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Sea_gull
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09/01/06 - 05:40 PM

A 40 yr old lady presents with ostomalacia and iron deficency anemia. Stool studies are negative for occcult blood and show a stool fat value of 20 g/24h. She has had no previous operation. In addition to hypchromic microcytic red blood cells, the peripheral bloood smear shows Howell-Jolly bodies. Which of the following is the mos likely explanation of theis woman's condition?

Whipple disease
intesinal lymphangiectasia
Tropical sprue
Celiac sprue
Bacterial overgrowth

NicoToscani
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09/01/06 - 06:22 PM

My nose is a little stuffy, but it smells like Celiac to me.

GDS2008
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09/01/06 - 06:37 PM

I am not sure, but will go for 1. Whipple disease. This patietn has both fat malabsorbtion and defective absorption of iron whihc occurs higher up in the intestine. Whipple disase usually has systemic manifestations but I will still go for it as none of the others fit into the picture. Please provide the answer with explanation..................esp if it is intesinal lymphangiectasia.

frank100
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09/01/06 - 06:45 PM

celiac.

GDS2008
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09/01/06 - 07:22 PM

Now, when I think about it it sounds more like Celiac disease...

Sea_gull
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09/01/06 - 07:25 PM

Answer is Celiac sprue.Now the question is

What makes you think it as Celiac disease??????????? Rationalize it

GDS2008
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09/01/06 - 07:31 PM

Whipple disease has systemic manifestations (arthralgias, myalgias)
Intestinal lymphangiectasia is a protein losing enteropathy, with abdominal distension, hypoalbuminemia (edema) and increased risk of infections
Tropical sprue although has a similar clinical manifestation as compared to celiac, it is uncommon in the US (and therfore called tropical)
Bacterial overgrowth usually presents in ppl with prior acid reducing surgeries and had abdominal pain and stuff.

Sea_gull
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09/01/06 - 07:37 PM

GDS you are right

An important clue is Howel Jolly bodies.

A patient with chronic diarrhea + Howel jolly bodies in absence of H/O splenectomy is very much suggestive of Celiac

GL

GDS2008
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09/01/06 - 07:47 PM

Thanks!

robin082006
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09/01/06 - 08:54 PM

#10

Good hint, thanks

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frank100
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09/02/06 - 08:53 AM

#11

yes good hint!!!, I put epidemiology on practice when it comes to these questions...but thanks...

study_ing
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09/02/06 - 10:28 AM

#12

thanx ppl valuable post..i was distracted away from celiac by one point though..its supposed to affect the proximal part of the SI more..as compared to eg.tropical which is more likely to involve the entire SI.

since iron= proximal,

and fat= distal..i kinda tot celiac shud be lower in the list..

i guess its the epidemiological factor then?

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Sea_gull
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09/02/06 - 11:01 AM

#13

study_ing wrote:
thanx ppl valuable post..i was distracted away from celiac by one point though..its supposed to affect the proximal part of the SI more..as compared to eg.tropical which is more likely to involve the entire SI.

since iron= proximal,

and fat= distal..i kinda tot celiac shud be lower in the list..

i guess its the epidemiological factor then?

Epidemiological factors are also important in decision making.In Celiac disease 10 - 15% cases undergo splenic atrophy and develop Howell Jolly bodies in PBS as a consequence.In the given scenario no other condition except Celiac can be associated with "Howell Jolly bodies".So their presenece is a pointer.

GL

GDS2008
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09/02/06 - 12:38 PM

#14

I did a little reading on the topic and it seems that megaloblastic anemia (and even any cause of hemolytic anemia) can be associated with peripheral Howell-Jolly bodies. This means that in cases of malabsorption (B12 or folate, and any of the above in the lsit can cause this) can resutl in simialr picture. I guess, epidemiological factros are more important then in such questions..................

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