Bowl Disorders Flashcards
Lactose Intolerance
- etiology (causes)
- symptoms
- Diagnosis
- Treatment
Etiology
- NOT a milk protein allergy
- this is due to the LACK or deficiency of the lactase enzyme to break down lactose
4 reasons
1. Primary etiology: no underlying disease; just dont have the enzyme
2. celica disease; destroyed mircovilli border/atrophy
3. post viral gastroenteritis (maybe)
4. during a giardial infection
Symptoms
- diarrhea/ loose stools
- abdomnial bloating
- flatulence
- abdominal pain
occuring after the ingestion of the lactose containing ingredients
Diagnosis
- hydrogen breath test
Treatment
- dietary management of lactose ingestions – toleraable to the pt.
(foods low in lactose, aged cheese and yoghurts may be ok)
- can use Lactase (Lactaid) when ingesting dairy
when ingesting dairy: this will not damage the intestine but just cause discomfort
Celiac Disease
Etiology
(risk factors, subtypes-6)
Etiology
- known as a gluten sensitive enteropathy
- an immune mediated inflammatory process within the small intestines: the patient ellicts an immune response to dietary gluten & its related protiens
- genetic predisposition: DR-DQ2, DR4-DQ8
High Risk Groups
- those with 1st or 2nd degree relative (genetic testing)
- type 1 DM
- autoimmune thyroiditis
- Turners/Downs syndrome
- pulmonary hemosiderosis
primarily thought of as a eurpoena decent disorder; but spreading to others
Subtypes
- Classic Celiac Disease
- Atypical Celiac Disease
- Subclinical/asymptomatic Celiac Disease
- Potential Celiac Diseae
- Latenet Disease
- Refractory Disease
Clinical Presentation of Celiac Disease
Classic
Atypical
Subclinical
Latent
Refractory
Classic Celiac
- diarrhea
- malabsorbtion (steatorrhea, weight loss, nutrient deficiencies/vitamins)
- atrophy of the villi
- the lesions (mucosa? mouth, GI?) disappear with stopping eating gluten
- postive for antibodies against (TTG)
Atypical Celiac
- minor GI symptoms
- Extra-intestinal symptoms is the key!! (normally because malabosrbtion)
1. anemia
2. denal enamel defects
3. osteoporosis
4. arthritis
5. increased aminotransferases
6. neurologic symptoms (due to malabsorbtion)
7. infertility
Subclinical
- asymptomatic; normally incidentally when doing endoscopy for another reason
Latent
- usuallt a diaagnosis as normal celiac as a kid, switch to gluten free then, if they eat gluten again later on ; no symptoms
Refractory Disease
- defined by persistant symptoms (villous atrophy) despite that their adhering to a gluten free diet
- commonly due to poor adhearance to their diet
longer breast feeding and later introduction of gluten putting this on teh rise for dx. between 10-40
Celiac Disease
Symptoms
Symptoms
- diarrhea with bulky, foule smelling stools which float
- flatulence
- malabsorbtion conequences
1. weight loss
2. severe anemia
3. neuro disorder
4. oteopenis/porosis
- celiac crisis (RARE) metabolic derrangments 2/2 severe diarrhea
in kidsl failure to thrive/ gain weight is a sign
Extra-Intestinal Signs
Dermatitis Herpetiformis
- grouper, intensley puritic vesicles and papules
- elbows, knees, forearms, scalps, back and buttock (pathognomic for celiac!!)
Atrophic Glossitis
- smooth/sore tongue
- can be due to the celiac directly OR due to lack of iron/b-12 deficiency
Metabolic Bone Disease
- secondary hyhpoparathyroidism (vit D def.)
- osteomalacia
- loss of density (ostoperosis)
- increase fracture risk
Hematologic
- irondefiency anemia
- hyposplenism
Neuropsych Symptoms
- to the Vit B deficiency (peripheral neuropathy)
- (epilepsy, depression, anxiety) with extreme
associated with IgA defiency & Lymphoma
Celiac Disease
Diagnosis
Low probability
- absess of signs/symptoms
- absense of relatives with celiac
- chinese, sub-saharan, japanese decent
- use serologic testing first
1. TTG
2. endomysial antibodies
3. also test IgA levels
- if serum + , then continue to upper GI endoscopy with duodenal biopsy
Mod/High probability
- GI or extraintestinal symptoms
- relatives with celiac
- ANY of the high risk pt. populations
- do serologica tests
1. TTG and total IgA
- do endoscopy with duodenal biopsy
Endoscopy: scalloped or mosaic appearance of mucosa is pathognomic
Test for the DQ-2 or DQ8 if…
1. those with serology or histology which does lineup
2. those on a gluten free diet with negative serology
3. thsoe we refractory diseaes
4. those with high risk – a neg. genotype will r/o disease
Celiac Disease
Treatment
lifelong adhearance to a gluten free diet
- not needed in latent disease, but frequent reassessment
Gluten Free Foods
- avoid wheat, rye & barley (some oats too)
- no malt vinagers, watch dressings and stabilizers
- no beers!!
- replenish any vitamin or nutrient defiencies
- ADEK, B
- copper, zinc, carotene, Mg, selenium
- psyllium (for fiber)
watch poor absorptino of oral contraceptives!!
Evaluate bone Loss
- DXA scan
- supplement vit D and calcium
- address loss of BMD if needed
HERPETIFORMIS: treat with daposone
ensure up to date on pneumococcal vaccines (often these pt. has hyposplenism)
Celiac Disease
Treatment Monitoring
3-6 months after initiating the gluten free diet…
- CBC
- folate
- B12
- iron
- liver panels
these should all be normalized by that 3-6 month time period
- the tTG, IgA will be normalized by 3-12 months of a gluten free diet (since the immune response is no longer trigger by the gluten)
- a small bowl biposy at the 4-6 month mark should confirm the dx & response to a GF diet
Refractory Celiac Disease
rare: but patients who have specific phenotypes
Type 1: normal lymphocytes
- treatment : responds will to corticosteriods
- +/- asathirprine
- long term treatment
Type 2: lost surface expression of CD3 & CD8
- less steroid responsive
- hig risk of progression to lymphoma T-cell
SIBO
Etiology
Symptoms
Small Intestine Bacterial Overgrowth
Etiology
- colonized SI with an excessive overgrowth of aerobic & anaerobic microbes = intestinatl and systemic effects as a result
- the disorders which put an individual at an increased risk predispose them to an altered mucosal defense system
- MC causes of SIBO: chronic pancreatitis & intestinal motility disorders
this overgrowth leads to destruction of the villi and therefore nutrient malabsorbtion of carbs, fats, proteins and vitamins
Symptoms
- bloating & gas
- abdominal discomfort
- chronic WATERY diarrhea
- nutriten deficiences
- kids : failure to gain weight
- steatorrhea is RARE!!
SIBO
Diagnosis
Treatment
Diagnosis
- confirmation is done with a postivie carbohydrate breath test or a bacterial concentration of > 10x3 CFU in a jujunal aspiration
- carb breath test is better (cheaper)
- an endsocpy will appear normals, colitis & ileilis are associated with SIBO
Treatment
- antibiotics: rifaximin
- alternatives = bactrum, norfloxicin/ciprofloxicin, metronidiazole, tetracyclines & ammox.clav.
- treat nutritional deficiencies & other issues
Relapse more common in
- older adults
- those with appendectomy
- PPI use (altered stomach acid)
- treat relaspe with another course of abx. but differnt kind
+/- the rold of low FODMAP, probiotics & a statin
IBS
- Etiology
patho
rome criteria
Irritable Bowl Syndrome
Etiology
- a functional disorder, meaning no physical alterations in the gut which are causing issues
- a combo or exclusive periods of diarrhea, constipation
- chronic = > 3 months
- female > male
Pathogenesis
- visceral hypersensitivity
- abnormal motility
- intestinal inflammation
- psychsocial abnormalities
Rome IV Criteria
- pain related to the defecation (relieved or worsened)
- chnges in frequency of stools
- changes in the consistency of stools (form/appearance)
- all the above occuring at least 1x day/week with 2+ of the above
IBS
Symptoms & Signs
Diagnosis
Symptoms
- intermittent, crampy abdominal pain (worse or better with defication)
- IBS-D: loose watery stool > 3x daily with urgency, incontinence (small volume and mucus in stool)
- IBS-C: less than 3x/week of hard lumpy stool
- mixed form possible
- NO NIGHTTIME SYMPTOMS/not waking them up
- firm stools in the AM
- tenuesmus (feeling like they have to go even though they just went)
- bloating
Red Flags– think its something else!! (IBS is usually a diagnosis of exclusion)
- acute onset, older age ( > 45), nocturnal issues, severe symptoms, blood in stool, weight loss/fever
Signs
- R/O other thigns: look for other diseae processes with a PE
- will have mild abdominal tenderness
Labs
- CBC: look for anemia and infection
- Fecal Calprotectin lavels ( for IBD)
- tTGA for celiac
- stool culutres
- O&P for parastites
no need for an endscopic or imaging (can do US to r/o ovarian cancer
Diagnosis
- usually a clinical dx. made on R/o other disease processes through labs, imaing (if needed)
IBS
Treatment
Treatment
- reassure & explain disease/diagnosis
- stress managment and other factors
- identify and elimate triggers
1. foods (fatty foods, alcohol, spicy foods, grains)
2. medication
3. hormones
4. stress
- low FODMAP diet no gluten free (not helpful)
Treatment of Abdominal Pain
- antispasmotics: peppermint oil (smoothe SI muscles)
- anticholenergics NOT recommended
Treatment of IBS-D
- First line: Loperamide : anti-diarrheal medication (immodium) used prophalyatically with triggers
- trail of bile salts
- eluxadoline (opioid antagonist)
Treatment of IBS-C
- fiber supplementation
- anti-constipation mediations
1. osmotic laxitives first line after fiber in diet
2. secretagotogues (increases muscus production)
3. 5-HT4 agonists: to increase peristalsis
4. lactulose & sorbitol
Psychotropic agents
- a low-dose TCA can help with the pain ( diarrhea > constipation)
- SSRIs: good to accelerate the GI transport if constipated
Rifaximin can be used in refractory pts.
probiotics no research
Psych based treatment
CBT, relaxation therapy, yoga
Diverticulosis
- Etiology
- Risk Factors
- Secondary complications
- treament of the diverticulosis (not infected)
Diverticula = outpouching of the colonic musclar walls (sac-like) usually forming due to a weak poing of the wall (commonly forming after a straining motion)
- the mucosa and submucosa herniate through the muscular layer (not entirely through)
- majority in the western: Sigmoid Colon
the diverticular themselves are not an issue- but are prone to infection and other issues
Secondary Issues
- Diverticulosis
- Diverticulitis
- Diverticular bleeding
- SUDD (symptomatic uncomplicated diverticular disease)
- diverticulitis and bleeding are common ED complaints
Predisposing Factors
- exaggerated segmentated contrations creates a separation in the lumen that creates the chamber
- increased interluminal pressure within the chambers causes herniation in the weak points of the wall
Risk Factors
- low fiber diet, high fat and red meat
- poor exercise
- obesity
- smoking
- connective tissue disorders (ED, marfans)
- autosomial dominant PKD
- common in the elderly
- if asian, cane be congenital (right sided) left sided is more due to lifestyle and diet
Treatment
- theyre icidently found on screenign
- treat them with lifestely cahgnes and education
- high fiber, low fat diet & stop smoking
Diverticulitis
- Etiology
- Symptoms
- Diagnosis
Etiology
- an inflammation of the diverticular
- usually due to a microperforation within the diverticulm
Symptoms
- MC = abdominal pain
- LLQ pain (sigmoid) most commonly
- constant pain
- can have changing bowel habits
- can have urinary complaints becuase sigmoid close to bladder
Signs
- fever
- hemodynamically unstable (if sick enough – rare)
- tender mass can be palpable (if theres pericolonic inflammation or peridiverticular abcess)
- DRE: can feel mass
- stool can be positive for occult blood
Diagnosis
Labs
- elevated CRP ( > 50)
- mildly elevated WBC
- amylase and lipase can be elevated
- urinalysis: sterile pyuria due to the closeness to the colon
- if you get colonic bacteria: indicates a fistula
can get stool cultures, liver enzymes, etc. to r/o other conditions (pertonitis)
Imaging
- CT scan with oral + IV contrast : test of choice
- see
1. a localized wall thickening
2. increases soft tissue in the pericolonic area
3. fat stranding
4. diverticula
5. complications
- can get US if the pt. is unstable to see inflammation and the diverticula
- MRI can be used to dx. good becuase no radiation
DO NOT DO A BARIUM ENEMA, SIGMOID OR COLONOSCPOY IF SUSPECTED DIVERTICULITIS: RISK OF PERFORATION
