View source for WBR0176

{{WBRQuestion
|QuestionAuthor={{YD}} (Reviewed by {{YD}})
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|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?
|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 cell]]s, [[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. 
|AnswerA=Ascites
|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.
|AnswerB=Dysarthria
|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. 
|AnswerC=Hemorrhoids 
|AnswerCExp=Hemorrhoids may be observed among patients with portal hypertension due to back-up of blood flow in the portal circulation. 
|AnswerD=Splenomegaly
|AnswerDExp=Splenomegaly may be observed among patients with hematological disorders and portal hypertension due to back-up of blood flow in the portal circulation. 
|AnswerE=Nystagmus
|AnswerEExp=Nystagmus may be a sign of eye disease, but is also a common ophthalmological manifestation of inner ear and neurological or diseases.
|EducationalObjectives=[[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.<br>
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.<br>
Bayerdorffer E, Ritter MM, Hatz R, et al. Menetrier's disease and Helicobacter pylori. N Engl J Med. 1993;329:60.<br>
First Aid 2014 page 351
|RightAnswer=A
|WBRKeyword=Menetrier's disease, Gastric hypertrophy, Premalignant, Precancerous, Edema, Ascites, Hypoalbuminemia, Protein-losing gastropathy, Gastropathy, Abdominal pain, Nausea 
|Approved=No
}}