WBR0176

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathophysiology
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 53-year-old man presents to the physician's office with complaints of persistent vague abdominal pain and nausea. He states that his pain is not associated with food intake or defecation. The patient's past medical history is only remarkable for hypercholesterolemia. He currently receives daily atorvastatin for the past 10 years and reports no known drug or food allergy. The patient then undergoes upper GI endoscopy and is told he has significant hypertrophy of the gastric folds with an alkaline gastric pH. At initial presentation, which physical examination finding is most likely consistent with this patient's condition?]]
Answer A	AnswerA::Ascites
Answer A Explanation	AnswerAExp::Menetrier's disease is a protein-losing gastropathy that is associated with hypoalbuminemia. Signs of edema, such as peripheral pitting edema and ascites, are often present on physical examination.
Answer B	AnswerB::Dysarthria
Answer B Explanation	AnswerBExp::Menetrier's disease is not usually associated with dysarthria on physical examination. Dysarthria is a speech impairment due to involvement of the motor nervous system. Dysarthria may be observed among patients with a history of stroke.
Answer C	AnswerC::Hemorrhoids
Answer C Explanation	AnswerCExp::Hemorrhoids may be observed among patients with portal hypertension due to back-up of blood flow in the portal circulation.
Answer D	AnswerD::Splenomegaly
Answer D Explanation	AnswerDExp::Splenomegaly may be observed among patients with hematological disorders and portal hypertension due to back-up of blood flow in the portal circulation.
Answer E	AnswerE::Nystagmus
Answer E Explanation	AnswerEExp::Nystagmus may be a sign of eye disease, but is also a common ophthalmological manifestation of inner ear and neurological diseases.
Right Answer	RightAnswer::A
Explanation	[[Explanation::Menetrier's disease (MD) is a rare protein-losing enteropathy that is characterized by rugal hypertrophy of the gastric fundus and body. It has 2 forms: The first form is a progressive pre-malignant disease that usually affects middle-aged men, and the second form is a self-resolving, acute-onset disease that affects children. The patient in this vignette has the first form of the disease, where diagnosis of MD often warrants further work-up for identification of malignant tumors, such as diffuse gastric carcinoma or lymphoma. Adult manifestations of MD are usually vague abdominal pain, nausea, and vomiting. On physical examination, signs of edema, such as peripheral pitting edema and ascites, are often present due to persistent protein loss. Work-up is remarkable for hypoalbuminemia and alkaline gastric pH (hypochlorhydria), and microscopic features include foveolar dilatation, deficiency of parietal cells, smooth muscle cell hyperplasia and edema, plasma cell and eosinophilic infiltration, and presence of parallel mucosal gland ducts. Although the infantile MD has been associated with CMV infections, MD in adults has been associated with H. pylori and other infections (such as CMV, HSV, HIV, and M. pneumoniae); but treatment of these infections has not generally demonstrated efficacy in treating MD. Educational Objective: Menetrier's disease (MD) is a rare protein-losing enteropathy that is characterized by rugal hypertrophy of the gastric fundus and body. On physical examination, signs of edema, such as peripheral pitting edema and ascites, are often present due to persistent protein loss and hypoalbuminemia. References: Eisenstat DD, Griffiths AM, Cutz E, et al. Acute cytomegalovirus infection in a child with Ménétrier’s disease. Gastroenterology. 1995;109:592–595. Pryczynicz A, Bandurski R, Guzinska-Ustymowicz K, et al. Ménétrier's disease, a premalignant condition, with coexisting advanced gastric cancer: A case report and review of the literature. Oncol Lett. 2014; 8(1):441-5. Bayerdorffer E, Ritter MM, Hatz R, et al. Menetrier's disease and Helicobacter pylori. N Engl J Med. 1993;329:60. First Aid 2014 page 351]]
Approved	Approved::No
Keyword	WBRKeyword::Menetrier's disease, WBRKeyword::Gastric hypertrophy, WBRKeyword::Premalignant, WBRKeyword::Precancerous, WBRKeyword::Edema, WBRKeyword::Ascites, WBRKeyword::Hypoalbuminemia, WBRKeyword::Protein-losing gastropathy, WBRKeyword::Gastropathy, WBRKeyword::Abdominal pain, WBRKeyword::Nausea
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