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  #1  
Old 10-25-2012
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GIT Localize the GI lesion?

A 35-year-old man presents to the physician with a 2-month history of non-bloody, non-mucoid, non-oily watery diarrhea. He has a diastolic murmur that gets louder with inspiration and is best heard over the left lower sternal border. His face is warm and appears to be engorged with blood for several minutes during the examination. Laboratory studies show:

Vanillylmandelic acid: 5 mg/day (normal 07 mg/day)
Metanephrine, urine: 250 μg/g of creatinine (normal 0300 μg/g)
Homovanillic acid, urine: 14 mg/day (normal 015 mg/day)
5-HIAA: 28 mg/day (normal 09 mg/day)

Gastrointestinal endoscopy is most likely to show a lesion located near which of the following?

A Gastroesophageal junction
B Ligament of Treitz
C Pancreaticoduodenal junction
D Rectosigmoid junction
E Splenic flexure
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Old 10-25-2012
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D Rectosigmoid junction
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Old 10-25-2012
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Metastatic Carcinoid syndrome
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Old 10-25-2012
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diagnosis--carcinoid tumor(mc small bowel tumor)

so, A,D,E can't be

will go with B) ligament of treitz.....thanks
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Old 10-25-2012
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yes B Ligament of Treitz more possible
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Old 10-25-2012
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Default my answer :)

Hmm.. nice question

sort of by exclusion: it's not A, C, D, nor E (if at all I think we would find something near the hepatic flexure - liver metas?)

so B Ligament of Treitz but still not sure

thanks for posting! can't wait to see the answer
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Old 10-25-2012
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Default My answer B

A tumor carcinoid without metastasis to the liver can NOT be clinical evident, so the posible anatomic place is the treitz ligament, spreading through portal vein to the liver
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The correct answer is B. This patient presents with chronic diarrhea, intermittent facial flushing, and a murmur consistent with tricuspid stenosis, a triad of findings classic for carcinoid syndrome. One-third of carcinoid tumors of the gastrointestinal tract occur in the midgut-derived small bowel, which begins at the ligament of Treitz and ends at the mid transverse colon. While adenocarcinoma is the most common type of small bowel tumor, carcinoid tumors are most likely to occur in the small bowel. Carcinoid tumors of the small intestine secrete serotonin, which is usually metabolized by the liver and doesn't cause the symptoms of the carcinoid syndrome. However, when metastases to the liver are present, the bioactive amines can no longer be metabolized and enter the systemic circulation causing diarrhea, abdominal cramps, gastrointestinal bleeding, malabsorption, flushing, bronchospasm, and right heart valvular disease from serotonin-mediated fibroelastosis. Electron microscopy reveals "salt and pepper" granulation of cells, consistent with their neuroendocrine origin. An elevated urinary 5-HIAA level is diagnostic of carcinoid syndrome.

Answer A is incorrect. The gastroesophageal junction is affected by gastroesophageal reflux disease, not carcinoid tumors.

Answer C is incorrect. The pancreaticoduodenal junction is the site where pancreatic endocrine and exocrine secretions empty into the small bowel to aid in digestion. It is part of the foregut-derived intestine, and it is a rare site for carcinoid tumors.

Answer D is incorrect. The rectosigmoid junction is not a common location for carcinoid tumors.

Answer E is incorrect. The splenic flexure is a watershed area that is susceptible to ischemic damage if cardiac output becomes low. It is not, however, a common site for carcinoid tumors.
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Old 10-25-2012
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carcinoid syndrome appendix> rectosigmoid junction
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