09-27-2011, 06:37 PM
A 71-year-old woman is evaluated for a 2-day history of progressive dyspnea on exertion. She has also had two episodes of black, tarry stool in the past week. She has not had fever, chills, cough, or abdominal pain or bright red rectal bleeding. The patient has a history of osteoarthritis for which she takes ibuprofen, 600 mg twice daily.
On physical examination, the temperature is 37.0 °C (98.6 °F), the blood pressure is 136/84 mm Hg, the pulse rate is 78/min, and the respiration rate is 12/min; the BMI is 24. Cardiac examination shows a grade 2/6 early systolic murmur at the base and regular rhythm with normal heart sounds. The lungs are clear, and there is no peripheral edema. Rectal examination reveals brown stool that is positive for occult blood. Laboratory studies reveal hemoglobin of 9.8 g/dL (98 g/L) with a mean corpuscular volume of 80 fL; serum biochemistry tests, including liver chemistry tests, and prothrombin time, activated partial thromboplastin time, and INR are normal. Chest radiography and echocardiography are normal; esophagogastroduodenoscopy, colonoscopy, and push enteroscopy are normal. Small-bowel capsule endoscopy shows a nonbleeding white ulcer in the mid-ileum.
Which of the following is the most appropriate next step in the management of this patient?
A Discontinue ibuprofen therapy
B Double-balloon enteroscopy
C Estrogen/progesterone therapy
D Mesenteric angiography
E Octreotide therapy