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NBME 23 Answers

nbme23/Block 4/Question#39 (48.0 difficulty score)
A 44-year-old woman comes to the physician ...
Celiac sprue🔍
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 +7 
submitted by masonkingcobra(236),
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nI otiidadn ot the pvseoiru niepna:lxota

Seh is iorn icnetidef dna celcia sffacte eht pilxamor mdedu.oun I" kFcdue tiryn"Bat = r,oIn oFtlea, B21 ofr eDou,ndmu nueJmju adn mleIu

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. +2  
fexx  OR you could just remember 'Iron Fist Bro' (F includes folate and fat, B includes B12 and bile salts) +3  

Y'all ignoring the osteopenia also. All those questions on celiac sprue fat malabsorption --> decrease Vit D

+4/- mdmikek89(-3),


 +1 
submitted by seagull(1134),
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'im slitl donecincv tshi is rarbtilie bowel onsmyr.de geCnha ym imn.d

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. +1  
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. +2  
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 +5  
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. +12  
arcanumm  I think you may have confused it with IBD, IBS would not present like this. +2  



 +0 
submitted by notadoctor(141),
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Caicel epurs si a slmbnaaoirtop osnydrme hatt stlures ni etsreathrao adn lusrtes ni iorn eifyccneid aeinam. sA rfa as I'm a,wrea none of teh osehrt eutslr ni noir decifeicyn a.inmea (I had leariBcat hvogerotrw sa a leosc cdosen tbu I 'tnod ebeveil 'athts sdactaeois hitw orni ieif.cdcyn)e

yb_26  bacterial overgrowth is associated with iron deficiency, but also with Vit B12-deficiency, so I guess pts will have macrocytic anemia +2  
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! +1  
covid2019  I wrongly chose bacterial overgrowth, but that is wrong because Small Intestine Bacterial Overgrowth (SIBO) must be instigated by something. Commonly, anatomic abnormalities (like surgery causing blind loop syndrome, strictures, or motility disorders that allow the poop to ~fester~). +3  



 +0 
submitted by axsa19(8),

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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215989/

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).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541375/

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.