Diverticulitis

Question 0

what is diverticulosis? what layers? most commonly occurs where? RFs? sxs? see on what procedure?

Answer 0

sac-like out-pouching of colon MUCOS & SUBMUSCOSA most commonly in sigmoid
dt factors that chronically increase intraluminal P: low fiber diet, high refined carbs
usu asx
may have chronic or intermittent LLQ abd pain, often constipation
may cause rectal bleeding if erosion of mucosa
often observed on barium studies

Question 1

Where is diverticular dz common? What are its 3 parts?

Answer 1

common in industrialized western society

diverticulosis, diverticulitis & Meckel’s diverticulum

Question 2

what is diverticulitis? usun from what? can potentially lead to what? prognosis? etiology?

Answer 2

inflammation of 1 or more diverticular, potentially leads to obstruction, perforation & to abscess & fistula formation
may heal spontaneously or may enlarge & adhere to adjacent organs, fistulas can form
repeated inflam may lead to obstruction & potentially dangerous perforation!

Question 3

etiology of diverticulitis?

Answer 3

low-fiber diet is highest RF= low bulk stool= increased intraluminal P & formation of diverticula
diet: high fat & grain-fed beef
genetic: asians have R sided diverticular, westerners mostly L
aging= change in collagen structure
colonic motility d/os
corticosteroids increase risk (not NSAIDs)
colonic segmentation: non-propulsive contractions
defects in colonic wall strength

Question 4

ssxs of diverticulosis vs diverticulitis?

Answer 4

diverticulosis: often asx, mb recurrent LLQ tenderness, flatulence, mb hx of painless rectal bleeding

diverticulitis: abd pain, LLQ, stead, severe & deep, fever/chills, previous episodes of dull, colicky & diffuse abd pain accompanied w/flatulence, distention & change in bowel habits
altered bowel habits: diarrhea, constipation, tenesmus
N/V, rectal bleeding, onset of bleeding is typically sudden, painless & accompanied by urge to defecate, bleeding may stop spontaneously

Question 5

Complications of diverticulitis or diverticulosis?

Answer 5

perforation or fistula development
pnematuria or recurrent UTIs
feculent vaginal d/c
severe & generalized abd pain,absent bowel sounds, fever
back or lower extremity pain

Question 6

PE for diverticular dz?

Answer 6

localized abd tenderness, rebound tenderness, may palpate mass
assess vial signs to determine hemodynamic stability
DRE
proctoscopic exam may reveal a mass in the cul-de-sac

Question 7

DDDx of diverticular dz?

Answer 7

hemorrhoids an/or anal fissures, UTI, nephrolithiasis, obstruction, colon CA, hx of wt loss & mucus in stools indicates IBD

Question 8

Imaging for diverticlar dz?

Answer 8

sigmoidoscopy shows narrowing & inflam

barium xray is hazardaous in acute phase & may cause a perforation

Question 9

What is Meckle’s diverticulum? more common in what gender? sxs? may look like what other dz?

Answer 9

congenital bulge in distal ileum, remnant of omphalomesenteric duct
2% of pop, more common in males
most asx
can produce bleeding, obstruction, volvulus, intussusception
acute presentation may look like appendicitis

Question 10

General SSXS of malabsorption?

Answer 10

chronic diarrhea, steatorrhea, abd bloating, wt loss, amenorrhea, macrocytic anemia, microcytic anemia, easy bruising, edema, glossitis, night blindness, bone pain/fractures, muscle spasm, peripheral neuropathy

Question 11

What are 6 causes of malabsorption?

Answer 11

insufficient digestive elements, carbohydrate intolerance/lactose intolerance, tropical sprue, celiac dz, whipple’s dz, short bowel syndrome

Question 12

What does having insufficient digestive elements include and lead to?

Answer 12

decreased pancreatic ezymes, liver enz, bile salts, HCl

post-surgical syndromes, biliary obstruction, CF, etc.

Question 13

What is carb/lactose intolerance? lack of what? what are the disaccharidases?

Answer 13

disaccharidases: lactase, maltase, isomaltase, sucrase
lack of splitting of molecules leads to increased osmotic load, then watery diarrhea
fermentation leads to gas, flatulence, distention, abd pain
enzyme deficiencies may be congenital (rare), primary or secondary

Question 14

Most common form of lactase deficiency? prevalence in different ethnicities? worldwide? very common among what populations?

Answer 14

acquired lactase deficient is most common form
in US 80% prevalence in blacks & hispanics, ~100% in Asian american pop, 25% in whites of NW european descent
worldwide >75% pop estimated, very common among Asian, South American & African pops

Question 15

what is congenital lactose intolerance? primary lactose intolerance? secondary lactase deficiency? what can cause secondary lactase deficiency?

Answer 15

congenital: inherited as autosomal recessive trait
primary: dt low levels of lactase, develop after childhood
secondary: develop w/small bowel mucosal damage dt: acute gastroenteritis, carcinoid syndrome, chemo, diabetic gastropathy, Kwashiorkor, tropical sprue, celiac sprue, Crohn’s dz, gastrinoma, HIV enteropathy, whipple syndrome

Question 16

Lab test of choice for carb/lactose intolerance?

Answer 16

hydrogen breath test

dietary elimination

Question 17

Who is tropical sprue common in ? etiology? what does it lead to?

Answer 17

residents/natives & prolonged visitors of Caribbean, South India, SE Asia, sxs may improve after moving but sxs may reappear yrs later
etiology unk but thought to be from SI chronic infxn by toxigenic coliform bac
leads to malabsorption of folate, B12, iron

Question 18

Ssxs of tropical sprue? two phases

Answer 18

acute phase: diarrhea w/fever & malaise

chronic phase: diarrhea, nausea, anorexia, abd cramps, steatorrhea, paresthesias

Question 19

PE will reveal what vitamin deficiency signs?

Answer 19

glossitis, stomatitis, cheilosis, cutaneous hyperpigmentation, dry rough skin, abd distention, tenderness & edema, wt loss, dehydration

Question 20

labs for tropical sprue?

Answer 20

no definitive marker exists
CBC shows megaloblastic anemia
stool analysis shows fecal fat >6 g in 24 hrs, fatty stools
CMP shows decreased serum protein, calcium, phosphorus, cholesterol & prothrombin, hypochlorhydria
D-xylose absorption test
upper Gi endoscopy will show characteristic histology

Question 21

What is celiac dz? epidemiology? peaks at what age? gender preference? all pts express what 2 possible antigens?

Answer 21

immune-mediated enteropathy rxn to gluten leads to mucosal damage)
AI condition: environmental trigger= gluten, autoantigen= tissue transglutaminase
elimination of environmental trigger leads to complete resolution
etiology: highest in europe & US, affects 0.5-1% of pop, high in those w/GI sxs & in those w/first-degree relative w/celiac, low in blacks, Asian & Hispanic descent
can occur at any age but peaks in 5th decade
females more than males
all pts express human leukocyte antigen (HLA-DQ2 or HLA-DQ8) which facilitates immune response against gluten proteins

Question 22

pathophys of celiac dz?

Answer 22

gliadins & glutenins in presence of CD4+ T cells w/HLD-DQ genotypes activate cytokine production & clonal expansion of antibody producing B cells= lymphocyte mediated destruction of proximal sm intestine mucosal villi
when villi damaged, vitamins, miners, calcium, carbs, proteins & fats are not well absorbed
T cells may react w/tissue transglutaminase & set in motion inflam events that result in characteristic celiac mucosal lesion

Question 23

RFs of celiac dz?

Answer 23

heredity, early intro of gluten in infant diet, type 1 DM, down syndrome, absent breastfeeding, Crohn’s dz, chronic fatigue syndrome, AI thyroid dz, viral exposures may trigger an immunologic response

Question 24

what pts will you screen for celiac dz? they are presenting with what sxs?

Answer 24

unexplained iron deficiency, early onset osteopenia, unexplained epilepsy, failure to thrive, poor glucose control, chronic diarrhea, infertility, miscarriages, elevated liver enzymes

Question 25

Ssxs of celiac dz?

Answer 25

some asx
class sxs: diarrhea, steatorrhea, bloating, flatulence, vit/min deficiencies, atypical presentation may have extraintestinal sxs: anemia, dermatitis herpetiformis, DM, aphthous stomatitis, neurological sxs, osteopathy

Question 26

ssxs more common in the infant with celiac dz? the older child? the adult?

Answer 26

infant: fulminant presentation likely but not common
diarrhea, abd distention, failure to thrive, anorexia, vomiting, psychomotor impairment, hypoproteinemia, acidosis

older child: usu ~ 4 yo, diarrhea or constipation, anemia, short stature, osteoporosis, aphthous ulcers

adult: intestinal sxs may be absent, diarrhea or constipation, anemia, aphthous ulcers, sore tongue & mouth, dyspepsia, abd pain, bloating, fatigue, infertility, neuropsychiatric sxs, bone pain, weakness, dermatitis herpetiformis

Question 27

labs for celiac dz? special tests?

Answer 27

CBC: anemia, leukopenia
CMP: increased AST, low albumin/plasma protein, low cholesterol increased alk phos
do a bone mineral density scan which will be low
special tests: serology: serum IgA quantitation & anti-endomysial abs, IgA anti-tissue transglutaminase abs, abn >100 units is highly specific,

tTG abs recommended as single serologic test for celiac dz screening in the primary care setting; deamidated gliadin peptide IgA & IgG= high sensitivity & specificity esp in elderly

Question 28

Procedure for dx of celiac?

Answer 28

small bowel biopsy is CONFIRMATORY
4 or more samples from 2nd & 3rd portion of SI, pt must include gluten in a diet a minimum of 2 wks, preferably 4+ weeks
characteristic villous atrophy is found

Question 29

5 ddxs of celiac dz?

Answer 29

anorexia nervosa, crohn’s dz, IBS, lactose intolerance, tropical sprue

Question 30

what can look similar in terms of ssxs to celiac dz but lacks villous atrophy? tTG levels, biopsy results, gliadin abs, total IgA levels?

Answer 30

non-celiac gluten intolerance!

negative IgA tTG antibody, biopsy negative, positive glidadin abs, total IgA normal

Question 31

What is whipple’s dz? caused by what? ssxs?

Answer 31

rare, multi-system condition caused by tropheryma whipplei

ssxs: diarrhea, wt loss, arthralgia, fever, malabsorption

Question 32

What is short bowel syndrome? what section esp?

Answer 32

malabsorption from surgical bowel resection, esp jejunum