2 Dis of Sm Bowel and appendix [5] devaraj?

Question 1

Tumors of the appendix

Answer 1

Carcinoid (0.5%) - most common

• neuroendo tumor with rare chance of metastasis
• carcinoid syndrome with metastasis = serotonin syndrome

Epithelial - rare
- show same range as colon polyps and cancers
(dysplasia to adenocarcinoma )

Question 2

Serotonin syndrome

Answer 2

episodic flushing
diarrhea
wheezing
right sided heart valve disease

• can present from carcinoid syndrome with mets

Question 3

4 types of diarrhea

Answer 3

1. watery
2. steatorrhea
3. inflammatory/exudative
4. fxnal (IBS)

Question 4

watery diarrhea

Answer 4

osmotic/secretory

osmotic: carbohydrate malabsorption or osmotic laxatives
- poorly absorbed luminal osmols

Secretory: bacterial toxins, neuroendocrine tumors, ileal bile salt malabsortion, STIMULANT laxatives, disordered motility regulation
- V. cholerae, Enterotoxogenic E.coli , Giardia lambia

Question 5

How to differentiate btwn osmotic and secretory diarrhea

Answer 5

Normal stool osmolality = 290
Osm gap = 290-2(stool sodium+potassium)

if difference is >50 = osmotic
- makes sense, more ions present in stool

if

Question 6

Steatorrhea/fatty diarrhea

Answer 6

malabsorption syndromes
- celiac, whipple’s

Short bowel syndrome

• after surgery
• Bacterial overgrowth

Maldigestion/malabsorption

• pancreatic insufficiency
• inadequate luminal bile salt [ ]

Question 7

Inflammatory/Exudative diarrhea

Answer 7

often bloody

Infecton
IBD
Ischemia

Infxn:
shigella, campylobacter, ETEC, salmonella, Yersinia, C. Diff

Question 8

functional (IBS) diarrhea

Answer 8

abdominal pain and altered bowel habits in absence of organic cause

• pain improves with defecation
• back and forth btwn constipation + diarrhea

concerning sx: weight loss, rectal bleed, anemia, nocturnal symp, electrolyte abnormalities, elevated inflamm marks.

Question 9

Clinical signs of malabsorption

Answer 9

weight loss
diarrhea
steaorrhea
vitamin deficiency

pale, bulky, malordorous stool - difficult to flush

Question 10

Causes of malabsorption

Answer 10

surgery
bacterial overgrowth
meds
- phenytoin
pancreatic insufficiency
liver disease
intestinal inflammation/villus flattening
- celiac, whipples disease, tripical sprue
Ulceration
ischemia infiltration
- amyloidosis

Question 11

malabsorption of this vit leads to...?
Vit A →
Vit D →
Vit E →
Vit K →

Answer 11

Vit A → night blindness (xeropthalmia)
Vit D → osteomalacia (common)
Vit E → hemolytic anemia
Vit K → clotting dysfxn (common)

Question 12

Pancreatic insufficiency + its affect on maldigestion

Answer 12

90% of pancreas burned out → lipid maldigestion FIRST
(protein and carb malab are rare)
- chronic pancreatitis or CF

Question 13

How does gastric bypass cause maldigestion?

Answer 13

not actually causing malabsorption, rather it is a mixing prob
causes inadequate mixing of food with biliary and pancreatic secretions.
- vit deficiencies (so give multivit!)

Question 14

Celiac Spruce (gluten-sensitive enteropathy)

• what is it?
• histo?
• gross?

Answer 14

inflammatory disease of SMALL INT with consumption of wheat, barley, or rye

Loss of villi/villous flattening
Crypt hyperplasia
inter-epithelial lymphocyte

Scalloping mucosa

(80% are asymptomatic)

Question 15

Celiac spruce is associated with MHC _____. and All have antibodies to _______, which leads to a _____ T cell response

Answer 15

Class II
Ab to tissue transglutaminase
CD4+

Question 16

Presentation of Celiac Sprue (gluten-sensitive enteropathy)

Answer 16

abdominal distention
abdominal pain
anorexia
bulky, sticky, pale stools
- STEATORRHEA
Flatulence
Failure to thrive
Vomiting

Question 17

Atypical Celiace Sprue sx

Answer 17

Iron def anemia
Dermatitis Herpetiformis
Elevated LFTs (AST+ALT)
Osteoporosis

Question 18

Celiac pathogenesis

- assoc with:

Answer 18

assoc. w/ autoimmune diseases

HLA-DQ2, HLA-DQ8 (40% US)
APC-MHCII present gluten peptides

CD4+ T cell response
Ab to TTG

Question 19

Tropical Spruce

• presentation
• dx
• tx

Answer 19

visit tropical areas → bacterial toxin or colonization of aerobic coliform bacteria → megaloblastic anemia from B12 + folate deficiency

• intestinal biopsy → villous flattening + travel hx
• antibiotics, B12, folate

Question 20

small bowel bacterial overgrowth

• pathogenesis
• presentation

Answer 20

should be less than 10^5 organisms/mL, but get overgrowth w/

• anatomic abnormalities
• hypo-motility (diabetes, scleroderma, narcs)
• partial intestinal obstruction
• decreased acid secretion
• colon fistula-crohns

Overgrowth present with:
 diarrhea/steatorrhea
abdom pain
bloating
weight loss
fat sol vitamin + B12 def
Normal/high folate level

Question 21

small bowel bacterial overgrowth

dx:

Answer 21

aspiration of duodenum with culture
glucose-hydrogen breath test
- give pts glucose, measure H prod by bacteria
Antibiotics - 2 weeks cipro