Name:
A 24-Year-Old with Abdominal Pain
Description:
A 24-Year-Old with Abdominal Pain
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Duration:
T00H06M17S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Episode 24: A 24-Year-Old with Abdominal Pain. Here's the question: A 24-year-old woman is evaluated by her primary care physician for diffuse crampy abdominal pain. Let's do things a little different today, Cathy. What else do you want to know?
CATHY: What's the timing of her symptoms?
CHARLIE: She reports that she's had abdominal pain for the last several years, but it's been getting worse over the past couple months.
CATHY: Any associated nausea, vomiting or diarrhea?
CHARLIE: Recently, she's been having intermittent diarrhea without flatulence.
CATHY: Alright, well, tell me more about the diarrhea-- how many stools is she having each day? What's the quality? Is there anything that makes it better or worse? Is she waking up in the middle of the night with diarrhea, or is it more only after eating?
CHARLIE: She notes that she has approximately two to three stools a day, and they are loose but not liquid. The need to go to the bathroom does not waken her at night, she is not having any nocturnal episodes. Her stools do have some form, but they don't float, and they're not hard to flush. She has not noticed any worsening with specific foods.
CATHY: Any blood?
CHARLIE: No blood.
CATHY: Any other systemic symptoms and that includes any VTEC symptoms, like fever, night sweats, or any weight loss?
CHARLIE: She does have an occasional itchy rash on her knees; that's the only other positive finding. She has not had any fever or night sweats, but she has had about a 10-pound of not deliberate weight loss over the past year.
CATHY: Anything relevant from her past medical history, or her social or family history?
CHARLIE: Other than these abdominal complaints, she has no other complaints and she takes no medications.
CATHY: Okay, so we have a young woman with diffuse crampy abdominal pain for years that's now getting worse, and it's also now associated with diarrhea, rash, but most importantly 10 pounds of weight loss. So, I'm concerned that she may have a malabsorption syndrome.
CHARLIE: Why do you say that?
CATHY: It doesn't sound like she has a secretory diarrhea because we only hear that she has two to three semi-formed stools per day and she doesn't have any nocturnal symptoms. Secretory diarrheas will typically also occur at night. What we do hear is it sounds like her episodes may be related to eating throughout the day, but it doesn't sound like an inflammatory diarrhea with no fever or no blood. And while this could be irritable bowel syndrome, I'm worried about the weight loss and the rash.
CATHY: This also doesn't sound like a pancreatic insufficiency malabsorption syndrome because she's not having any fatty stools.
CHARLIE: Okay, so the question now asks, which of the following is the most appropriate recommendation at this point for this patient? Option A says, increase her dietary fiber intake. Option B says, measurement of an anti-endomysial antibody. Option C says, measurement of 24-hour fecal fat. Option D is, referral to gastroenterology for endoscopy. Or Option E is, trial of a lactose-free diet
CATHY: There are a few I don't think we should do right now. So, usually patients with lactose intolerance can relate symptoms to consumption of milk-based products, and they'll also report a strong history of crampy pain and flatulence. My sister actually called me with this once and said that she was only getting symptoms after she had hot chocolate from her favorite coffee shop, which turned out was almost entirely made of milk. Or it only happened when she ate ice cream. So, obviously two triggers in that case and you can usually identify those.
CATHY: (Charie) So, I assume you told your sister to stop drinking milk?
CATHY: I did and all of her symptoms resolved.
CHARLIE: Which of the other options are not top on your list?
CATHY: Measuring fecal fat also probably won't be helpful in this case, so, as I said before, her diarrhea doesn't sound like steatorrhea and there's no nocturnal diarrhea, so, that would eliminate Option C. And then going to Option A-- increasing fiber intake-- is usually for patients with irritable bowel syndrome, but with her weight loss and rash, I think that this would be a diagnosis of exclusion.
CHARLIE: Option B asks about measurement of anti-endomysial antibodies-- what is that?
CATHY: So, that's part of the diagnostic evaluation for suspected celiac disease or gluten enteropathy, and that's actually a good possibility in her case. I'd probably start there, even before a referral for endoscopy because her symptoms of abdominal pain, rash, diarrhea, and weight loss are consistent with celiac disease. Sometimes you see fatty diarrhea, but often not, and dermatitis herpetiformis is a classic rash that's associated with celiac disease and can be severe and may be what she's experiencing.
CHARLIE: So, Option B is the correct answer. Is the positive anti-endomysial antibody diagnostic for celiac disease?
CATHY: Well, it's a good test; the sensitivity and specificity are high in the 90% range, so that makes it a reasonable first test in symptomatic patients. The other test that's commonly used is immunoglobulin A anti-tissue transglutaminase, or the IgA for tTG antibody, and that's also a very good serologic test and actually the preferred initial testing for diagnosis of celiac disease. And that has a sensitivity and specificity around the 95%. These tests have to be done while on a gluten-rich diet because they can change on a gluten-free diet.
CATHY: But just the presence of either antibody is not diagnostic and usually duodenal biopsy is recommended. So, referral to GI would be in the pathway.
CHARLIE: So, eventually, we will likely refer this patient to a gastroenterologist for endoscopy. What would you expect to find in a duodenal biopsy?
CATHY: Typically, in celiac disease there is villous atrophy, absent or reduced tight villi and cuboidal appearance of the surface epithelial cells. Also, you'll find increased lymphocytes and plasma cells in the lamina propria. But these can also go away with removal of gluten from the diet.
CHARLIE: So, the teaching point in this case is that in a patient with long-term abdominal complaints and notably, weight loss and skin findings be suspicious of the diagnosis of celiac disease or gluten enteropathy. Your diagnostic workup can start with measurement of serum autoantibodies but eventually will likely lead to referral to a gastroenterologist for a duodenal biopsy.
CATHY: To read more about this, you can check out Harrison's chapter on Disorders of the Gastrointestinal System, and also you can check out the latest guideline from 2013, from the American College of Gastroenterology, on the diagnosis and management of celiac disease. ♪ (music) ♪