A 42-year-old woman is evaluated for chronic abdominal pain and fatigue. Her pain is epigastric, burning, and sometimes awakens her from sleep. She has no recent weight loss, nausea, or vomiting. Her diet consists primarily of fruits and vegetables. The patient also complains of a "strange appetite" for paper and ice that she has never had before. Upper gastrointestinal endoscopy shows duodenal erythema and an ulcer on the anterior wall of the duodenal bulb but is otherwise normal. Her unusual appetite is most directly related to which of the following?

Question

A 42-year-old woman is evaluated for chronic abdominal pain and fatigue.  Her pain is epigastric, burning, and sometimes awakens her from sleep.  She has no recent weight loss, nausea, or vomiting.  Her diet consists primarily of fruits and vegetables.  The patient also complains of a "strange appetite" for paper and ice that she has never had before.  Upper gastrointestinal endoscopy shows duodenal erythema and an ulcer on the anterior wall of the duodenal bulb but is otherwise normal.  Her unusual appetite is most directly related to which of the following?

Quizplus · Accepted Answer

Pica is an appetite for items other than food, such as paper products, clay, or dirt. It is a behavioral symptom that occasionally develops in iron deficiency anemia. Pagophagia is pica for ice and is quite specific for iron deficiency. It may be present before anemia develops and responds rapidly to iron supplementation. Pica may also be a manifestation of psychiatric disease; these patients may eat very odd items, including light bulbs or hair. This patient has a low-iron diet and likely chronic gastrointestinal bleeding from the ulcer, which has led to iron deficiency and pica. (Choice B) Helicobacter pylori infection is the most common cause of peptic ulcer in the developed world and likely accounts for this patient's ulcer. However, it is the depletion of iron from chronic bleeding, not the H pylori infection itself, that causes pica. (Choice C) Lactose intolerance is a common cause of gastrointestinal symptoms, but it does not lead to bleeding and does not cause iron deficiency or pica. (Choice D) Oral leukoplakia is a precancerous white patch or plaque on the oral mucosa. Approximately 1%-20% of plaques will progress to cancer within 10 years. Oral leukoplakia is not associated with iron deficiency anemia or pica. (Choice E) Reflux esophagitis can cause low-grade bleeding and iron deficiency if present for a prolonged period. It is a much less common cause of iron deficiency than peptic ulcer. (Choice F) Vitamin B12 (cobalamin) deficiency can occur in the setting of chronic gastritis due to decreased production of intrinsic factor. Vitamin B12 deficiency can cause anemia, but it is not associated with ulcers and does not cause pica (iron is a mineral, not a vitamin). Educational objective: Pica is an appetite for nonnutritive substances such as ice, clay, dirt, and paper products. Pica, especially for ice, can be indicative of iron deficiency. References: Pica: common but commonly missed. (http://www.ncbi.nlm.nih.gov/pubmed/11001006)

A 42-Year-Old Woman Is Evaluated for Chronic Abdominal Pain and Fatigue