Sunday, February 22, 2015

A 60-year-old woman complains of diarrhea and weight loss for the past several weeks

A 60-year-old woman complains of diarrhea and weight loss for the past several weeks. She also complains of “hot flashes” similar to what she underwent 10 years ago during menopause. You notice several “spider veins” on her nose and cheeks.

On physical examination, you hear a heart murmur, which gets louder when she takes a deep breath.

The most helpful test you can order to confirm your suspected diagnosis is:
a. Serum serotonin level.
b. Liver ultrasound.
c. Serum sodium bicarbonate level.
d. Plasma chromogranin A (CgA) level.
e. Stool for Clostridium difficile.

The answer is d. The syndrome strongly suggests a carcinoid tumor, which accounts for up to one-third of small intestine tumors. Carcinoid involvement of the heart resulting in right-sided valvular lesions is a late manifestation of metastatic disease. The most sensitive screening test for small intestine carcinoids is a CgA level, which is elevated in almost 90% of patients with advanced small bowel carcinoid. Urinary 5-HIAA or platelet serotonin levels are also elevated in patients with metastatic carcinoid, but are less sensitive than CgA.

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