USMLE® Step 1 style questions USMLE
A 26-year-old man comes to the office for an evaluation of diarrhea. For the past 2 weeks, he has had bulky, pale, and foul-smelling stools. Medical history is relevant for a recent gastroenteritis a few weeks ago. Upon further questioning, the patient mentions that he has malodorous flatulence and intense bloating after any meal. He recently immigrated from Cuba. Physical examination shows abdominal distention and discomfort on palpation. His temperature is 36.1°C (96.9°F), pulse is 60/min, respirations are 17/min, and blood pressure is 116/70 mmHg. Which of the following processes is most likely to occur in this patient as a result of the disease?
Content Reviewers:Rishi Desai, MD, MPH
Tropical sprue is a gastrointestinal disease that results in malabsorption of nutrients and water.
Just like the other “sprue” diseases, like celiac sprue which is more often known as celiac disease, in tropical sprue the villi of the small intestine become flattened, but the exact cause isn’t known.
The biggest clue is that tropical sprue seems to mostly affect individuals living in the the tropical regions of the world, like the Caribbean, India, and Southeast Asia.
The most widely accepted theory is that an acute intestinal infection, which could be bacterial, viral, or protozoal, initially damages the intestinal lining, and this causes the first bit of inflammation.
In response, the intestinal cells secrete enteroglucagon, which is a hormone that decreases intestinal motility.
Decreased motility means that food’s allowed to linger in the intestines for longer than usual.
Bacterial overgrowth refers to the idea that some organisms begin to overpopulate and therefore dominate the bacterial ecosystem of the intestines.
In tropical sprue, Klebsiella, E. coli, and Enterobacter end up becoming those dominant bacteria. These guys release toxic byproducts as they ferment the food that lingers in the gut, and these toxins can damage the intestinal lining, leading to more inflammation.
Over time, all of this chronic inflammation leads to villous atrophy, which is flattening of the villi that line the small intestine.
Villi are important because they provide the surface area and digestive enzymes necessary for nutrient absorption.
Flattening of the villi reduces this surface area, which means less nutrients and water can be absorbed across the intestinal wall, which leads to malabsorption.
This (1) means more food is left behind for the bacteria, which leads to more intestinal wall injury and inflammation, and (2) the malabsorption also causes depletion of vitamin B12 and folate over time.
Tropical sprue typically affects adults and the usual pattern is of a chronic disease with exacerbations or flare ups from time to time.