Diseases of small intestine Flashcards
Duodenum is responsible for absorbing what?
Iron**, calciuim, phophorus, mag, copper, thiamin, riboflavin
Jejunum absorbs what?
ADEK and **Folate
Ileum
B12, bile salts/acids
What is Celiac disease
Gluten sensitive enteropathy
Diffuse damage to the proximal small intestinal mucosa (immune)
Celiac disease is “Grossly” underdiagnosed. What clinical signs should we be on the look out for?
GI issues including **Steatorrhea, flatulance, borborygmi, weakness/muscle wasting
Extraintestinal - Fatigue, depression, Iron def, transaminitis, *****Dermatitis herpetiformis
What is dermatitis herpetiformis
Pruritic papules and vesicle (herpes like)
Extensor surfaces of extremities, trunk, scalp, neck
What labs should be drawn for Celiac?
CBC, CMP, UA (rule out stuff)
Specific serology:
IGAtTG antibody- ***Test of Choice… if neg, draw serum IgA (maybe IgA def.)
IgG-deamidated gliadin peptides (DGPs)
-If you have an identified IgA def
Describe IgA function and abundance
Function - Protect mucosal tissue from the microbial invasion and maintain immune homeostasis
*most abundant
If we have positive serology for celiac disease, what should we do to confirm or exclude diagnosis?
Mucosal biopsy of **proximal small intestine
Looking for blunting or atrophy of intestinal villi
Describe the overarching diagnostic approach for celiac
HPE
Serologic testing algorithm
Try to eliminate all gluten (2-3 weeks should be good)
Mucosal biopsy
Refer to dietician.
Celiac disease carries a SLIGHT increased risk of what?
lymphoma and adenocarcinoma
What is Whipple disease?
Rare multisystem illness caused by T. Whippelii
Common in white males 30-50
No human spread
Contact with sewage/waste
What is the classic patient presentation with whipple disease?
Pt w/
- Migratory arthralgia (large joint)
- Diarrhea (flatulance, steatorrhea)
- ABD pain, weight loss, fever
How do we establish diagnosis for whipple disease?
Mucosal biopsy w/ evidence of bacterium
“Foamy macrophages”
How do we treat whipple?
- IV ceftriaxone x 2 wks
2. THEN** (not or) TMP-SMX DS PO (septra) x 1 year
What is tropical sprue? Where is it found?
Tropics (no shit) N/S of equator to 30 degrees
Chronic diarrheal disease characterized by entire small intesting involvment and ** folic acid and B12
What are the hallmark s/sx of tropical sprue
CHRONIC diarrhea Steatorrhea weight loss anorexia malaise **B12 and Folate deficiency (glossitis and chelitis)
What labs/procedures do we use to diagnose tropical sprue?
CBC - Megaloblastic anemia
Endoscopy w/ biopsy - Flattening of duodenal folds and blunted villi w/ elongated crypts
What is prevention and treatment of Tropical sprue?
Prev = boil water and peel fruit
TX = Septra x 6 months (TMP-SMX). Folate and B12.
What happens to malabsorbed lactose?
It gets fermented by intestinal bacteria which produces gas and organic acids.
As intake of lactose increases in lactade deficiency, what else increases?
Symptoms - Small –> asymptmatic, Large = osmotic diarrhea
Should signs of general malabsorption be present in lactase deficiency?
No… If wt loss, look for other diagnosis
What are our treatment options for Lactase deficiency
Presumptive = Stop 2-3 weeks and observe
Diagnose = Hydrogen breath test ***
Then treat with *Titration to patient symptoms.
What products are available for people with lactase deficiency?
Lactase-enhanced products
Lactase enzyme replacement supplements
When should we consider Bacterial Overgrowth in patients?
- Pt on chronic PPI (gastric *achlorhydria)
- Anatomic abnormality of small intestine
- Small intestine motility disorder
- Gastrocolic or coloenteric fistula (crohns, cancer, surg resect)
What are the symptoms of bacterial overgrowth?
Flatulance, wt loss, abd pain, diarrhea, steatorrhea, **Macrocytic anemia
Pair w/ patient risk catagory*******
How do we treat a bacterial overgrowth
Cipro –> Augmentin –> Rifaximin
Removing a segment of the small intestine can cause what? What is this?
Short Bowel Syndrome
Malabsorption secondary to shit being gone… Depends on the length, location etc…
An acute paralytic ileus (AKA adynamic or post-operative) lacks what? What is it usually secondary to?
No mechanical obstruction
ABD surgery (immediate post) Severe illness (inpatient) Intestinal motility drugs (opiods, Antichols)
What S/Sx do we look for in Acute Paralytic Ileus?
CONSTANT abdominal pain - diffuse
NO abdominal TTP - no peritonitis
DIMINISHED bowel sounds - or absent
N/V and distention*
What is the diagnostic test of choice for acute paralytic ileus?
Plain ABD x-ray shows gas filled loops of either bowel
Also, get labs to see if you need to fix stuff.
How do we treat Acute paralytic ileus?
Supportive
Tx illness, pain, fluid/electrolytes, *bowel rest, *Nasogastric decompression if sever or vomit
What is a Chronic Intestinal Psuedo Obstruciton
S/SX similar to gastroparesis
Looks like an obstruction but there isnt one. (Psuedo….)
What should we do to diagnose CIPO?
CT or endoscopy to r/o obstruction
If none, fix malnutrition or electrolyte imbalance…
Refer them to GI
Small bowel obstruction is most commonly attributed to what?
Postoperative adhesions or hernias
Besides the most common cause, what other things can cause SBO?
Neoplasms Strictures Foreign Body Intussusception Gallstones (gallstone ileus)
What are the risk factors for SBO?
Prior ABD or pelvic surgery ** ABD wall or groin hernia ** Prior irradiation Foreign body ingestion Neoplasm shit and inflammation
How will a patient present with an SBO?
COLICKY abdominal pain
Nausea, vomiting, OBSTIPATION
ABD DISTENTION w/ TYMPANY
HYPERACTIVE–> HYPOACTIVE sounds
dehydrated
How do we workup a suspected SBO patient?
CBC, CMP, UA, Type and cross for surg
Plain ABD film**
CT if pt has systemic signs or Localized ABD pain (r/o strangulation)*
We have diagnosed a SBO. How do we treat the pt?
EARLY SURGICAL CONSULT
ADMIT this patinet
TX supportive : Fluid resus, Decomp bowel, pain, anti emetic.
What is a gallstone ileus? Who is most likely to have this?
Impaction of gallstone in ileum after going through biliary-enteric fistula….
Must have gallstones (Four F’s)
Telescoping intestine (invagination) is known as what? What can it cause? What is seen in kids?
Intussusception
Bowel Obstruction
Currant Jelly Stool (red)
Primary malignancy for SI is _______. But a neoplasm may cause what?
Rare
Intussusception
Differentiate Adenocarcinoma and lymphoma of the small intestine
Adenocarcinoma - duodenum of prox jejunum. Obstruction, Chronic GI bleed or weight loss
Lymphoma - assoc w/ aids, immunosuppres, Crohns
What is Protein-losing enteropathy? Why would we get it? What should we do about it
Loss of serum protein (hypoalbuminemia) into the GI tract
Secondary to established disorder
CMP/BMP to diagnose
Replace it via diet or straight up Albumin
List types of Mesenteric Ischemia
Acute arterial occlusion - emboli/thrombus
Mesenteric venous thrombosis
Non-occlusive - Low card output, Vasospasm
What is the classic physical exam sign for Mesenteric Ischemia?
Pain out of proportion to exam
**look at history of cardiac issues too
What test diagnosis Mesenteric ischemia? How do we treat it?
CT angiography
Admit
Papaverine* - smooth muscle relaxer
Thrombolytics
Surgical referral
Meckel’s diverticulum is a _______ abnormality, it follows the rules of ______
Congenital (most common)
Two
What is the rule of twos?
Meckels diverticulum
2% population
2:1 male-femal
2 types of mucosa
2 years old or younger
How will a patient with Meckel’s present? How do we diagnose? How do we treat?
GI bleed from mucosa with Abdominal pain (like apendicitis pain)
Kid under 10 = painless bleeding w/ IBD symptoms
Adults under 40 w/ unidentified GI bleed
**Diagnose w/ capsule endoscopy of Meckels nuclear (99m tech pertech)
Tx = Stabilize and refer to surgery.
