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Old 05-19-2013
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Default Gastroenterology q6

A 42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diar-rhea is large volume, occasionally greasy, and non-bloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossi-tis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well.

1. Which of the following is the most likely diag-nosis for this patient?
(A) chronic pancreatitis (B) Crohn’s disease (C) celiac sprue (D) Whipple disease (E) ulcerative colitis

2. Which of the following is the best test to con-firm the suspected diagnosis?
(A) abdominal CT scan with contrast (B) small bowel x-ray (C) esophagogastroduodenoscopy with small bowel biopsy (D) colonoscopy with colonic biopsy (E) 72-hour fecal fat quantification

23. What is the most serious long-term complica-tion this patient could face?
(A) pancreatic cancer (B) small bowel cancer (C) gastric cancer (D) colon cancer (E) rectal cancer
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Old 05-19-2013
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Originally Posted by cingulate.gyrus View Post
A 42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diar-rhea is large volume, occasionally greasy, and non-bloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossi-tis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well.

1. Which of the following is the most likely diag-nosis for this patient?
(A) chronic pancreatitis (B) Crohn’s disease (C) celiac sprue (D) Whipple disease (E) ulcerative colitis

History of smoking+Alcoholism suggest chronic pancreatitis

2. Which of the following is the best test to con-firm the suspected diagnosis?
(A) abdominal CT scan with contrast (B) small bowel x-ray (C) esophagogastroduodenoscopy with small bowel biopsy (D) colonoscopy with colonic biopsy (E) 72-hour fecal fat quantification

The best test would be secreting stimulation test, but of these only A makes sense...

23. What is the most serious long-term complica-tion this patient could face?
(A) pancreatic cancer (B) small bowel cancer (C) gastric cancer (D) colon cancer (E) rectal cancer
Pancreatic cancer risk increases with smoking alone.. if you add chronic pancreatitis and alcoholism the risk is way way more.. the only thing that bugs me is the lack of episodes of pancreatitis in the past.. but it is not necessary for the dx I believe...
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Old 05-19-2013
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Pancreatic cancer risk increases with smoking alone.. if you add chronic pancreatitis and alcoholism the risk is way way more.. the only thing that bugs me is the lack of episodes of pancreatitis in the past.. but it is not necessary for the dx I believe...
I am sorry XpaezX u again missed coeliac disease.
I too was suspecting pancreatitis thats why I put this question...

The key feature is skin manifestation. ?.
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Old 05-19-2013
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1(C)
2. (C)
3. (B)

Explanations

The patient has chronic diarrhea superimposed on a long history of loose stools, steatorrhea, and significant weight loss. While these fea-tures could be seen in several diseases, the pres-ence of the pruritic vesiculopapular lesions on his extensor surfaces makes the diagnosis highly likely to be celiac sprue, with its fre-quently accompanying skin manifestation der-matitis herpetiformis. Crohn’s disease is not usually associated with steatorrhea, and ulcer-ative colitis is often associated with bloody stools. Chronic pancreatitis and Whipple dis-ease could cause a similar clinical picture but would not have the associated skin findings.
A small bowel biopsy would confirm histopathologic features consistent with celiac sprue, such as villous atrophy and crypt hyperplasia. A small bowel biopsy could also diagnose or rule out Whipple disease by look-ing for the pathognomonic PAS (periodic acid-Schiff)

in celiac sprue. A fecal fat quantification would likely confirm and assess the degree of steatorrhea, but would offer little other diag-nostic information. A small bowel x-ray is too nonspecific to confirm the diagnosis and an abdominal CT scan would likely be normal unless the patient had developed a complica-tion of advanced sprue, such as intestinal lymphoma.

Patients with celiac sprue are at increased risk for malignancies of the small bowel with adenocarcinoma and lymphoma being the two most commonly encountered. Patients with celiac sprue are not at greatly increased risk of the other malignancies listed. Limited data suggest that strict adherence to a gluten-free diet may decrease the incidence of malignancy in these patients. (positive organism Tropheryma whippelii. Colonic biopsies would be unhelpfu
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Old 05-19-2013
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LOL, better to be wrong right now and nail the dx in the exam!
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Old 05-20-2013
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LOL, better to be wrong right now and nail the dx in the exam!


Sure thats how we learn......
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Old 05-26-2013
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C
C
B

Excellent question from Lange Q&A for step 3
__________________
The highest attainable standard of health is one of the fundamental rights of every human being!
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