Uworld qid 1662

[notbobtrustme]

A 34-year old male patient with a history of alcoholism presents with upper gastrointestinal bleeding. Gastric lavage fluid initially shows bleeding, but repeated samples turn normal. This patient's mucosal tear is associated with which of the following acid-base disturbances?

A.) High anion gap metabolic acidosis
B.) Normal anion gap metabolic acidosis
C.) Metabolic alkalosis
D.) Respiratory acidosis
E.) Respiratory alkalosis

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[alicealicealice]

The fact that it stopped bleeding means that it was mallory weiss, which means that he was vomiting for a while.
Therefore my guess is C, metabolic alkalosis (havent gotten to this q yet)

 

[NeuroLAX]

I would also select C for the same reasons stated above.

 

[notbobtrustme]

why isn't A also acceptable? EtOH is another cause of MW tears, which would cause a high anion gap alkalosis...

 

[alicealicealice]

True but its a best answer thing imo. If you threw up enough to get a MW tear, alcoholic or not, you're highly likely to have a metabolic alkalosis, so the two are more directly linked; not every MW tear is a patient in AKA. For example, if the question was changed to "This patient's underlying substance use is associated with which of the following" then you'd have a much stronger case for A. Plus to play devils advocate AKA + vomiting = mixed acid base disturbance.
What did uw say? wouldnt be surprised if its A and if so ignore evetyhing i just said

 

[notbobtrustme]

True but its a best answer thing imo. If you threw up enough to get a MW tear, alcoholic or not, you're highly likely to have a metabolic alkalosis, so the two are more directly linked; not every MW tear is a patient in AKA. For example, if the question was changed to "This patient's underlying substance use is associated with which of the following" then you'd have a much stronger case for A. Plus to play devils advocate AKA + vomiting = mixed acid base disturbance.
What did uw say? wouldnt be surprised if its A and if so ignore evetyhing i just said

no, you guys are right, it was C, but then they don't really explain why A is wrong. They just said that MW tears are assoc with EtOH and that EtOH causes an anion gap acidosis, so that's why I was confused on why A isn't a right answer as well, especially given the patient's history. If it were just a random person, then I would have had no problem picking C, but since he had a history of EtOH use, that made me lean towards A.

 

[alicealicealice]

I understand completely, I got similarly thrown off on a q and just started another thread, maybe you can give me your 0.02 on that one lol

I hate when UW basically says "this answers incorrect because its not the answer" without explaining; its not common but frustrating if you get thrown for a loop

 

[thehundredthone]

It's not the alcohol that caused the bleed, it is the vomiting. For this reason the acid-base disorder that is likely is the one associated with the vomiting, and not the alcohol intake.

 

[ChessMaster3000]

Don't overthink it--even if a patient was acutely drunk and had a metabolic acidosis, for that same patient to develop a M-W tear they would have had to be vomiting considerable amount of gastric acid, so practically by definition (especially for step 1 purposes) they would be metabolically alkalotic. If anything, they might have gotten anion-gap acidotic and then vomited all the way back to a normal pH, but they certainly wouldn't still be acidotic.

 

[notbobtrustme]

Don't overthink it--even if a patient was acutely drunk and had a metabolic acidosis, for that same patient to develop a M-W tear they would have had to be vomiting considerable amount of gastric acid, so practically by definition (especially for step 1 purposes) they would be metabolically alkalotic. If anything, they might have gotten anion-gap acidotic and then vomited all the way back to a normal pH, but they certainly wouldn't still be acidotic.

okay, I think I just got thrown off big time by the alcoholism. curse you uworld

 

[ChessMaster3000]

okay, I think I just got thrown off big time by the alcoholism. curse you uworld

Haha, I get thatUW makes you want to overthink, but there's nothing deceptive about this particular question. that is 100% how NBME could phrase that question on the real test, and they may not even mention vomiting. Alcoholic: upper GI bleeding: either varices or M-W: resolve on its own: M-W. The vomiting does not need to be in the stem whatsoever.

 

[ChessMaster3000]

Haha, I get thatUW makes you want to overthink, but there's nothing deceptive about this particular question. that is 100% how NBME could phrase that question on the real test, and they may not even mention vomiting. Alcoholic: upper GI bleeding: either varices or M-W: resolve on its own: M-W. The vomiting does not need to be in the stem whatsoever.

edit: The only other thing I would add is, in a cirrhotic with varices, they do NOT have to drunk or currently vomiting to start bleeding, whereas M-W the person is most likely currently drinking and definitely vomiting. Ive never seen that distinction in a question, but it could be helpful.

 

[notbobtrustme]

Haha, I get thatUW makes you want to overthink, but there's nothing deceptive about this particular question. that is 100% how NBME could phrase that question on the real test, and they may not even mention vomiting. Alcoholic: upper GI bleeding: either varices or M-W: resolve on its own: M-W. The vomiting does not need to be in the stem whatsoever.

yea, I mistakenly thought that EtOH can cause a MW tear. It ups your risk for them, but doesn't actually cause them straight up.