3.05 Malabsorption & IBD: Celiac, IBS

Question 1

“Malabsorption” denotes problems with what?

Answer 1

digestion or absorption

Question 2

Steatorrhea implies?

Answer 2

fats/fat soluble findings
decreased serum cholesterol & vitamin A, carotene (fat-soluble vitamins)

Question 3

xeropthalmia associated with?

Answer 3

vitamin A deficiency

Question 4

Paresthesias, tetany, positive Trousseau (BP cuff), and Chvostek sign (cheek tap) associated with?

Answer 4

calcium deficinecy

Question 5

Tests that differentiate digestion vs. malabsorption problems?

Answer 5

D-xylose test
(sugar that doesn’t need to be digested so if low = malabsorption)
OR
a-1-antitrypsin test
(if more cleared in stool than normal it means more protein loss than malabsorption)

Question 6

What are the three phases of malabsorption?

Answer 6

1. intraluminal
2. mucosal
3. absorptive

Question 7

What gets hydrolyzed in the lumen by pancreatic/biliary secretions? Pathogenesis is focused on?**

Answer 7

fats** > proteins, and carbs

Question 8

Mucosal phase centers on pathogenic malabsorption of?

Answer 8

all nutrients across the board: fat, proteins, carbs

Question 9

Obstruction of what may lead to impaired chylomicron and lipoprotein absorption leading to steatorrhea/protein loss?

Answer 9

lymphatic system

Question 10

What’s causing the bile salt issues (fat malabsorption)?

Answer 10

biliary obstruction, cholestatic liver diseases, or terminal ileum problem
destruction/loss of bile salts (bacteri, acid, meds)

Question 11

Fat malabsorption is linked with a decency of what vitamins?

Answer 11

A, D, E K

Question 12

What can cause pancreatic insufficiency?

Answer 12

chronic pancreatitis, CF, or cancer + pancreatic enzyme inactivation (ZE)

Question 13

Pancreatic issues tend to result in malabsorption of what?

Answer 13

triglycerides

Question 14

Celiac causes diffuse damage to what due to an immune response to gluten?

Answer 14

small intestinal mucosa

Question 15

What are the demographics for celiacs?

Answer 15

1:100 White Euro
10% diagnosed

Question 16

The “classic” GI symptoms for celiacs are most obvious in what group of people?

Answer 16

infants (<2yo) and become less obvious over time

Question 17

Many adults with Celiacs present what kind of “atypical” manifestations with lil to no GI symptoms?

Answer 17

fatigue, depression, iron deficiency anemia, osteoporosis, short stature, etc.

Question 18

What derm problem can appear in <10% of celiacs but is very specific?

Answer 18

dermatitis herpatiformis

Question 19

Celiacs differentials?

Answer 19

IBD
lactase/pancreatic deficiency
Whipple disease
viral gastroenteritisis
eosinophilic gastroenteritis
giardiasis
gastrinoma

Question 20

Intracellular gram + infection that can lead to +PAS, foamy macrophages, cardiac symptoms, arthralgias, and neuro symptoms?

Answer 20

T. whipplei
(“Mr. whipple likes to use soft foamy charmin on the “CAN”)

Question 21

What are some generic tests you can order for Celiacs?

Answer 21

CBC, PT, serum: albumin, iron, ferritin, calcium, alkaline phosphatase, vitamin levels ..

Question 22

What should be performed on everyone suspected of celiac?

Answer 22

serologic IgA endomysial or tTG tests

Question 23

If IgA endomysial antibody comes back negative in patients with celiacs what should you test next?

Answer 23

IgA deficiency

Question 24

Even if the patient has celiac, when could the serologic tests come back negative?

Answer 24

dietary gluten withdrawal for 3-12 months

Question 25

What genes tend to lead to an increased risk of celiac and patients tend to carry?

Answer 25

HLA DQ2 and/or DQ8
(not diagnostic)

Question 26

What can lead to a hereditary 40% risk of developing celiac disease even if asymptomatic?

Answer 26

same genotype as first-degree relative with celiacs

Question 27

What confirms a celiac diagnosis? What can affect accuracy?

Answer 27

duodenal biopsy
changes in diet can affect (must still be eating gluten)

Question 28

What is the treatment for celiac?

Answer 28

remove all gluten and maybe avoid diary until healed (a few weeks) + nutrient supplements (avoid osteoporosis)
maybe nonoral treatment/steroids

Question 29

prognosis of celiacs?

Answer 29

excellent with tx (gluten withdraw)
if refractory (<5% then poor prognosis)

Question 30

What can you find in celiac duodenal biopsy if positive?

Answer 30

villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis

Question 31

What are people with celiac at higher risk of developing?

Answer 31

T cell lymphoma

Question 32

What is a common, chronic disorder characterized by abdominal pain with alterations in bowel habits?

Answer 32

irritable bowel syndrome

Question 33

What kind of disorder is IBS (no obvious abnormal physical exam findings or cause)?

Answer 33

functional

Question 34

What is the IBS demographic?

Answer 34

2/3 women, usually begins late teens to early twenties

Question 35

Differential for IBS?

Answer 35

IBD
colonic neoplasia
celiac
depression and anxiety

Question 36

Diagnostic for IBS?

Answer 36

no definitive one
Rome II criteria

Question 37

What are the Rome III criteria?

Answer 37

recurrent abdominal pain or discomfort for at least 3 days per month for the last 3 months with 2 or more:
relief with defecation
when in pain change in stool:
freq or form/appearance

Question 38

Diagnostic testing for IBS is NOT required if??

Answer 38

compatible with ROME III
AND no complaint that suggest organic disease (nocturnal dx, red stool, weight loss, feecr, FHx)

Question 39

When should someone with IBS get diagnostic tests?

Answer 39

if symptoms did not improve 2-4 weeks post empiric therapy

Question 40

What are some tests you should do if a patient with IBS is diagnosed and refractory to tx after a month?

Answer 40

Complete CBC + serum tests, thyroid function tests, celiac tests, ova+ parasite tests, small bowel parasite overgrowth, lactose intolerance test

Question 41

At what point should screen patients for colonic neoplasms with a colonoscopy?

Answer 41

> 50 yo
or symptoms unrefractory to empiric therapy

Question 42

What are therapeutic procedures for IBS?

Answer 42

reassure patient
regular follow up
behavioral modification with relaxing/hypnotherapy technique, moderate exercise is helpful

Question 43

IBS prognosis?

Answer 43

chronic, episodic, majority learn to cope