ANSWERS // From page 3
Q1: Answer: B
The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with
voluntary reswallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern
of regurgitation is with almost every meal, within minutes,
and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of
regurgitation is not consistent with gastroparesis; in addition, she is not diabetic. She has no psychiatric history and
there are no findings suggestive of bulimia.
1. Marrero, F.J., Shay, S.S. Regurgitation and rumination. In: Richter, J.E.,
and Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wi-ley-Blackwell, 2012.
Q2: Answer: D
Objective: Appraise the relative roles of different regulators
of iron homeostasis in the context of chronic inflammation.
Iron deficiency is a common finding in IBD. When iron
stores are depleted, the two most common routes of re-
placement are oral and intravenous. The decision as to the
route of replacement is based in part on severity and acui-
ty of iron deficiency as well as symptoms.
The principal regulator of iron homeostasis is hepcidin.
In states of iron deficiency, hepcidin decreases, allowing for
more transport of absorbed iron from the enterocyte into
systemic circulation; conversely, states of iron overload
lead to increases in hepcidin, resulting in breakdown of the
basolateral enterocyte membrane transporter ferroportin,
thereby trapping iron in the enterocyte and decreasing systemic availability.
In the setting of chronic inflammation, hepcidin increases,
limiting iron bioavailability when taken orally; further, when
the chronic inflammation is in the gut, there is impaired
absorption across the apical enterocyte membrane. These
compounding effects significantly impair oral iron assimilation in the setting of active IBD. Therefore, the best route
of administration, particularly when the iron deficiency is
severe and the patient is symptomatic, is intravenous.
There are some data suggesting that oral iron is capable of
meeting iron needs in less severe cases of iron deficiency, but
it more often leads to drug discontinuation due to side effects.
1. Nemeth, E. Acta Haematol. 2009;122:78-86.
2. Oustamanolakis, P. Eur J Gastroenterol Hepatol. 2011;23:262-8.
3. Semrin, G. Inflamm Bowel Dis. 2006;12:1101-6.