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Self -Assessment in Gastroenterology
Malabsorption and Vitamin Deficiencies Due
to Gastrointestinal Illness: Review Questions
Douglas G. Adler, MD
QUESTIONS
Choose the single best answer for each question.
1.
2.
A 50-year-old man presents for evaluation of 3 years
of chronic diarrhea and weight loss. He also
complains of chronic flatulence and severe fatigue.
The patient is unaware of any trigger foods. His
diarrhea is clear and watery, without evidence of
blood. He responds poorly to over-the-counter
antidiarrheal medications. On examination, he is
thin and has diffuse muscle wasting but is in no
acute distress. He has multiple clear vesicular
lesions on his elbows and knees, which cause
severe itching; he has scratched himself to the
point of bleeding on several occasions. What is this
patient’s most likely diagnosis?
(A) Celiac sprue
(B) Chronic pancreatitis
(C) Crohn’s disease
(D) Microscopic colitis
(E) Ulcerative colitis
A 20-year-old man sustains a shotgun wound to his
right lower abdomen at close range. He undergoes
surgical resection of a small amount of jejunum,
all of his ileum, and a portion of his right colon,
with the creation of an internal jejunocolonic anastomosis. He does well but has some degree of
chronic steatorrhea. Two months after discharge,
he presents with paresthesias in his hands and feet.
He has sustained several falls at work and has
severe fatigue. On examination, he appears well,
but neurologic examination discloses marked ataxia
on formal testing. This patient is suffering from a
deficiency of which of the following vitamins?
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(A) Vitamin B1 (thiamine)
(B) Vitamin B2 (riboflavin)
(C) Vitamin B6 (pyridoxine)
(D) Vitamin B9 (folic acid)
(E) Vitamin B12 (cobalamin)
3.
A 44-year-old woman with alcoholism presents for
evaluation of chronic abdominal pain. She is subsequently found to have chronic pancreatitis with
pancreatic exocrine insufficiency and steatorrhea.
With counseling, the patient is able to abstain from
alcohol and experiences significant improvement
in her abdominal pain. Several months later at
follow-up, the patient informs you that she was
recently injured in an accident wherein she drove
her car into a parked car at night. Her blood alcohol
level, which was ascertained by police on the scene,
was zero. She states that she has also had several
“close calls” when driving at night. What is the
most likely cause of the patient’s difficulties?
(A) Vitamin A (retinol) deficiency
(B) Vitamin C (ascorbic acid) deficiency
(C) Vitamin D (ergocalciferol) deficiency
(D) Vitamin E (α-tocopherol) deficiency
(E) Vitamin K (phylloquinone) deficiency
Questions 4 and 5 refer to the following case.
A 60-year-old man presents to your office for evaluation of weight loss and chronic diarrhea. The patient
has had a variety of symptoms for many years including
chronic watery diarrhea, joint pains, the inability to
maintain a stable weight, and occasional unexplainable
fevers. On examination, the patient is thin with significant muscle wasting and prominent peripheral
lymphadenopathy. He has a grade I/IV heart murmur
over his left upper sternal border. His abdomen is mildly distended and slightly tender without focal abnormalities. Laboratory testing reveals anemia and severe
Dr. Adler is assistant professor of medicine and director of gastrointestinal endoscopy, University of Texas–Houston Health Science Center,
Houston, TX.
Hospital Physician June 2005
35
Self -Assessment in Gastroenterology : pp. 35 – 36
hypoalbuminemia. Upper endoscopy is normal, but
small bowel biopsies reveal infiltration of the lamina
propria with periodic acid-Schiff–positive macrophages.
The small bowel villi are distorted and appear widened.
4.
What is the most likely cause of the patient’s illness?
(A) Celiac sprue
(B) Irritable bowel syndrome
(C) Small bowel lymphoma
(D) Tropical sprue
(E) Whipple’s disease
5.
Which of the following is the best therapy option
for this patient?
(A) Antibiotics
(B) Chemotherapy
(C) Resection of the involved small intestine
(D) Small intestine transplantation
(E) Systemic steroids
ANSWERS AND EXPLANATIONS
1. (A) Celiac sprue. The patient most likely has celiac
sprue (also called gluten-sensitive enteropathy). If
untreated, all of the listed diagnoses may be accompanied by findings of chronic diarrhea without clear
trigger foods for several years and a chronically wasted appearance with diffuse muscle loss. However,
the case patient has a vesicular rash on his extensor
surfaces that is intensely pruritic (ie, dermatitis herpetiformis), which is a classic finding in patients
with celiac sprue, and is not seen in the context of
the other illnesses listed.
2. (E) Vitamin B12 (cobalamin). Vitamin B12 is principally
absorbed in the terminal ileum, an intestinal segment
that the case patient no longer has. The vitamin B12
intrinsic factor unit complexes with bile acids and is
absorbed via proteins that are present in ileal
mucosal cells. Thus, the patient cannot absorb vitamin B12. Patients with vitamin B12 deficiency can present with ataxias (which can lead to falls), confusion,
paresthesias in the extremities, and occasionally diarrhea.
3. (A) Vitamin A (retinol) deficiency. The patient has
untreated pancreatic exocrine insufficiency caused
by steatorrhea. Although these patients can malabsorb many vitamins and minerals, fat-soluble vitamin deficiencies (vitamins A, D, E, and K) are often
prominent. The case patient has difficulty seeing in
low-light conditions (ie, night blindness), which is
likely due to vitamin A (retinol) deficiency. Vitamin
D deficiency can cause osteopenia, muscle weakness,
and/or deep bony pains, and vitamin E deficiency
can result in peripheral neuropathy and hemolysis.
Vitamin K deficiency often manifests as easy bruising and a prolonged clotting time, and vitamin C
deficiency can result in gingival inflammation with
associated bleeding and scurvy. The case patient
should be treated with vitamin supplementation
and pancreatic enzyme replacement therapy to
replace the zymogens the patient’s pancreas can no
longer produce.
4. (E) Whipple’s disease. Whipple’s disease is caused by
infection with Tropheryma whippelii (a gram-negative
bacillus), and it often manifests with multiorgan involvement. Adenopathy (from lymphatic involvement), joint pains (from arthritis), and fevers are
often prominent symptoms. Patients can also develop pulmonary, cardiac, or neurologic manifestations; they may present with chronic cough, congestive heart failure, or a variety of neurologic
complaints ranging from cranial nerve abnormalities (eg, deafness, diplopia) to overt dementia.
Anemia with associated flow murmurs are also
common. The finding of periodic acid -Schiff–
positive macrophages in the lamina propria on
small bowel biopsy is definitive for a diagnosis of
Whipple’s disease.
5. (A) Antibiotics. Patients with Whipple’s disease usually
have a prompt and impressive response to antibiotic
therapy. The optimal antibiotic for the treatment of
Whipple’s disease is unknown, but many patients
respond to trimethoprim/sulfamethoxazole. Penicillin, tetracycline, and erythromycin (among others)
have all been shown to be effective agents as well.
Patients are often treated for protracted periods of
time, and antibiotic use for 6 to 12 months is not
uncommon, with some patients requiring longer
courses. It should be noted that even with treatment
(and after clinical improvement has occurred), patients may still have abnormal small bowel biopsy
results for years. Steroids may help with arthritis but
will not treat the infection. Chemotherapy, small
bowel resection, and transplantation will not cure the
infection.
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36 Hospital Physician June 2005
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