Correct!
4. Perform percutaneous biopsy of a retroperitoneal lymph node
Among the choices listed, percutaneous biopsy of one of the enlarged lymph nodes in the retroperitoneum is the most direct approach to answer the question of whether or not there is a second process superimposed on the patient’s ulcerative colitis. Neither an upper gastrointestinal series nor upper endoscopy is indicated at this point because the patient does not have complaints referable to the upper gastrointestinal system. Chest MRI would offer no particular value for the evaluation of this patient. 18FDG-PET scan could be of benefit to determine if there are other sites of potential involvement by a second process, but there is already a target for such an evaluation- the retroperitoneal lymph nodes- and hence 18FDG-PET scan is premature at this point.
The retroperitoneal lymph node biopsy showed scant lymphoid tissue with histiocytic aggregates. The sample was insufficient for flow cytometry. Acid-fast bacilli staining and GMS staining for fungi on the biopsy sample were both negative. The patient underwent flexible sigmoidoscopy, which showed severe inflammation of the distal colon and rectum.
Which of the following represents an appropriate next step for the patient’s management? (Click on correct answer to be directed to the fourth of ten pages)