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Old 05-19-2013
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Default gastroenterology q4

A 23-year-old woman is evaluated by her primary care physician for diffuse, crampy abdominal pain. She reports that she has had abdominal pain for the last sev-eral years, but it is getting worse and is now associated with intermittent diarrhea without flatulence. This does not waken her at night. Stools do not float and are not hard to flush. She has not noted any worsening with spe-cific foods, but she does have occasional rashes on her lower legs. She has lost about 5 kg over the last year. She is otherwise healthy and takes no medications. Which of the following is the most appropriate recommendation at this point?

A. Increased dietary fiber intake
B. Measurement of antiendomysial antibody
C. Measurement of 24-hour fecal fat
D. Referral to gastroenterologist for endoscopy
E. Trial of lactose-free diet
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Old 05-19-2013
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Originally Posted by cingulate.gyrus View Post
A 23-year-old woman is evaluated by her primary care physician for diffuse, crampy abdominal pain. She reports that she has had abdominal pain for the last sev-eral years, but it is getting worse and is now associated with intermittent diarrhea without flatulence. This does not waken her at night. Stools do not float and are not hard to flush. She has not noted any worsening with spe-cific foods, but she does have occasional rashes on her lower legs. She has lost about 5 kg over the last year. She is otherwise healthy and takes no medications. Which of the following is the most appropriate recommendation at this point?

A. Increased dietary fiber intake
B. Measurement of antiendomysial antibody
C. Measurement of 24-hour fecal fat
D. Referral to gastroenterologist for endoscopy
E. Trial of lactose-free diet
Wow this is a pretty good question... by being female and the nature of the symptoms I would be inclined to irritable bowel syndrome.. however she has lost some weight and has occasional rash on her lower legs... which dont go in favor of Irritable bowel syndrome.. there is not an association with specific foods therefore celiac B and E are out.. One must never refer in Simple choice questions contrary to CCS...

I will pick C haha.. probably wrong tho...
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Wow this is a pretty good question... by being female and the nature of the symptoms I would be inclined to irritable bowel syndrome.. however she has lost some weight and has occasional rash on her lower legs... which dont go in favor of Irritable bowel syndrome.. there is not an association with specific foods therefore celiac B and E are out.. One must never refer in Simple choice questions contrary to CCS...

I will pick C haha.. probably wrong tho...
Hai Xpezx ur thought process is good.
I appreciate it.... U have picked up the weight loss which excludes the IBD.

Weight loss is malabsorption... its not fat as it is not floating...so may be lactose which may be there in coeliac disease....rash - Dermatitis herpatiform. ? Supports it...
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Hai Xpezx ur thought process is good.
I appreciate it.... U have picked up the weight loss which excludes the IBD.

Weight loss is malabsorption... its not fat as it is not floating...so may be lactose which may be there in coeliac disease....rash - Dermatitis herpatiform. ? Supports it...
Yeah I know.. damn that is true.. the rash supports celiac disease.. then it would be option B.. I know I was wrong damn!
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The answer is B Measurement of antiendomysial antibody

The patient presents with nonspecific gastrointestinal symptoms, but the presence of weight loss suggests malabsorption syndrome. Patients with lactose intolerance are usually able to relate symptoms to consumption of milk-based products and also report a strong history of crampy pain and flatulence. Therefore, a lactose-free diet is unlikely to be helpful. The patient does not have nocturnal diarrhea, which is commonly a feature of steatorrhea along with floating stools. In the absence of symptoms suggesting fat malabsorption, the first test should not be fecal fat meas-urement. As the patient has weight loss, irritable bowel syndrome is less likely, and an increase dietary fiber is unlikely to be useful. Finally, her symptoms may be consistent with celiac disease. The widespread availability of antibodies to gliadin, endomysial, and tTG can be easily measured in peripheral blood. Antiendomysial antibody has a 9095% sensitivity and equal specificity, making it a reasonable first test in symptomatic indi-viduals. The presence of the antibody is not diagnostic, however, and duodenal biopsy is recommended. Duodenal biopsy will show villous atrophy, absence or reduced height of villi, cuboidal appearance of surface epithelial cells, and increased plasma cells in the lamina propria. These changes regress with complete removal of gluten from the diet.



lymphocytes and [/LIST]
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But guys....do we need to confirm malabsorption with 72hr fecal test before proceeding to do a specific test like antiandomysial antibodies test..? just a doubt...been a long time touching books....

Or is it like cumbersome to do that 72 hr stool collection, which i doubt anyone does it in hospitals now and hence do a specific test directly to identify the disease?

I agree that rash supports celiac as the cause of her symptoms...
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Yeah I know.. damn that is true.. the rash supports celiac disease.. then it would be option B.. I know I was wrong damn!

Never mind u r doing great......good going....I didnt think that much...
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"In the absence of symptoms suggesting fat malabsorption, the first test should not be fecal fat measurement."

oops got my answer....
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But guys....do we need to confirm malabsorption with 72hr fecal test before proceeding to do a specific test like antiandomysial antibodies test..? just a doubt...been a long time touching books....

Or is it like cumbersome to do that 72 hr stool collection, which i doubt anyone does it in hospitals now and hence do a specific test directly to identify the disease?

I agree that rash supports celiac as the cause of her symptoms...
I believe even the 24 Hr stool fat count is not done anymore.. moreso the 72 hr fat... I believe that anything that is faster and easier is done.. in this case and according to what I just read in MTB3 and I will quote this "The most sensitive test for any malabsorption sx is 72 hr fat, however the most accurate test will be small bowel biopsy and in the case of celiac disease the best initial test will be the measurements of the 3 common abs associated with the disease: Antigliadin, antiendomysial and anti tissue transglutaminase antibodies."
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Never mind u r doing great......good going....I didnt think that much...

Thank you! you were awesome in step 2 CK forum and now having you here is a big big plus
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I believe even the 24 Hr stool fat count is not done anymore.. moreso the 72 hr fat... I believe that anything that is faster and easier is done.. in this case and according to what I just read in MTB3 and I will quote this "The most sensitive test for any malabsorption sx is 72 hr fat, however the most accurate test will be small bowel biopsy and in the case of celiac disease the best initial test will be the measurements of the 3 common abs associated with the disease: Antigliadin, antiendomysial and anti tissue transglutaminase antibodies."
makes sense now.........thanks man.....
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