route over the NG route (Answer C

is incorrect, Answer D is correct).

Answer: C

Fistula output is defined as high if the output is greater

than 500 mL/day, moderate if it is 200–500 mL/day, and

low if it is less than 200 mL/day. This patient’s fistula

output has decreased significantly (Answers A and D

are incorrect) from 570 mL/day to 250 mL/day, but it

is still not enough to classify her fistula output as low

(Answer B is incorrect). Her output has decreased from

high to moderate (Answer C is correct).

Answer: B

In a long-term study of alvimopan for opioid-induced

bowel dysfunction, alvimopan was associated with

higher rates of myocardial infarction than was placebo.

To mitigate this risk, the FDA has limited the use of

alvimopan to short-term, inpatient use, and patients can-

not receive more than 15 doses (Answer B is correct);

however, its use is not contraindicated in patients with

a history of myocardial infarction (Answer D is incor-

rect). The FDA-approved dose is 12 mg twice daily, and

there is no requirement for QTc monitoring with alvi-

mopan (Answers A and C are incorrect).

Answer: D

Dexamethasone and aprepitant should be given before

inducing anesthesia for the prevention of PONV

(Answers A and C are incorrect). Ondansetron and other

serotonin-3 antagonists are most effective if given at the

end of surgery (Answer B is incorrect). Droperidol is

effective for the prevention of PONV when given at the

end of surgery (Answer D is correct).

Answer: A

H. pylori is a recognized carcinogen and should be

eradicated using a 14-day PPI/antibiotic combination

(Answer B is incorrect). Patients with an acute UGIB

who present with a high-risk bleed should have a diag-

nostic and therapeutic endoscopy within 24 hours of

admission (Answer C is incorrect). Blood transfusions

should be administered to keep the hemoglobin con-

centration greater than 7 g/dL (Answer D is incorrect).

Therefore, the only inappropriate treatment option is

using octreotide (Answer A is correct).

Answer: B

Thyroid storm is an uncommon but deadly manifesta-

tion of hyperthyroidism; therefore, TSH will be low,

whereas T4 and T3 will be high (Answer B is correct).

Myxedema coma is a manifestation of hypothyroidism;

therefore, patients will typically have high TSH and low

T4/T3. When TSH is high, both T3 and T4 are typically

low (Answer A is incorrect). Conversely, if TSH is low,

both T3 and T4 are typically high (Answers C and D are

incorrect).