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Old 08-29-2012
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GIT GI Question

A 55 year old male comes to the physician with a history of diarrhea, weight loss, bloating ,and excessive flatulence. He has a history of gastric ulcers and was well until 2 years ago, when he has an abdominal surgery at a small rural hospital for abdominal pain and a low blood count. He is unable to give any further details of the surgery. He has since had episode of watery and loose bowel movements with bloating and excessive flatulence,20 pounds weight loss in the past year and vague diffuse abdominal discomfort. His current medications are omeprazole and multivitamins. His BP 120/70, pulse 84 and resp 14/min.
Physical examination shows a large midline scar on the abdomen associated with past surgery ,and abdomen distention with identifiable succussion splash.laboratory studies show anemia with MCV of 105 fl.Which of the following is the most likely diagnosis?

A. Short bowel syndrome
B. Bacterial overgrowth
C. Peptic ulcer disease
D. Crohns disease
E. Ulcerative colitis

Please everyone give it a try .....
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Old 08-29-2012
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Chrons disease...
With history of strictures in past and blind loup syndrome..?
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Old 08-29-2012
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Try try try anyone ?
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Old 08-29-2012
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I would go with short bowel syndrome due to surgical resection.


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Old 08-29-2012
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I think it is peptic ulcer disease, the patient was fine and had gastric ulcers only then had surgery for ULCERs from a RURAL center,surgeon may have done a bilroth surgery and cut down the stomach and now he is having DUMPING SYNDROME, he has MCV showing megaloblastic anemia that might be due to Vitamin B12 deficiency (half stomach removed), if it was due to small Gut surgery alone it would have been Microcytic anemia.

Well this is my theory i would like to know the answer..
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Old 08-29-2012
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You know, I wanna say its Crohn.

Huge scar is definitely some previous big bowel resection...
So I was left with Short Bowel / Crohn / UC...

Those ulcers in the stomach kinda tempt to go with UC,
But the splash makes me wanna think of a transmural inflamation/perforation or fistula with some leak into peritoneum.

Crohn's
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Quote:
Originally Posted by Syndrome X View Post
I think it is peptic ulcer disease, the patient was fine and had gastric ulcers only then had surgery for ULCERs from a RURAL center,surgeon may have done a bilroth surgery and cut down the stomach and now he is having DUMPING SYNDROME, he has MCV showing megaloblastic anemia that might be due to Vitamin B12 deficiency (half stomach removed), if it was due to small Gut surgery alone it would have been Microcytic anemia.

Well this is my theory i would like to know the answer..
Smart.
But IF-B12 complex might simply not being able to be absorbed in the resected gut...

But you are right about rural hospital - fixing ulcer with a jigsaw...
Lets see whet S_E will say
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Old 08-29-2012
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Quote:
Originally Posted by step_enhancer View Post
A 55 year old male comes to the physician with a history of diarrhea, weight loss, bloating ,and excessive flatulence. He has a history of gastric ulcers and was well until 2 years ago, when he has an abdominal surgery at a small rural hospital for abdominal pain and a low blood count. He is unable to give any further details of the surgery. He has since had episode of watery and loose bowel movements with bloating and excessive flatulence,20 pounds weight loss in the past year and vague diffuse abdominal discomfort. His current medications are omeprazole and multivitamins. His BP 120/70, pulse 84 and resp 14/min.
Physical examination shows a large midline scar on the abdomen associated with past surgery ,and abdomen distention with identifiable succussion splash.laboratory studies show anemia with MCV of 105 fl.Which of the following is the most likely diagnosis?

A. Short bowel syndrome
B. Bacterial overgrowth
C. Peptic ulcer disease
D. Crohns disease
E. Ulcerative colitis

Please everyone give it a try .....
wil go with A- short bowel syndrome.
h/o surgery at rural hospital with abdominal pain and midline scar suggest open surgery probably resection of bowel. patient is on multivitamins yet shows megaloblastic anemia , presentation of dumpling syndrome further adds to answer.
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Old 08-29-2012
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Quote:
Originally Posted by step_enhancer View Post
A 55 year old male comes to the physician with a history of diarrhea, weight loss, bloating ,and excessive flatulence. He has a history of gastric ulcers and was well until 2 years ago, when he has an abdominal surgery at a small rural hospital for abdominal pain and a low blood count. He is unable to give any further details of the surgery. He has since had episode of watery and loose bowel movements with bloating and excessive flatulence,20 pounds weight loss in the past year and vague diffuse abdominal discomfort. His current medications are omeprazole and multivitamins. His BP 120/70, pulse 84 and resp 14/min.
Physical examination shows a large midline scar on the abdomen associated with past surgery ,and abdomen distention with identifiable succussion splash.laboratory studies show anemia with MCV of 105 fl.Which of the following is the most likely diagnosis?

A. Short bowel syndrome
B. Bacterial overgrowth
C. Peptic ulcer disease
D. Crohns disease
E. Ulcerative colitis

Please everyone give it a try .....
in real exam with pressure, i would do C !! whats ans ?
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Old 08-29-2012
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Quote:
Originally Posted by doxorubicin View Post
wil go with A- short bowel syndrome.
h/o surgery at rural hospital with abdominal pain and midline scar suggest open surgery probably resection of bowel. patient is on multivitamins yet shows megaloblastic anemia , presentation of dumpling syndrome further adds to answer.
as per my know, short bowel syndrome is when you remove small bowel loop. isnt ? that then leads to diarrhea and stuff. but then why this patient getting succussion splash. he has history of gastric ulcer, short bowel syndrome isnt complication for billroth..is it ?
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Old 08-29-2012
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Quote:
Originally Posted by tyagee View Post
as per my know, short bowel syndrome is when you remove small bowel loop. isnt ? that then leads to diarrhea and stuff. but then why this patient getting succussion splash. he has history of gastric ulcer, short bowel syndrome isnt complication for billroth..is it ?
that's true it isnt complication of billroth but as here question does not mention what surgery the patient. had and assuming it involved removing small bowel somehow as patient shows midline scar and malabsorption symptoms. i say its small bowel syndrome.
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Old 08-29-2012
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Quote:
Originally Posted by step_enhancer View Post
A 55 year old male comes to the physician with a history of diarrhea, weight loss, bloating ,and excessive flatulence. He has a history of gastric ulcers and was well until 2 years ago, when he has an abdominal surgery at a small rural hospital for abdominal pain and a low blood count. He is unable to give any further details of the surgery. He has since had episode of watery and loose bowel movements with bloating and excessive flatulence,20 pounds weight loss in the past year and vague diffuse abdominal discomfort. His current medications are omeprazole and multivitamins. His BP 120/70, pulse 84 and resp 14/min.
Physical examination shows a large midline scar on the abdomen associated with past surgery ,and abdomen distention with identifiable succussion splash.laboratory studies show anemia with MCV of 105 fl.Which of the following is the most likely diagnosis?

A. Short bowel syndrome
B. Bacterial overgrowth
C. Peptic ulcer disease
D. Crohns disease
E. Ulcerative colitis

Please everyone give it a try .....
I would go with B
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Old 08-29-2012
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Originally Posted by Anders View Post
I would go with B
The development of the symptoms along with the hx of peptic ulcer& surgery may indicate bacterial overgrowth . One of the peptic ulcer surgey consequences is B because of the blind loop formation & stasis of intestinal content.
Bacterial consumption of vit. B 12 & iron result in their deficiencies.
If it affect proximal bowel most likely be Iron , if it affects the distal bowel can result into Vit. B 12 deficiency & that what we see in this case.
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Old 08-29-2012
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this is a Uworld question
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Old 08-29-2012
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D. agree with Doc Sikorski
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Quote:
Originally Posted by step_enhancer View Post
A 55 year old male comes to the physician with a history of diarrhea, weight loss, bloating ,and excessive flatulence. He has a history of gastric ulcers and was well until 2 years ago, when he has an abdominal surgery at a small rural hospital for abdominal pain and a low blood count. He is unable to give any further details of the surgery. He has since had episode of watery and loose bowel movements with bloating and excessive flatulence,20 pounds weight loss in the past year and vague diffuse abdominal discomfort. His current medications are omeprazole and multivitamins. His BP 120/70, pulse 84 and resp 14/min.
Physical examination shows a large midline scar on the abdomen associated with past surgery ,and abdomen distention with identifiable succussion splash.laboratory studies show anemia with MCV of 105 fl.Which of the following is the most likely diagnosis?

A. Short bowel syndrome
B. Bacterial overgrowth
C. Peptic ulcer disease
D. Crohns disease
E. Ulcerative colitis

Please everyone give it a try .....
B. Bacterial overgrowth leading to malabsorption (B12 deficiency----> magaloblastic anemia) due to blind loop syndrome aka afferent loop syndrome

Unlikely to be:

A. Short bowel syndrome since he had surgery for a bleeding gastric ulcer.

C. Peptic ulcer disease since he is on Omeprazole

D. Crohns disease his symptoms are more of malabsorption than IBD

E. Ulcerative colitis his symptoms are more of malabsorption than IBD

Last edited by Novobiocin; 08-29-2012 at 05:50 PM.
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Quote:
Originally Posted by Novobiocin View Post
B. Bacterial overgrowth leading to malabsorption (B12 deficiency----> magaloblastic anemia) due to blind loop syndrome aka afferent loop syndrome

Unlikely to be:

A. Short bowel syndrome since he had surgery for a bleeding gastric ulcer.

C. Peptic ulcer disease since he is on Omeprazole

D. Crohns disease his symptoms are more of malabsorption than IBD

E. Ulcerative colitis his symptoms are more of malabsorption than IBD
Answer B. Bacterial Overgrowth
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Answer. B Bacterial overgrowth

Choice B.This patient had a surgery for a bleeding peptic ulcer that created an afferent loop of the small inestine that then became stagnant and led to bacterial overgrowth.The clinical manifestation may be non specific and include abdominal pain,watery diarrhea ,dyspepsia and weight loss.Advanced cases may also have tetany(hypocalcemia due to vitamin d deficiency) ,night blindness,due to vit A deficiency,neuropathy from Vit B12 deficiency,dermatitis,arthiritis and hepatic injury
Physical examination may reveal abdominal distention with identifiable succussion splash from palpable soft,fluid filled loops of bowel.Macrocytic can be seen due to Vit B12 deficiency.
Diagnosis -An upper GI follow through can help diagnose bacterial overgrowth by showing hypomotility, partial obstruction, dilation, with delayed Gastrointestinal motility.The Gold standard is obtaining jejunal aspirate during endoscopy showing excessive bacterial concentrations.
Treatment -is dedicated at the underlying cause ,dietary changes and antibiotics.This patient should be treated with a course of antibiotics and may require another surgery to correct his anatomic defects leading to bacterial overgrowth.

Choice A Short bowel syndrome is usually due to massive resection of the small intestine in diseases such as crohn's disease requiring surgery.It is unlikely since this patient had a surgery for peptic ulcer disease ,in which significant segments of small intestine are not removed.

Choice C This patient already had a history of peptic ulcer disease treated with ompeprazole ,but his curretn symptoms are not concictent with peptic ulcer disease.

Choice D and E This patient's history of abdominal surgery due to peptic ulcer disease makes bacterial overgrowth a more plausible diagnosis than Crohns diesase or ulcerative colitis .
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Oh I missed it..I was searching for cause of blind loop syndrome...I thought Chrons diesease can cause blind loops due to strictures...

Thanks for the discussion...
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Old 08-30-2012
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9/10 by a scale of crazy/hardness question
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9/10 by a scale of crazy/hardness question
Totally agreed
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if question of this level comes as last question of last block
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Old 09-13-2012
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Just came across this q in UW.

14% answered right (bacterial owergrowth) and 75% answered short bowel syndrome...

I have noticed that GI section of UW is the least fair 92 questions.
Explanations are vague and most of the questions can be answered with at least 2 answer options.

Kinda feels like these are old questions from some other format where you could chose up to 4 right answers...

Ridiculous
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