DSA 7: Fatigue, Unintentional Weight Loss Flashcards
where are:
iron, calcium, folate, fats, carbs, triglycerides absorbed?
proximal small intestine
- absorbed as micelles after solubilization by bile salts
where are:
vitamin B12, bile salts and water absorbed?
distal small intestine
where are:
water and electrolytes absorbed?
colon
what should be on your DDX for fatigue? (5)
- occult GIB
- cancer
- IBD
- chronic liver dz
- malnutrition/malabsorption
what should be on you DDX for unintentional wt loss? (4)
- cancer
- malabsorption syndromes
- IBD
- poor dentition
how does fatigue typically present?
difficulty initiating or maintain voluntary mental or physical activity
what ROS finding should raise you suspicious for an occult infection or malignancy?
presence of fever, chills, night sweats, or weight loss
what should be used instead of 10/10 scale for severity of fatigue?
impact of fatigue on daily functioning
what should be included for diagnosis of fatigue?
- CBC with diff
- electrolytes
- thyroid function
- testing for HIV
- adrenal function
- erythrocyte sedimentation rate (ESR), just helps support other findings
rapid fluctuation of weight over days suggest what?
loss or gain of fluid
long-term changes usually involve what?
loss of tissue mass
loss of how much weight should prompt further evaluation?
loss of 5-10% of body weight over 6 months
hx of GI symptoms should be obtained, including difficulty eating, dysgeusia (distorted sense of taste), dysphagia, anorexia, nausea, and change in bowel habits
for unintentional weight loss
causes of weight loss McGowan wants us to know
- cancer
- malabsoprtion
- obstruction
- peptic ulcer
- celiac disease
- IBD
- pancreatitis
- pernicious anemia
iron deficiency anemia is most commonly attributed to what, in premenopausal women?
menstrual bleeding and pregnancy-associated iron loss
what is the diagnostic eval for occult bleeding?
positive FOBT -> colonoscopy
pt with iron deficiency anemia should be evaluated for what?
possible celiac disease with either IgA anti-tissue TG or duodenal biopsy
what is the first think you should think of in a person over 45 with iron deficiency anemia?
colon cancer
what are the main complications of colonoscopy?
perforation and clinically significant bleeding
hundreds-thousands of colonic adenomatous polyps
- 90% have mutation in APC gene (AD)
- 10% have mutation in MUYTH gene (AR)
familial adenomatous polyposis (FAP)
what is the tx of FAP?
complete prostocolectomy with ileoanal anastomosis before age 20
- prophylactic colectomy recommended to prevent inevitable colon cancer
defect in one/several genes that are important in detection and repair of DNA base-pair mismatches (MLH1, MSH2, MSH6, PMS2)
- polyps believed to undergo rapid transformation over 1-2 years from normal tissue -> adenoma -> cancer
Lynch syndrome (aka HNPCC) - lifetime risk of colorectal cancer (22-75%), endometrial cancer (30-60%), ovarian, renal/bladder develop at a YOUNG age
what is the tx of HNPCC?
subtotal colectomy with ileorectal anastomosis (followed by ANNUAL surveillance of rectal stump)
- prophylactic hysterectomy and oophorectomy recommended in women over 40, or once they have finished childbearing
hamartomatous polyps throughout GI tract (esp small intestine)
- mucocutaneous pigmented macules on the lips, buccal mucosa and skin
- AD inheritance, serine threonine kinase 11 gene mutation
Peutz-Jeghers syndrome
several juvenile hamartomatous polyps, mostly in colon
- increased risk (up to 50%) of adenocarcinoma
- AD inheritance, defects on loci 18q and 10q (MADH4 and BMPR1A)
familial juvenile polyposis
hamartomatous polyps and lipomas throughout Gi tract
- trichilemmomas (benign neoplasms on face/neck) and cerebellar lesions
- increased rate of malignancy in thyroid, breast and urogenital tract
Cowden’s syndrome
painless bleeding: melena, hematochezia or occult blood loss
- proximal to ligament of Treitz (then presents as melena)
- most common in pt over 70, and in those with chronic renal failure or aortic stenosis
AVM
- dx: CBC with iron studies -> triggers us to do endoscopy, upper EGD, lower colonoscopy, capsule
what type of esophageal cancer presents as:
more common in African American males, over 50
- heavy smokers, alcohol use
- progressive dysphagia, weight loss, anorexia, bleeding, hoarseness, cough
- 50% in MIDDLE 1/3 of esophagus
SCC of esophagus
what type of esophageal cancer presents as:
more common in caucasian males
- DISTAL 1/3 of esophagus
- Barrett metaplasia -> dysplasia -> ?
- dx: EDG with biopsy
- tx: endoscopic ablation
adenocarcinoma of esophagus
risk factors:
- smoked fish/meat
- pickled veggies
- nitrosamines
- benzpyrene
- h. pylori
- smoking
- blood type A
gastric adenocarcinoma
- histo shows signet ring cells
- virchow’s node on PE
streptococcus bovis bacteremia??
COLON CANCER! (adenocarcinoma)
what side colon cancer presents as:
- rectal bleeding
- altered bowel habits (narrowing, constipation, tenesmus)
- abd or back pain
left-sided
what side colon cancer presents as:
- anemia (50%)
- occult blood in stool
- weight loss
- perforation, fistula, volvulus, inguinal hernia are complications
right-sided
CEA >5ng/mL ?
diagnostic marker for colon cancer
painless jaundice, NV, fatigue, weight loss, steatorrhea
- mid-epigastric pain that radiates to the back, hurts the most at night lying flat, is relieved by bending forward
- Courvoisier sign (palpable, painless gallbladder)
- Trousseau sign of malignancy -> hypocalcemia
pancreatic cancer
CA19-9 >100U/mL ?
CA= tumor biomarker carbohydrate antigen
highly specific for PANCREATIC malignancy
- NOTE: mutations on K-ras and p16 on xsome 9 may also be implicated
- smoking**
- obesity
- male
- Af american
- > 65 y/o
- DM
- chronic pancreatitis
- liver cirrhosis
- family hx
risk factors for pancreatic cancer
pt with cachexia, abdominal pain, fever
- jaundice, asthenia (abnormal physical weakness)
- elevated a-fetroprotein (AFP)
hepatocellular carcinoma
primary sclerosing cholangitis (PSC) is am important risk factor for what?
cholangiocarcinoma
- surveillance in PSC pt recommended with annual imaging (MRCP: cholangiopancreatography) and CA19.9 serum testing
acute ileitis, diarrhea (with/without blood)
Crohn disease
- tx: corticosteroids, immunoglobulating agents, ABX
bloody diarrhea, mucus, fever, tenesmus
- recently stopped smoking
UC
- tx: corticosteroid, immunoglobulating agents
pt presents with fatigue, malaise, anorexia, jaundice
- chronic inflammatory reaction in liver for at least 6 months
chronic hepatitis
what are the two immuno-complex mediated types of hepatitis?
- HBV: polyarteritis nodosa
- HCV: mixed cryoglobulinemia
what is the most important treatment for cirrhosis?
abstinence from alcohol
- pt should also receive HAV, HBV, pneumococcal and yearly flu vaccines
what are the most important classifications for liver biopsy?
grade and stage
what test should be done on pt with ascites?
CMP (bilirubin, albumin)
- EGD to look for varices before they rupture
what are the classic signs of malabsorption?
steatorrhea and weight loss
what small bowel mucosal disorders are listed as malabsorption syndromes? (3)
- celiac sprue
- Whipple disease
- bile salt malabsorption
- Crohn disease
what pancreatic disorders are listed as malabsorption syndromes?
- cystic fibrosis
- pancreatic carcinoma
what disease develops in people with HLA-DQ2 or HLA-DQ8 class II molecules?
celiac sprue
- causes diffuse damage to proximal small intestinal mucosa with malabsorption of nutrients
- weight loss
- chronic diarrhea
- dyspepsia
- flatulence
- abd distention/bloating
- growth retardation/short stature
- fatigue
can also have
- depression
- iron deficiency anemia
- osteoporosis
celiac sprue
- histologically: see complete loss of intestinal villi
what is one PE finding that you should always associate with celiacs?
- *dermatitis herpetiformis**
- pruritis papulovesicles over extensor surfaces of extremities, trunk, scalp and neck
other than tTG antibodies, what else should be tested for in celiacs?
IgG Ab to anti-DGP (deamidated GLIADIN peptides)
- for people with IgA deficiency!!!
what does the malabsorption of triglycerides cause?
steatorrhea
- resulting in weight loss, gaseous distention/flatulence, large greasy foul-smelling stools
- decreased fecal chymotrypsin
- decreased pancreatic fecal elastase (<100mcg/gram)
exocrine pancreatic insufficiency
what is the mnemonic TIGAR-O, and what is it for?
for causes of chronic pancreatitis
- toxic/metabolic (alcohol 45-80% of cases)
- idiopathic
- genetic (CFTR)
- autoimmune (IgG4 hypergammaglobulinemia)
- recurrent
- obstructive
what can Crohn disease lead to?
bile salt malabsorption
- if terminal ileum is resected -> that is where bile salts are resorbed
- impaired absorption of fat-soluble vitamins (A, D, E, K) is common
- causes watery secretory diarrhea
rare multi-system disease
- gram positive bacilus, not acid fast
- weight loss
- malabsorption
- chronic diarrhea
- endoscopy with duodenal biopsy: PAS positive macrophages with characteristic bacillus
Whipple disease
- tx: ABX (should see dramatic improvement within weeks)
- is FATAL if left untreated
what should you always remember to ask your patient about who presents with weight loss?
teeth hygiene!
- poor dentition compromises oral intake
