Diarrhea and malabsorption syndrome Flashcards
what are the two types of diarrhea
acute < 14 days
chronic > 28 days
what are the etiologies of acute diarrhea
infections
- viral
- bacterial
- parasitic
which vira are involved in acute diarrhea ?
Rotavirus
norovirus
adenovirus
Astrovirus
coronarvirus
which bacteria are invovled in acute diarrhea
- Campylobacter jejuni
- Escherichia coli
- Salmonella
- Shigella
- Clotridium difficile
which parasites are involved in acute diarrhea ?
- Entamoeba histolytica
- Giardia lamblia
- Cryptosporidium
When do symptoms of Clostridium difficile infection typically occur?
Usually after antibiotic treatments.
How does antibiotic use contribute to Clostridium difficile colonization?
Reduction of saprophytic (beneficial) flora allows for colonization of the colon with other, non-saprophytic bacteria, including Clostridium difficile.
widespread in europe - mostly in hospitals
What survival mechanism does Clostridium difficile possess?
The bacteria can form spores that survive for months, making it difficult to eradicate and contributing to recurrence.
What is the first-line treatment for Clostridium difficile infection (CDI)?
Oral Vancomycin or Fidaxomicin.
10 days of treatment
What is an alternative antibiotic that can be used for CDI if Vancomycin or Fidaxomicin are not available or appropriate?
Metronidazole.
What is the most important measure to prevent Clostridium difficile infection (CDI)?
Careful prescription of antibiotics - only when necessary.
Do recent AGA guidelines recommend probiotics for CDI prevention?
No, they do not recommend probiotics due to lack of efficiency.
How do proton pump inhibitors (PPIs) affect the risk of CDI?
Administration of PPIs reduces gastric acidity, which can make it easier for Clostridium difficile bacteria to survive and colonize the gut.
Provide an example of a situation where the benefit of antibiotics and other interventions might outweigh the risk of CDI.
In a patient with severe COPD (GOLD IV) and bacterial pneumonia, administration of antibiotics, corticosteroids, and PPIs may be necessary despite the increased risk of CDI due to the life-threatening nature of the pulmonary pathology.
What type of sample is used for Clostridium difficile testing?
Stool sample.
What toxins are detected in stool tests for Clostridium difficile infection (CDI)?
Toxins A and B.
What is GDH, and what is its role in CDI testing?
GDH stands for glutamate dehydrogenase.
It is an enzyme produced by Clostridium difficile bacteria.
It is not a toxin itself but is used as a marker for the presence of the bacteria.
Can GDH be used alone to diagnose CDI?
No, a positive GDH test alone is not sufficient for diagnosis. It must be correlated with clinical symptoms.
What is the risk of recurrence after an episode of Clostridium difficile infection (CDI)?
The risk of recurrence is high, up to 6 months after an event.
What is fecal matter transplant (FMT)?
FMT involves transplanting stool from a healthy donor into the patient’s colon to restore the normal gut microbiota.
When is FMT typically considered for CDI?
It is often considered a last-resort measure for recurrent or refractory CDI.
What are some challenges associated with FMT?
Legal and organizational difficulties, such as donor screening, stool processing, and ethical considerations.
In which age group are most cases of Giardia infection seen?
children
50% are asymptomatic of i nfected people
What is the main symptom of Giardia infection?
diarrhea
What are some other symptoms of Giardia infection?
Abdominal pain, changes in stool aspect (e.g., greasy, foul-smelling stools), and potential weight loss.
What is the main diagnostic test for Giardia infection?
Coproprasitological examination of stool.
How should the stool sample be collected for Giardia testing?
The sample should be taken from the altered-looking area of the stool, as this is where the parasites are most likely to be concentrated.
What is the primary treatment for Giardia infection?
Metronidazole
Chronic diaarhea etiology
- Chronic infectious diarrhea – untreated Giardia, Clostridium difficile
- Inflammatory bowel disease
- Irritable bowel syndrome (functional)
- Malabsorption
- Drug induced diarrhea - laxatives or side-effects
- Bile acid abnormalities
- Bacterial overpopulation
- Effect of other diseases – endocrine (hypothyroidism), after radiation
What are the two main types of inflammatory bowel disease?
Crohn’s disease and ulcerative colitis.
What is the most common symptom of IBD?
Diarrhea, sometimes with rectal bleeding.
What causes the inflammation in IBD?
The inflammation is caused by an abnormal immune response, even in the absence of an infection.
How is IBD diagnosed?
Inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, fecal calprotectin)
Colonoscopy
Histopathological examination (biopsy)
What is the main treatment for IBD?
nti-inflammatory medications.
What type of disease is Irritable Bowel Syndrome (IBS)?
A functional disease, meaning there’s no visible damage or inflammation in the digestive tract.
What are the Rome IV criteria for diagnosing IBS?
Recurrent abdominal pain on average at least 1 day/week in the last 3 months
Rome IV Criteria (Part 2)
associated with two or more of the following criteria:
Related to defecation
Associated with a change in frequency of stool
Associated with a change in form (appearance) of stool
What type of reaction does gluten trigger in people with celiac disease?
An immune reaction, leading to inflammation in the small intestine.
Celiac disease symptoms are ?
- Chronic watery diarrhea
- Weight loss
- Bloating
- Dyspepsia
- Herpetiform dermatitis (rare)
- Edema (protein malabsorption)
what are the malabsorption in celiac disease?
Iron malabsorption
Calcium and vitamin D3 malabsorption
Vitamin K malabsorption
Protein malabsorption
Iron deficiency anemia
Osteoporosis
Coagulation deficit
Hypoalbuminemia, hypoproteinemia
What are the two main categories of tests used to diagnose Celiac Disease?
Serum tests and Genetic tests.
Name three types of serum tests used in Celiac Disease diagnosis.
Anti-tissue transglutaminase antibodies (IgA), Total IgA, and Antigliadinic antibodies.
Why is it important to measure Total IgA in Celiac Disease diagnosis?
due to false negative
What genetic markers are tested for in Celiac Disease diagnosis?
HLA-DQ2 and HLA-DQ8.
What procedure is used to visually examine the duodenum in Celiac Disease diagnosis?
upper digestive endoscopy
What is a typical visual finding in the duodenum during an endoscopy for Celiac Disease?
A smooth aspect of the second part of the duodenum.
What cellular finding in a duodenal biopsy is indicative of Celiac Disease?
Intraepithelial lymphocytes.
What structural change in the duodenal lining is seen in Celiac Disease?
Atrophy of the villi.
what is the testing for carb intolorence ?
hydrogen breath test
What is the main consequence of exocrine pancreatic failure?
Inability of the pancreas to secrete pancreatic enzymes.
Name three conditions that can lead to exocrine pancreatic failure.
Chronic pancreatitis, Post pancreatic resection, and Cystic Fibrosis.
What is the primary digestive issue caused by exocrine pancreatic failure?
Fat malabsorption.
What is a common stool test used to diagnose exocrine pancreatic failure?
Stool elastase test.
What is another method to detect fat malabsorption in exocrine pancreatic failure?
Fat in stool test (microscopic examination).
Which diagnostic test for exocrine pancreatic failure is usually performed in specialized centers?
Secretin test.
What are the two main approaches to treating Exocrine Pancreatic Failure?
Diet and Medicine.
What dietary modification is recommended for patients with Exocrine Pancreatic Failure?
Reduced fat intake.
What type of medication is used to supplement enzyme deficiency in Exocrine Pancreatic Failure?
Pancreatic enzymes.
What is the typical dosage of pancreatic enzymes taken per meal for Exocrine Pancreatic Failure?
30,000 - 50,000 U/meal.
Drug induced diarrhea
- Enteral nutrition
- Proton pump inhibitors
- Chemotherapy
- Antibiotics
- Colchicine
- Metformin
- NSAID
- Mesalamine
What are the two main approaches to treating Exocrine Pancreatic Failure?
Diet and Medicine.
What dietary modification is recommended for patients with Exocrine Pancreatic Failure?
reduced fat intake
What type of medication is used to supplement enzyme deficiency in Exocrine Pancreatic Failure?
Pancreatic enzymes.
What are the two main mechanisms that can lead to bile acid induced diarrhea?
Malabsorption of bile acids at the terminal ileum and overproduction in the liver.
Where does bile acid malabsorption occur in bile acid induced diarrhea?
The terminal ileum.
How does overproduction of bile acids in the liver lead to diarrhea?
As a result of negative feedback mechanism malfunction.
What is the primary cause of symptoms in Bile Acid Induced Diarrhea?
The excessive effect of bile acids on the colon wall.
Besides diarrhea, what other abdominal symptoms are common in Bile Acid Induced Diarrhea?
Abdominal pain and Bloating.
What substance is used in the 75SeHCAT test?
Bile with a marked isotope (Selenium-75).
What type of test is the C4 test?
Serum test.
What is the primary dietary recommendation for treating Bile Acid Induced Diarrhea?
Low fat diet.
What class of medications is used to bind and remove excess bile acids in the treatment of Bile Acid Induced Diarrhea?
Bile removal agents.
Name two common bile removal agents used to treat Bile Acid Induced Diarrhea
Colestiramine and Colestipol
What is a common challenge in the treatment of Bile Acid Induced Diarrhea?
Low treatment compliance.
What is the defining characteristic of Bacterial Overpopulation Syndrome?
Excessive number of bacteria in the small intestine.
What is the primary diagnostic test mentioned for Bacterial Overpopulation Syndrome?
Glucose breath test respirator.
exhaled hydrogen
What are the sensitivity values mentioned for the glucose breath test using glucose and lactulose?
62% (glucose) / 56% (lactulose).
What is the preferred treatment for Bacterial Overpopulation Syndrome?
Antibiotics, preferably rifaximin.
What type of disease is Microscopic Colitis?
Inflammatory bowel disease.
What is a key characteristic of the symptoms of Microscopic Colitis?
Recurrent symptoms.
What is a common finding during a colonoscopy in patients with Microscopic Colitis?
Normal colonoscopy.
What is essential for diagnosing Microscopic Colitis?
Hystopathology (histopathology) - typical aspect.
What are the two main subtypes of Microscopic Colitis?
Collagenous colitis and Lymphocytic colitis.
risk factors microscopic colitis
- Smoking and previous smoking (ex-smokers = lower incidence)
- More frequently in women
- Chronic use of:
- Proton pump inhibitors
- NSAIDs
- SSRIs
What type of examination is crucial for diagnosing Microscopic Colitis?
Histopathological examination using Hematoxylin-eosin coloration.
What is the defining histological characteristic of Collagenous Colitis?
A sub-epithelial collagen band of over 10 µm.
What other histological finding is present in Collagenous Colitis?
Inflammatory infiltrate in the lamina propria.
What is the defining histological characteristic of Lymphocytic Colitis?
Intraepithelial lymphocytes of over 20 per 100 cells.
What other histological finding is present in Lymphocytic Colitis?
Inflammatory infiltrate in the lamina propria.
What is the first-line medication for inducing remission in Microscopic Colitis?
Oral budesonide.
What are the two phases of treatment where oral budesonide is used?
Induction and Remission.
What medications are considered if budesonide treatment fails in Microscopic Colitis?
Thiopurine, antiTNF, and vedolizumab.
What is one general category of mechanisms that can lead to malabsorption syndrome?
Deficiency of enzymes with roles in digestion.
Give an example of a specific protein deficiency that can cause malabsorption.
Castle factor (leading to Vitamin B12 deficiency).
How can a deficiency in the absorption membrane cause malabsorption?
Insufficient permeability.
How can surgical resection lead to malabsorption?
Decrease of total absorption surface.
What types of transport abnormalities can cause malabsorption?
Lymphatic or vascular obstruction.
Malabsorption syndrome etiology
- Celiac disease
- Protein or carbohydrate intolerance
- Chronic pancreatitis
- Post surgical resection of pancreas or intestines
- Inflammatory or infectious bowel disease, including bacterial overpopulation syndrome
- Atrophic gastritis
- Bile acid abnormalities
- Autoimmune diseases
Malabsorption syndrome - Treatment
Depends on each individual etiology
