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NBME 18 Answers

nbme18/Block 2/Question#25 (30.3 difficulty score)
40 yo man, 1 year of orthostatic hypotension ...
Motility disorderπŸ”

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submitted by usmile1(103),

Like t123 said, I think the key to this question was to rule out the other answer choices as they would not have normal stool. I found this article that essentially breaks down GI disorders in diabetes into gastroparesis and intestinal enteropathy. These complications and their symptoms are often caused by abnormal GI motility, which is a consequence of diabetic autonomic neuropathy involving the GI tract.

Intestinal enteropathy in patients with diabetes may present as diarrhea, constipation, or fecal incontinence. The prevalence of diarrhea in patients with diabetes is between 4 and 22 percent.4,5 Impaired motility in the small bowel can lead to stasis syndrome, which can result in diarrhea. In addition, hypermotility caused by decreased sympathetic inhibition, pancreatic insufficiency, steatorrhea, and malabsorption of bile salts can further contribute to diarrhea. Abnormal internal and external anal sphincter function caused by neuropathy can lead to fecal incontinence. When evaluating a patient with diabetes who has diarrhea, drug-related causes (e.g., metformin [Glucophage], lactulose) should be considered.

cbreland  I agree, felt like all the other choices would have something odd in the stool studies +  
jurrutia  Orthostatic hypertension implies sympathetic dysfunction. Loss of sympathetic input causes dishinibition of intestinal motility. +  

submitted by t123(19),

This question is really testing what the different types of diarrhea show. Key is "stool shows no abnormalities". In malabsorption, exudative, osmotic, and secretory diarrhea, your poop would be weird in some way. A motility disorder is the ONLY type here that would cause normal poop.

myoclonictonicbionic  How would stool be different in secretory or osmotic diarrhea? They state that he has loose stool which could also indicate osmotic/secretory diarrhea. I think they are trying to hint that he has diabetes for 26yrs therefore he has diabetes enteropathy and therefore motility issues +4  
takayasuarteritis  I'm with you on this. I think it's a myenteric nerve plexus issue from long-standing diabetes. +10  
drpee  Neuropathy makes sense for T1DM, I guess I just expected a motility issue to cause constipation rather than diarrhea... +12  

submitted by sugaplum(323),
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azibird  That article does not once mention the word diarrhea. +2