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Old 06-26-2011
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Question What is expected if this diarrhea is left untreated?

A 19-year-old woman presents to the physician, because of intermittent watery diarrhea for the last 6 weeks. She has also lost 4 kg (8.8 lb) unintentionally over the last 2 months. Dermatitis herpetiformis is present bilaterally on the anterior lower limbs. Esophagogastroduodenoscopy is performed, and a biopsy taken in the duodenum. Histology reveals villous atrophy and crypt hyperplasia, as well as an increased number of lymphocytes in the lamina propria. If left untreated, what finding would be most expected?

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A. Hypercalcemia secondary to vitamin D deficiency
B. Macrocytic anemia secondary to vitamin B12 deficiency
C. Microcytic anemia secondary to iron deficiency
D. Nystagmus secondary to vitamin A deficiency
E. Perifollicular hemorrhages secondary to vitamin C deficiency

i think this is easy q and very imp they ask about it a lot
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Old 06-26-2011
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celiac disease.....



Over 80% with Dermatitis herpetiformis have celiac and 10% with celiac have Dermatitis herpetiformis..

i m with c because iron is absorbed in the duodenum...
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Old 06-26-2011
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Default B

I'll go for B
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iron deficiency
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Answer is D
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C. Microcytic anemia secondary to iron deficiency
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i would also go with C . iron deficiency.... B12 is absorbed in terminal ileum
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Option C (Microcytic anemia secondary to iron deficiency) is correct. Diarrhea, weight loss, and the biopsy findings are consistent with the diagnosis of celiac disease, a malabsorptive state primarily involving the proximal small bowel. The substances absorbed in the proximal small bowel most commonly resulting in a deficiency are iron, calcium, and folic acid. Consequently, the most likely finding will be an iron-deficiency anemia.

Option A (Hypercalcemia secondary to vitamin D deficiency) is incorrect. Vitamin D is a fat-soluble vitamin and fat absorption can be hindered in this patient with celiac disease. However, it would produce hypocalcemia, not hypercalcemia.

Option B (Macrocytic anemia secondary to vitamin B12 deficiency) is incorrect. Vitamin B12 is absorbed at the terminal ileum, the area most commonly affected by Crohn disease. Celiac disease also affects this area, but less commonly than the proximal bowel. It is less likely to result than iron-deficiency anemia.

Option D (Nystagmus secondary to vitamin A deficiency) is incorrect. Vitamin A is a fat-soluble vitamin, and deficiency could occur, but nystagmus is not a result of vitamin A deficiency. Rather, night vision impairments are characteristic. Iron deficiency remains more common.

Option E (Perifollicular hemorrhages secondary to vitamin C deficiency) is incorrect. Vitamin C is a water-soluble vitamin, and its absorption is not known to be impaired in patients with celiac disease. Perifollicular hemorrhages are a sign of vitamin C deficiency.

High-yield Hit 1
Celiac Sprue (also Nontropical Sprue, or Gluten-Sensitive Enteropathy)
Celiac disease is characterized by intestinal mucosal injury resulting from immunologic damage from gluten in persons genetically predisposed to this condition. The prevalence of the disease among relatives of patients with celiac sprue is approximately 10%. There is a strong association of celiac sprue with human leukocyte antigen (HLA) class II molecules, particularly HLA-DQ2 and HLA-DQ8. The disease is induced by exposure to storage proteins found in grain plants such as wheat (which contains gliadin), barley, and rye and their products. Oats are implicated not because of gliadin, but because of contamination with wheat during packaging and transportation. The exposure initiates a cellular immune response that results in mucosal damage, particularly in the proximal intestine. Results of investigations suggest that an enzyme, tissue transglutaminase, may be the autoantigen of celiac sprue.

From Cecil Essentials of Medicine 6E by Andreoli et al
High-yield Hit 2
Clinical Presentation.
Celiac disease can manifest with the classic constellation of symptoms and signs of a malabsorption syndrome. Not uncommonly, the manifestation may be atypical, with nonspecific GI symptoms such as bloating, chronic diarrhea (with or without steatorrhea), flatulence, lactose intolerance, or deficiencies of a single micronutrient, as in iron deficiency anemia. Extraintestinal complaints such as depression, weakness, fatigue, arthralgias, osteoporosis, or osteomalacia may predominate. A number of diseases, including dermatitis herpetiformis, type 1 diabetes mellitus, autoimmune thyroid disease, and selective immunoglobulin A (IgA) deficiency, are found in significant association with celiac disease.

From Cecil Essentials of Medicine 6E by Andreoli et al
High-yield Hit 3
Diagnosis.
Although celiac disease is a leading consideration in every patient with the malabsorption syndrome, it should be included as well in the differential of patients with atypical manifestations. Intestinal biopsy is the most valuable test in establishing the diagnosis of celiac sprue. There is a spectrum of pathologic changes ranging from normal villous architecture with an increase in mucosal lymphocytes and plasma cells (the infiltrative lesion) to partial blunting or total villous flattening. Although abnormal findings in intestinal biopsy are not specific, they are highly suggestive, particularly because most other conditions that can mimic celiac disease (such as Crohn's disease, gastrinoma, lymphoma, tropical sprue, graft-versus-host disease, or immune deficiency) may be distinguished on clinical grounds. A clinical response to a gluten-free diet, in the presence of an abnormal biopsy, establishes the diagnosis and precludes the need, in adults, to document healing by repeated biopsies. Serologic blood tests (antigliadin, antiendomysial, and reticulin antibodies) are helpful in screening of patients with atypical symptoms or asymptomatic relatives of patients with celiac sprue.
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