ANSWERS // From page 13
Q1: ANSWER: B
The patient has multiple organs involved and cytology brushing from the bile duct is negative. The clinical evidence for
IgG4-associated systemic disease (ISD) is strong with suspected involvement of pancreas (autoimmune pancreatitis), bile
duct, and salivary glands. Further confirmation of the diagnosis would include an elevated antinuclear antibody titer
and elevated serum IgG4 level. Imaging of a diffuse pancreatic
gland without focal mass, and with pancreatic duct narrowing
in contrast to dilation is also supportive of the diagnosis, and
not at all suggestive of focal pancreatic neoplasm.
1. Yamamoto M., et al. A new conceptualization for Mikulicz’s disease as an
IgG4-related plasmacytic disease. Mod Rheumatol. 2006;16:335-40.
2. Hamano H., Kawa S., Horiuchi Y., et al. N Engl J Med. 2001;344:732-8.
Q2: ANSWER: C
First variceal hemorrhage in patients with cirrhosis and
portal hypertension occurs at a rate of 5%-15% and car-
ries a significant morbidity, increased health care costs,
and mortality of 20% at 6 weeks. Therefore, prevention of
first hemorrhage is an important part in the treatment of
portal hypertension. High risks for variceal hemorrhage in-
clude large variceal size (greater than 5 mm), small varices
(less than 5 mm) that have red wale signs, and advanced
cirrhosis class Child B/C. The patient in question has medi-
um-size varices. Medium-size esophageal varices are larger
than 5 mm and are at high risk for bleeding, especially
in advanced cirrhosis (ascites in this case). High-quality
large controlled trials have shown equal efficacy for non-
selective beta-blockers (nadolol and propranolol) and
endoscopic variceal ligation in the prophylaxis of first
variceal bleeding in patients with cirrhosis and large size
varices. Beta-blockers reduce portal pressure by reducing
portal venous inflow through a beta-1 reduction in cardi-
ac output, and beta- 2 splanchnic vasoconstriction effects.
Metoprolol is a selective beta-1 blocker and is less effective
due to lack of vasoconstricting action on the splanchnic cir-
culation. Sclerotherapy has been replaced with endoscopic
variceal ligation because of its side effects. Antibiotics have
no role in the prophylaxis of variceal bleeding.
1. Abraldes J.G., Villanueva C., Bañares R., et al. Spanish Cooperative Group
for Portal Hypertension and Variceal Bleeding. Hepatic venous pressure
gradient and prognosis in patients with acute variceal bleeding treated with
pharmacologic and endoscopic therapy. J Hepatol. 2008 Feb;48:229-36.
2. North Italian Endoscopic Club for the Study and Treatment of Esophageal
Varices: Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N
Engl J Med. 1988;319:983-9.
3. Gluud L.L., Klingenberg S., Nikolova D., Gluud C. Banding ligation versus
beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007 Dec;102:2842-8.
4. de Franchis R., Primignani M.. Endoscopic treatment for portal hypertension. Semin Liver Dis 1999;19:439-55.
5. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management
of gastroesophageal varices and variceal hemorrhage in cirrhosis. Practice
Guidelines Committee of the American Association for the Study of Liver
Diseases; Practice Parameters Committee of the American College of Gastroenterology. Hepatology. 2007 Sep;46:922-38.