The next step of management of this GIT case - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 06-24-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
GIT The next step of management of this GIT case

A 23-year-old female presents to the university health clinic with a 6-week history of vague abdominal pain and altered stools. Her stools have been unusually bulky and foul-smelling over this period. She has had reduced appetite and lost 4 kg (8.8 lb) unintentionally over the last month. She is a graduate student in anthropology and was on an expedition in India 5 months ago. On examination, there is glossitis, stomatitis, and generalized pallor. Her abdomen is diffusely tender to superficial palpation, and bowel sounds are normal. Laboratory investigations reveal a macrocytic anemia. A 72-hour stool collection reveals elevated fat content. A D-xylose absorption test is also abnormal. Jejunal biopsy reveals mild villous atrophy. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Gluten-free diet
B. Lactose-free diet
C. Metronidazole
D. Total colectomy
E. Trimethoprim-sulfamethoxazole
Reply With Quote Quick reply to this message
The above post was thanked by:
cerebrum85 (07-27-2011)



  #2  
Old 06-24-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default

History of travel and symptoms suggest Giardiasis.

Treat with Metronidazole.
Reply With Quote Quick reply to this message
  #3  
Old 06-24-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

Quote:
Originally Posted by ibmsyd View Post
History of travel and symptoms suggest Giardiasis.

Treat with Metronidazole.

A 31-year-old man presents to the university health clinic with diarrhea, flatulence, and abdominal cramps for the last week. He has also had a subjective feeling of bloating and has felt nauseous during this period. The diarrhea is described as foul-smelling and watery. He specifically denies seeing blood or mucous. His symptoms began shortly after returning from a camping trip in the Pacific Northwest of the United States. Physical examination is normal. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Bismuth subsalicylate
B. Intravenous saline
C. Metronidazole
D. Oral vancomycin
E. Trimethoprim-sulfamethoxazole
Explanation
Option C (Metronidazole) is correct. Watery diarrhea combined with bloating and abdominal cramps following a camping trip is highly suspicious of Giardiasis. Infection with Giardia lamblia is one of the clear indications for antibiotic therapy in infectious diarrhea, and the agent of choice is metronidazole.

Option A (Bismuth subsalicylate) is incorrect. This is a modifier of fluid transport and may somewhat ease the symptoms, but antibiotics are clearly indicated in this situation.

Option B (Intravenous saline) is incorrect. Patients who present with severe diarrhea may be significantly dehydrated and require intravenous fluids. In this patient, physical examination was normal, indicating that intensive rehydration is not needed.

Option D (Oral vancomycin) is incorrect. This is a second-line treatment for Clostridium difficile overgrowth and pseudomembranous colitis.

Option E (Trimethoprim-sulfamethoxazole) is incorrect. TMP-SMX is often used in infectious diarrhea, but in this case, metronidazole is the agent of choice.
Reply With Quote Quick reply to this message
 
  #4  
Old 06-24-2011
USMLE Forums Addict
 
Steps History: Not yet
Posts: 192
Threads: 0
Thanked 47 Times in 40 Posts
Reputation: 57
Default

Quote:
Originally Posted by miss patho View Post
A 23-year-old female presents to the university health clinic with a 6-week history of vague abdominal pain and altered stools. Her stools have been unusually bulkyand foul-smelling over this period. She has had reduced appetite and lost 4 kg (8.8 lb) unintentionally over the last month. She is a graduate student in anthropology and was on an expedition in India 5 months ago. On examination, there is glossitis, stomatitis, and generalized pallor. Her abdomen is diffusely tender to superficial palpation, and bowel sounds are normal. Laboratory investigations reveal a macrocytic anemia. A 72-hour stool collection reveals elevated fat content. A D-xylose absorption test is also abnormal. Jejunal biopsy reveals mild villous atrophy. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Gluten-free diet
B. Lactose-free diet
C. Metronidazole
D. Total colectomy
E. Trimethoprim-sulfamethoxazole
glossitis, stomatitis, and generalized pallor macrocytic anemia indicate B12 or folic acid malabsorbtion so no lactose intolerance//

no blood or mucus diarhoeano skip lessions string sign so no crohn no D(i think no total colectomy anyway)

whipple is rare and in biopsy pAS + macrophages no E

celiac has characteristic findings in biopsy no A

positive history of recent trip mild atrophy-not characteristic points to c. lamblia maybe(very very common)...in microscope it looks back to you
Reply With Quote Quick reply to this message
  #5  
Old 06-24-2011
USMLE Forums Addict
 
Steps History: CK+CS
Posts: 144
Threads: 34
Thanked 82 Times in 37 Posts
Reputation: 92
Warning!

Quote:
Originally Posted by MANIAKOS View Post
glossitis, stomatitis, and generalized pallor macrocytic anemia indicate B12 or folic acid malabsorbtion so no lactose intolerance//

no blood or mucus diarhoeano skip lessions string sign so no crohn no D(i think no total colectomy anyway)

whipple is rare and in biopsy pAS + macrophages no E

celiac has characteristic findings in biopsy no A

positive history of recent trip mild aatrophy-not characteristi points to c..lamblia maybe(very very common)...in microscope it looks back to you
SOOO it is malabsorption dt G.Lambilia....???
he had stool analysis for fat while not asking for stool examination of parasites...??!!!!!!!!!!!!!!!!...
__________________
“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning. ”
Albert Einstein
Reply With Quote Quick reply to this message
  #6  
Old 06-24-2011
USMLE Forums Addict
 
Steps History: Not yet
Posts: 192
Threads: 0
Thanked 47 Times in 40 Posts
Reputation: 57
Default

Quote:
Originally Posted by cerebrum85 View Post
SOOO it is malabsorption dt G.Lambilia....???
he had stool analysis for fat while not asking for stool examination of parasites...??!!!!!!!!!!!!!!!!...
stool microscopic examination is usually negative when searching for G.L..
ELISA can be used here..

infection from G.L can be asymptomatic but can lead to malabsorbation too..
Reply With Quote Quick reply to this message
The above post was thanked by:
cerebrum85 (06-28-2011)
  #7  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default


Acute giardiasis

Acute giardiasis occurs in less than half of people infected with Giardia. Symptoms include:
-Diarrhea that is sudden in onset and may be initially watery-(90% patients)
-Malaise(85%)
-Foul-smelling and fatty stools (steatorrhea)—(70%)
-Abdominal cramps and bloating —(70%)
-Flatulence —(75%)
-Nausea —(70%)
-Weight loss —(65%)
-Vomiting —(30%)

Fever occurs in only 10 to 15 percent of patients and may be unrelated to giardiasis. Symptoms usually develop after an incubation period of one to two weeks (range 1 to 45 days). Distinguishing features of giardiasis are the prolonged duration of symptoms, often at least two to four weeks, and the associated significant weight loss (10 percent of body weight) that occurs in over 50 percent of cases. Clinical findings that have helped identify cases of giardiasis in epidemiologic studies include a duration of illness lasting seven or more days with at least two of the following six symptoms: diarrhea, flatulence, foul-smelling stools, nausea, abdominal cramps, and excessive fatigue.

Chronic giardiasis
Chronic giardiasis may follow the acute phase of illness or may develop without an antecedent acute illness. In one study, 84 percent of experimentally infected people self-cured by a mean of 18.4 days following inoculation, while the remainder became chronically infected. A chronic syndrome can develop in as many as 30 to 50 percent of symptomatic patients characterized by:
-Loose stools but usually not diarrhea
-Steatorrhea
-Profound weight loss
-Malabsorption
-Malaise
-Fatigue
-Depression

Other symptoms can include abdominal cramping, borborygmi, flatulence, and burping. The manifestations often wax and wane over many months.

Malabsorption is well documented and may be responsible for the significant weight loss that can occur in giardiasis (10 to 20 percent of body weight). Even when the infection is asymptomatic, malabsorption of fats, sugars, carbohydrates and vitamins may occur. This can lead to vitamin deficiencies (A, B12), folate deficiency, hypoalbuminemia, and especially secondary lactase deficiency.

[Source: UpToDate]
Reply With Quote Quick reply to this message
  #8  
Old 06-25-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

my friends try to think in another choice
Reply With Quote Quick reply to this message
  #9  
Old 06-25-2011
kemoo's Avatar
USMLE Forums Guru
 
Steps History: 1+CK+CS
Posts: 378
Threads: 161
Thanked 103 Times in 52 Posts
Reputation: 117
Default

i would go with A
Reply With Quote Quick reply to this message
  #10  
Old 06-25-2011
USMLE Forums Scout
 
Steps History: 1+CK+CS
Posts: 91
Threads: 3
Thanked 120 Times in 47 Posts
Reputation: 130
Default

Also go with A.
Reply With Quote Quick reply to this message
  #11  
Old 06-25-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

think more my friends
to find the answer
Reply With Quote Quick reply to this message
  #12  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: Not yet
Posts: 192
Threads: 0
Thanked 47 Times in 40 Posts
Reputation: 57
Default

Quote:
Originally Posted by miss patho View Post
think more my friends
to find the answer
Whipple? this is infectious too...so E
although i didn't say previously.....

i'm very curious about the answer...

Why only Jejunal biopsy?

Last edited by MANIAKOS; 06-25-2011 at 05:45 AM. Reason: incomplete
Reply With Quote Quick reply to this message
  #13  
Old 06-25-2011
USMLE Forums Scout
 
Steps History: 1+CK+CS
Posts: 91
Threads: 3
Thanked 120 Times in 47 Posts
Reputation: 130
Default

I also thought of Whipple disease, but biopsy should have demonstrated PAS+ macrophages. Also, initial therapy (next step in management) should be parenteral ceftriaxone, and then followed by TMP/SMX for 1 year.
Reply With Quote Quick reply to this message
  #14  
Old 06-25-2011
aksyonez's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 218
Threads: 74
Thanked 116 Times in 64 Posts
Reputation: 128
Default

Answer is E because this is Tropical Sprue which is different than celiac sprue . It can cause flattening of the vili and inflammation of lining of small intestines. Symptoms are diarrhea, weight loss , steattorhea and vitamin deficiencies : vit A, Vit B12 and folic acid, vit D and Calcium.. It occurs in tropical climates : Carribean, Asia and it is endemic in INDIA.
Treatment is TMP-SMX or tetracycline and vit B12 and folic acid for at least 6 months.
Reply With Quote Quick reply to this message
  #15  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: 1+CK+CS
Posts: 132
Threads: 11
Thanked 185 Times in 70 Posts
Reputation: 195
Default

The following is the info I gathered from qbank questions:

-suspect in diarrhea with recent travel of > 1 month in endemic areas such as Puerto Rico
-chronic diarrheal disease characterized by malabsorption of nutrients, esp B-12 and folic acid (leading to megaloblastic anemia)
-etiology unknown, but most likely infectious
-sx of malabsorption: glossitis, cheilosis, protuberant abdomen, pallor, pedal edema
-also fatty diarrhea, cramps, gas, fatigue and progressive weight loss
-hyperactive bowel sounds and borborygmi on PE
-dx: small intestine mucosal biopsy, shows blunting of villi and infiltration of chronic inflammatory cells, including lymphocytes, plasma and eosinophils
tx: tetracycline (or TMP-SMX) and vit B12 and folic acid for 3-6 months
Reply With Quote Quick reply to this message
The above post was thanked by:
cerebrum85 (07-27-2011), USMLE-Syndrome (06-25-2011)



  #16  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default

Why can't the diagnosis be giardiasis?

Steatorrhea, weight loss, vitamin deficiencies, abnormal D-xylose absorption test and villous atrophy can all be found in giardiasis.

In tropical sprue, small intestinal biopsy will show mucosal infiltration with chronic inflammatory cells including lymphocytes, plasma cells, and eosinophils, in addition to blunting of villi.
Reply With Quote Quick reply to this message
  #17  
Old 06-25-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

Quote:
Originally Posted by ibmsyd View Post
Why can't the diagnosis be giardiasis?

Steatorrhea, weight loss, vitamin deficiencies, abnormal D-xylose absorption test and villous atrophy can all be found in giardiasis.

In tropical sprue, small intestinal biopsy will show mucosal infiltration with chronic inflammatory cells including lymphocytes, plasma cells, and eosinophils, in addition to blunting of villi.
return to uw there is q like this also
the biopsy make the dx so that is y not giardiasis
Reply With Quote Quick reply to this message
  #18  
Old 06-25-2011
aksyonez's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 218
Threads: 74
Thanked 116 Times in 64 Posts
Reputation: 128
Default

So miss patho, what is the answer?
Reply With Quote Quick reply to this message
  #19  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default

Quote:
Originally Posted by miss patho View Post
return to uw there is q like this also
the biopsy make the dx so that is y not giardiasis
Well,i read from UpToDate that blunting of villi on biopsy can be seen in giardiasis.
For me, UpToDate is a much more reliable source than UW. Anyway,that's just my opinion.
Reply With Quote Quick reply to this message
  #20  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: 1+CK+CS
Posts: 132
Threads: 11
Thanked 185 Times in 70 Posts
Reputation: 195
Default

I believe the D-xylose absorption test is also normal in giardiasis
Reply With Quote Quick reply to this message
  #21  
Old 06-25-2011
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 132
Threads: 1
Thanked 120 Times in 51 Posts
Reputation: 130
Default

Quote:
Originally Posted by healer2b View Post
I believe the D-xylose absorption test is also normal in giardiasis
D-xylose absorption test
Lower than normal values may be seen in:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004073/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001333/
Reply With Quote Quick reply to this message
  #22  
Old 06-25-2011
USMLE-Syndrome's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,203
Threads: 180
Thanked 1,251 Times in 441 Posts
Reputation: 1265
Default

Option E (Trimethoprim-sulfamethoxazole) is correct. This patient has tropical sprue. The diagnosis is made by the travel history to an endemic area combined with confirmed malabsorption to two substances as well as biopsy findings of villous blunting. The exact etiology of tropical sprue is unknown, but an infectious agent is strongly suspected. Consequently, tetracycline or trimethoprim-sulfamethoxazole (TMP-SMX) are first-line agents for therapy. Ampicillin can also be used.

Option A (Gluten-free diet) is incorrect. A gluten-free diet is the recommended management of celiac disease. The temporal relationship between travel to an endemic region combined make tropical sprue more likely.

Option B (Lactose-free diet) is incorrect. The history does not provide a link between the symptoms and lactose intolerance. The test of choice is the breath hydrogen test, which is able to detect lactase deficiency.

Option C (Metronidazole) is incorrect. Metronidazole is not known to be effective in the treatment of tropical sprue. It is first-line therapy for pseudomembranous colitis.

Option D (Total colectomy) is incorrect. Total colectomy is not indicated in this patient. It is a treatment option for ulcerative colitis.

High-yield Hit 1
DEFINITION
Tropical sprue is a malabsorption syndrome occurring primarily in tropical regions, including Puerto Rico, India, and Southeast Asia.

From Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 2
PHYSICAL FINDINGS & CLINICAL PRESENTATION
Diffuse, nonspecific abdominal tenderness and distention
Low-grade fever
Glossitis, cheilosis, hyperkeratosis, hyperpigmentation
Diarrhea
ETIOLOGY
Unknown
Associated with overgrowth of predominantly coliform bacteria in the small intestine
DIAGNOSIS
The clinical features of tropical sprue include anorexia, diarrhea, weight loss, abdominal pain, and steatorrhea; these symptoms can develop in expatriates even several months after immigrating to temperate regions.

From Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 3
WORKUP
Diagnostic workup includes a comprehensive history (especially travel history), physical examination, laboratory evidence of malabsorption (see "Laboratory Tests"), and jejunal biopsy; the biopsy results are nonspecific, with blunting, atrophy, and even disappearance of the villi and subepithelial lymphocytic infiltration.
Reply With Quote Quick reply to this message
The above post was thanked by:
cerebrum85 (07-27-2011), drmuh (06-26-2011)



Reply

Tags
Gastroenterology-, Infectious-Diseases, Step-2-Questions

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Digoxin Toxicity Management; Initial step! docoftheworld USMLE Step 2 CK Forum 9 06-15-2011 12:35 PM
Cardiology Case: Next step in managment? kemoo USMLE Step 2 CK Forum 0 05-17-2011 11:30 PM
We have a Hypertensive Management case here! incidentaloma USMLE Step 2 CK Forum 8 04-06-2011 09:38 AM
Looking for USMLE Step 2 CS study partner in Cleveland, OH, better near CASE doctor226 USMLE Step 2 CS Study Partners 0 02-26-2011 05:59 AM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)