43. Chronic diarrhea. Malabsorption syndrome. Celiac disease Flashcards
What are the different types of diarrhea
Diarrhea can be :
Osmotic -Can be osmotic
Sugar alcohols such as mannitol and xylitol
Magnesium containing antacids
Secretory
Anti arrhythmic drugs such as quinine
Enterotoxin produced by vibrio cholera
Mixed seceretory and osmotic - rotavirus
Dysmotility
Exudative
Presence of blood and pus - inflammatory bowel disease
- dysentery when blood is visible in the stool
definition of diarrhea
When there is more than three stools which are passed in a day
Acute when it lasts less than a 14 days.
CHRONIC WHEN More than one month
What’s re the different types of malabsorption syndrome
Always caused by the decrease in absorption of intestinal food because there is change in the intestinal mucosa
There is global - diffuse mucosal damage or reduction in absorptive surface such as celiac disease
Lactose intolerance
There is also partial
Localised absorption impairment
Inflammatory vowel disease such as Chris’s
Infections - giardiasis
Etiology of lactose intolerance
decrease in lactase activity is primarily observed during childhood or adolescence.
Lactase levels decline with age and are further influenced by genetic factors.
Secondary
underlying disorders of the small intestine that result in mucosal damage, e.g.:
Autoimmune disorders (e.g., gluten-sensitive enteropathy)
(Viral) gastroenteritis (e.g., rotavirus)
Clinical manifestations of lactose intolerance
Diarrhea (often watery, bulky, and frothy)
Cramping abdominal pain (often periumbilical or in the lower abdomen)
Abdominal bloating, flatulence
Nausea
Diagnosis of lactose intolerance
Trial lactose‑free diet: see if symptoms resolve
Hydrogen breath test
Fasting for 8–12 hours
Ingestion of lactose
Measurement of breath hydrogen levels at baseline and at 30‑minute intervals over 3 hours
Breath hydrogen levels > 20 ppm are considered diagnostic of lactose intolerance
Lactose tolerance test: Following the administration of lactose, the normal rise in blood glucose levels is pathologically reduced and symptoms appear (rarely used, as the test has low sensitivity and specificity)
Stool analysis
↑ Stool osmotic gap
↓ Stool pH (< 6): due to lactose fermentation by colonic bacterial flora
assessment of lactase via endoscopic tissue biopsy (conclusive, but rarely used, as the test is more invasive than other tests).
Primary lactose intolerance: normal intestinal architecture
Secondary lactose intolerance
Mucosal damage
Genetic test (if primary lactose malabsorption is suspected)
Treatment for lactose intolerance
lactose‑free or lactose‑reduced diet
And Use of alternative foods, such as soy‑based products
Oral lactase supplements
Recommended when traveling or before consuming food or milk products containing
celiac disease primarily affects in what location ?
primarily affects the proximal small intestines
What is the etiology of celiac disease
Genetic predisposition with association to HLA antigens
Common:
HLA-DQ2 (90–95%)
HLA-DQ8 (5%)
Associated chromosomal syndromes:
Turner syndrome,
Down syndrome
Other associated conditions: autoimmune hepatitis inflammatory bowel disease rheumatoid arthritis sarcoidosis selective IgA deficiency
Endocrine associations: autoimmune thyroid disease
type 1 diabetes mellitus
celiac diseases are classified according to what clinical spectrum ?
active - DQ2/8 symptomatic postive biopsy positive autoimmune serology
silent - DQ2/B aysmptomatic positive biopsy positive autoimmune serology
latent DQ2/8 symptomatic/ asymptomatic negative biopsy positive or negative autoimmune serology
potential DQ2/8 SYMPTOMATIC OR ASYMPTOMATIC negative biopsy posittive serology
What are the clinical features of celiac disease
Chronic recurring diarrhea: steatorrhea
Flatulence, abdominal bloating, and pain
vomiting
Dehydration
Malabsorption symptoms: weight loss, vitamin deficiency, iron deficiency anemia, osteoporosis, Hypocalcemia severe hypokalemia
In children:
failure to thrive,
growth failure,
delayed puberty
Extraintestinal
Aphthous ulcer
Dental enamel hypoplasia
Delayed tooth eruption
Chronic hepatitis and hypertransaminasemia
Dermatologic associations:
dermatitis herpetiformis - severely itchy blisters and raised red skin
Neuropsychiatric symptoms: peripheral neuropathies (numbness, burning and tingling of the hands and feet) headache, ataxia, depression, irritability
Gynecological associations: reduced fertility or infertility
what are the serological markers for celiac disease ?
tTG -IgA or IgG (tissue tranglutaminase antibody ) for children over 2 years old!
antiendomysial antibody EMA -IgA
TOTAL IGA tested because of its deficiency in celiac disease
these two not recommended because low sensitivity and specificity
deaminated gliadin peptide antibody - IgG/ IgA for children under 2 years old
with tTG-iga
what is the histopathological classification of celiac disease
MARSH CLASSIFICATION
0
intraepithelial lymphocytes less than 40
normal crypts
normal villi
1
more than 40
normal crypts and villi
2
more than 40
increased crypts
norma l villi
3a
more than 40
increased crypts
mild atrophy
3b
more than 40
increased crypts
marked atrophy
3c
more than 40
increased crypts
villi absent
current criteria for definitivediagnosis of Celiac disease?
both requirements are mandatory
villous atrophy with crypt hyperplasia and abnormal surface epithelium
clinical remission from withd r awal of gluten from diet
celiac antibodies - and their disappearance in gluten free diet = adds weight to diagnosis
HLA testing
What is the treatment for celiac disease
IV hydrating
Strict gotten free diet
Iron and vitamin supplements
