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NBME 23 Answers

nbme23/Block 4/Question#39

A 44-year-old woman comes to the physician because ...

Celiac sprue

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In addition to the previous explanation:

She is iron deficient and celiac affects the proximal duodenum. "I Fucked Brittany" = Iron, Folate, B12 for Duodenum, Jejunum and Ileum

krewfoo99  Great analogy lol. But just a correction, First Aid states that Celiac Disease affects distal duodenum and proximal jejunum. But you are right, it would still cause iron deficiency anemia as it affects the duodenum. +1  

 +2  upvote downvote
submitted by seagull(529),

i'm still convinced this is irritable bowel syndrome. Change my mind.

mousie  haha I picked this too bc she's 44.... isn't celiac something that would present much younger?? but I don't think IBS would cause an iron deficiency anemia is the hint they were trying to give us. +  
sympathetikey  If it was IBS, they would have mentioned something about them having abdominal pain, different stool frequency, and then relief after defecation, me thinks. +1  
aknemu  I was between celiac sprue and IBS but what pushed me towards celiac's was a few things: 1. The Iron deficency anemia (I think that would be unlikely in IBS) 2. Steatorrhea (which would also be unlikley in IBS) 3. Osteopenia- I was think vitamin D deficency 4. Lack of a psychiatric history +4  
catch-22  IBS is a diagnosis of exclusion. If you haven't excluded Celiac (and this can't be excluded based on epidemiology alone), you can't diagnose IBS. +5  
arcanumm  I think you may have confused it with IBD, IBS would not present like this. +  

Celiac sprue is a malabsorption syndrome that results in steatorrhea and results in iron deficiency anemia. As far as I'm aware, none of the others result in iron deficiency anemia. (I had Bacterial overgrowth as a close second but I don't believe that's associated with iron deficiency).

yb_26  bacterial overgrowth is associated with iron deficiency, but also with Vit B12-deficiency, so I guess pts will have macrocytic anemia +1  
nor16  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/. Vit B12 is key here, moreover, no bloating (IBS and bacterial overgrowth with bloating). bacterial overgrowth is a close one! +  

 +0  upvote downvote
submitted by axsa19(4),

The stems also states that lateral chest x-ray shows mild osteopenia. Celiac disease can lead to malabsorption due it's pathology affecting absorption of nutrient. Celiac disease is often a cause of low bone density and patients with celiac disease have an increased fracture risk. This is thought to be due to lack of absorption of vitamin D and calcium causing a secondary hyperparathyroidism.


Furthermore, in celiac disease, impaired iron uptake from the duodenal lumen is the most likely cause since Iron enters the epithelial cell of the duodenal mucosa in ferrous form through an apical or brush border membrane transport protein termed the divalent metal transporter (DMT1).


Taking into account the following, based on her lab values she has microcytic anemia given her hemoglobin level of 9.6 and her MCV of 74 which is < 80. Lab values of a pt w/ Iron deficiency would be: decreased 􏰄iron,􏰂 high TIBC, decreased 􏰄ferritin,􏰂 increased free erythrocyte protoporphyrin.

FA 2017 page 396.

PTH is increased because serum calcium is low. Because PTH is increased, phosphorous is decreased. The woman in unable to absorb vitamin D (a fat soluble vitamin), so calcitriol is decreased (no vitamin D for the kidney to activate into calcitriol).

gabeb71  What does this have to do with the Celiac Sprue? +1  
medpsychosis  I believe they were explaining the reason for the mentioned "mild osteopenia" in the pt presentation. +  
meningitis  No, I think this person got confused with another question about celiac sprue, PTH, Calcitriol, and Vit D (it was an arrow type question). +  
diabetes  explanation for decreased bone density . +