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NBME 23 Answers

nbme23/Block 2/Question#33

A 68-year-old man who has been treated for the past ...

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submitted by emh(2),

Prostaglandins increase GI motility due to peristalsis. It's the same reason why the uterus contracts during menstruation.





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submitted by dubchak7(0),

They suggest Misoprostol to counteract NSAIDs... Why not PPIs?

hayayah  PPI's don't have many side effects! If the question didn't involve the diarrhea side effect the answer would have been to give her a PPI. +  
tsarcoidosis  I guess one takeaway is that PPIs don't directly cause diarrhea, but they do increase the risk for C-diff, which causes diarrhea. +2  
usmleuser007  PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium) +  
temmy  The patient got severe gastric burning and discomfort as an effect of the drug. My logic was since the patient was taking an NSAID it had to be a COX 1 inhibitor that destroys the protective barrier of the GI mucosa due to inhibition of prostaglandin so we needed to treat with a drug that will regenerate prostaglandin and prostaglandin is a vasodilation which might be the reason for the diarrhea. +  




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submitted by mousie(84),

Not sure I am understanding this question - the patient got an NSAID for RA and this decreased her prostaglandins so she developed GERD... Doc added Misoprostol to counteract the decreased Prostaglandins I the gut and an adverse reaction of Misoprostol is diarrhea .. Correct?

chris07  Yes. Diarrhea is a side effect of misoprostol. +1  




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submitted by criovoly(2),

The first drug given was an NSAID (prostaglandins inhibitor) this caused GERDS/ulcer because of decrease mucosal protection.

The second drug was misoprostol which gives mucosa protection and a common side effect is diarrhea.





My guess for not choosing PPI is because the duration of drug-using. PPI increases the risk of C. diff by long-term using which considered as over 1 year of using. This pt should have used the second drug less than 4 weeks according to the question. So PPI is unlikely to cause C. diff diarrhea within this short period of usage, especially when this pt is not immunocompromised, or using antibiotics.





PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium)

imnotarobotbut  That's not the right answer tho, the answer is the binding of PGE to it's receptor +  
tinydoc  Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1  
maxillarythirdmolar  Keep it simple, stupid. +  
roaaaj  @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +