qr12.8 - sami2004

[ArchivalUser]

A 39-year-old white man presents because of a 3-year history of worsening polyarticular pain. When he wakes, he has 3 hours or more of morning stiffness in his hands and wrists. His knees, ankles, and shoulders are somewhat less stiff, and he has a 6-month history of low back stiffness that lasts all day. For the last 2 years he has had nearly daily attacks of painless, watery, nonbloody diarrhea (six to eight episodes a day) that occasionally wakes him from sleep. There is no mucus or pus in the stools, but there is a foul smell and an oily quality to the toilet water after he defecates. He has lost 4.5 kg (10 lb) since the onset of his illness. Imaging studies of the upper gastrointestinal tract, endoscopy, and analysis of the stools for ova and parasites have been unrevealing in the past.

Physical examination reveals synovitis of the wrists and knees. There is no tenderness noted over the Achilles tendon, sacroiliac joints, or tendinous insertions.

What is the most likely diagnosis?

(A) Lactose intolerance

(B) Irritable bowel syndrome with fibromyalgia

© Inflammatory bowel disease

(D) Bacterial infectious diarrhea

(E) Celiac disease

[ArchivalUser]

E,

[ArchivalUser]

(E) Celiac disease

[ArchivalUser]

C,

[ArchivalUser]

how explain?

[ArchivalUser]

Celiac disease : malabsorption + arthropathy

[ArchivalUser]

cccc

[ArchivalUser]

the way i remember to avoid confusion is..

IBD-- diarrhea first then arthritis

Malabsorption-- Arthritis first then diarrhea

[ArchivalUser]

answer is E, celia sprue
This patient has a malabsorption syndrome accompanied by polyarthritis. Diagnostic considerations would include inflammatory bowel disease (IBD), Whipple’s disease, amyloidosis, and celiac disease. Celiac disease (celiac sprue) is caused by gluten-induced damage to the small intestinal mucosal cells and is identified by demonstration of villus atrophy on analysis of biopsy specimen. The clinical and pathologic abnormalities are reversed on a gluten-free diet. Arthralgia or arthritis has been reported in up to 26% of patients with celiac disease. The onset may precede or follow the gastrointestinal symptoms, and, similar to the arthritis see in patients with IBD, the arthritis improves with successful treatment of the bowel disorder. Various patterns of arthropathy have been reported with celiac disease, including polyarthritis, oligoarthritis, and spondylitis.

Inflammatory bowel disease is less likely to cause a painless diarrhea, without blood or mucus, and the arthropathy is usually a large joint monarthritis or oligoarthritis. Nocturnal diarrhea makes lactose intolerance and irritable bowel syndrome unlikely. Lactose intolerance is not associated with a rheumatic disorder. The rheumatic syndrome in this case is clearly a polyarthritis rather than fibromyalgia. A reactive arthritis frequently follows bacterial enteritis, but the prolonged duration of illness and the onset of arthritis before bowel symptoms developed makes reactive arthritis very unlikely. This clinical picture is compatible with Whipple’s disease and primary amyloidosis, both of which would be identified on intestinal biopsy.

[ArchivalUser]

Inflammatory bowel disease is less likely to cause a painless diarrhea, without blood or mucus, and the arthropathy is usually a large joint monarthritis or oligoarthritis.

Thanks, now I got it.