30 // THE NEW GASTROENTEROLOGIST: INSIGHTS FOR FELLOWS & YOUNG GIS WINTER 2016
ANSWERS // From page 3
Q1: ANSWER: C
This patient has hereditary hemochromatosis. Risk factors for advanced fibrosis include ferritin > 1,000 microg
or elevated liver enzymes. A serum ferritin level > 1,000
microg/L with an elevated aminotransferase level and a
platelet count < 200 × 103 micro/L predicted the presence
of cirrhosis in 80% of C282Y homozygotes. With a ferritin
of 1,393 microg/L, elevated transaminases, and relatively
low platelets, a liver biopsy would be the most appropriate
next step. Phlebotomy may also be performed but does not
provide clinically important and prognostic information
such as the presence of cirrhosis and its implications for
variceal bleeding and HCC screening. MRI for iron quantification is not required for the diagnosis of HH in light
of positive gene testing and evidence of serologic iron
overload and does not provide information regarding the
degree of fibrosis in this case. Although obesity may be
associated with elevated iron stores, this degree of ferritin
elevation would be unusual. In the long term, weight loss
should be encouraged, however, obesity is not the immediate cause of potentially significant liver disease. This
patient is a healthy inactive carrier of hepatitis B and treatment is not indicated.
1. Beaton M., Adams P.C. Assessment of silent liver fibrosis in hemochromatosis C282Y homozygotes with normal transaminase levels. Clin Gastroenterol Hepatol 2008;6:713-4.
2. Morrison E.D., et al. Serum ferritin level predicts advanced hepatic fibrosis among U.S. patients with phenotypic hemochromatosis. Ann Intern Med
Q2: ANSWER: E
Choices A through D of the presented answers are correct.
Resection of 50% of the small intestine is usually well tolerated, whereas resection of more than 75% of the small
bowel usually requires parenteral nutrition. The ileocecal region provides a brake that slows intestinal transit,
allowing for absorption of nutrients. The terminal ileum
is required for absorption of vitamin B12 and bile salts.
The remaining intestine, namely the terminal ileum, can
adapt by increasing the height and diameter of the villi to
produce a greater surface area for absorption. Finally, the
colon absorbs nutrients that are not absorbed in the small
intestine as well as fluids and electrolytes. Taken together,
presence of a terminal ileum, ileocecal valve, and colon in
addition to length of remaining small bowel are all positive
prognostic indicators of enteral nutrition tolerance. Adaptation and fluid balance is more successful with residual
ileum, in contrast to patients who only have residual jejunum.
1. O’Keefe S.J.D., et al. Short bowel syndrome and intestinal failure: consensus definitions and overview. Clin Gastroenterol Hepatol 2006;4: 6-10.
2. American Gastroenterological Association medical position statement:
short bowel syndrome and intestinal transplantation. Gastroenterology.