exocrine pancreatic insufficiency Flashcards

1
Q

exocrine pancreatic insufficiency

A

-pancreas is not making EXOcrine enzymes
-common in aging -> cysts, fatty replacement**
-Common Causes: chronic pancreatitis; gastric, pancreatic, or small bowel resection; cystic fibrosis; duct obstruction, fatty replacement
-Symptoms: bloating, diarrhea

-Signs: none or weight loss, anemia
-Lab findings: none or iron deficiency, vitamin A, D, E or K deficiency
-DDX: celiac, lactose intol, SIBO, Giardia
**
-Dx: Fecal elastase stool specimen (make sure not falsely diluted with urine)
-if + ->
-Imaging-MRI or CT: fatty replacement/atrophy of pancreas; calcifications, ductal dilatation, enlargement of the pancreas, or peripancreatic fluid collections
-Treatment: Pancreatic enzymes -> dosed based on lipase dose

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2
Q

pancreas

A

-endocrine and exocrine organ
-insulin, amylase, lipase, protease

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3
Q

bacterial overgrowth

A

-Small intestine: a small number of bacteria should be
-Bacterial overgrowth in small intestine-> malabsorption:
-Bacterial deconjugation of bile salts
-Bacteria directly damage epithelial cells and brush border
-Microbial uptake of specific nutrients
-colon bacteria goes to small bowel or stomach

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4
Q

Causes of Bacterial Overgrowth

A

-Gastric achlorhydria- high pH in stomach -> bacteria overgrowth
-Anatomic abnormalities of the small intestine with stagnation - ileocecal valve abnormalities, small intestine diverticulum (things suck and bacteria)
-Afferent limb of Billroth II, resection of ileocecal valve, small intestine diverticula, obstruction, blind loop
-Small intestine motility disorders - slow movements -> bacteria grow, Scleroderma, diabetic enteropathy
-Gastrocolic or coloenteric fistula- Crohn’s disease, malignancy, surgical resection
-Miscellaneous disorders - AIDS, chronic pancreatitis

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5
Q

clinical findings in Bacterial Overgrowth

A

-Many patients asymptomatic
-Bloating, gas, abdominal pain, diarrhea
-Severe overgrowth: malabsorption symptoms and signs (RARE):
-Distention, weight loss, and steatorrhea
-Watery diarrhea is common
-Megaloblastic anemia or neurologic signs
-Testing: *Noninvasive breath tests (hydrogen, methane or both) vs empiric tx with nonabsorbable antibiotic 2 weeks 3x day

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6
Q

treatment for bacterial overgrowth***

A

-Correct the anatomic defect
-Nonabsorbable antibiotic- Rifaximin 500 mg three times daily x 14 days
-Cyclic therapy may be used for pts with scleroderma
-maintain on Probiotics

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7
Q

short bowel syndrome

A

-Malabsorptive condition that arises secondary to removal of significant segments of the small intestine.
-Most common causes in adults:
-Crohn’s disease
-Mesenteric infarction
-Radiation enteritis
-Volvulus- bowel is twisted on itself
-Tumor resection
-Trauma

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8
Q

primary lactase deficiency

A

-Lactase is a brush border enzyme- hydrolyzes the disaccharide lactose (milk sugar) into glucose and galactose (simple sugars that can be absorbed)
-lactose cannot be absorbed in whole form -> if its not broken down it draws fluid into bowel
-The concentration of lactase enzyme levels is high at birth
-Declines steadily in most people of non-European ancestry
-Degree is genetically determined

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9
Q

secondary lactase deficiency

A

-disease that washes away the lactase enzyme on the brush border
-it can be produced though -> once bowel heals it will come back
-Crohn’s disease
-Celiac ds
-Gastroenteritis
-Short bowel syndrome
-Malabsorbed lactose is fermented by intestinal bacteria, producing gas and organic acids- Increased stool osmotic load and fluid loss
-osmotic diarrhea

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10
Q

lactase deficiency S&S

A

-Great variability in clinical symptoms
-Severity of deficiency
-Amount ingested
-Symptoms:
-Bloating, abdominal cramps, and flatulence
-Osmotic diarrhea will result with higher lactose intake

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11
Q

lactase deficiency diff dx

A

Inflammatory bowel disease, mucosal malabsorptive disorders, irritable bowel syndrome, and pancreatic insufficiency
-secondary to other gi disorders!
-treat underlying

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12
Q

lactase deficiency dx and tx

A

-Diagnosis:
-Hydrogen breath test- ingest lactose -> blow -> hydrogen produced by bacteria that digests lactose -> differentiate primary and secondary
-Blood test- many sticks :(
-Bx
-Empiric trial- lactaid pills

-Treatment:
-Lactaid pills
-should never avoid dairy
-pts find their own dairy threshold
-Patient comfort is the goal
-Calcium and vitamin D supplement

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13
Q

tumors of small bowel

A

-Benign and malignant tumors-rare
-Often incidental finding and no symptoms/signs
-May cause acute or chronic gi bleed
-May cause obstruction
-act like a lead Intussusception- can cause telescoping bowel fold on itself
-Usually ID CT
Scan or Small Bowel Series- Require bx
-Most are single
-Multiple polyps suggestive of hereditary polyposis syndrome
-With the exception of lipomas, surgical or endoscopic excision!

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14
Q

benign tumors of small bowel

A

-Adenomatous polyps-most common: can turn into cancer so must be removed
-Majority asymptomatic +/- bleeding
Endoscopic or surgical resection warranted
-act like a lead Intussusception- telescoping, ulcer

-Lipomas occur commonly in ileum:
Most asymptomatic, incidental finding
Rarely obstruction with intussusception
-lipoma common on iliocecal valve- bx

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15
Q

gastrointestinal stromal tumors

A

-GST tumors
-Begin within the autonomic system of the GI tract so can be anywhere
-Stomach MC, Small bowel 2nd
-Most are asymptomatic but can ulcerate and cause acute or chronic bleeding or obstruction (acts like a lead)

-Benign stromal tumors:
-Submucosal, fibroid like
-soft tissue tumors
-Intraluminal, intramural, or extraluminal

-Malignant stromal tumors:
-1% of GI tumors
-Type of soft tissue sarcoma

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16
Q

other malignant small bowel tumors: lymphoma

A

-Most commonly in distal* small intestine
-Majority are non-Hodgkin’s intermediate or high-grade B cell lymphoma (associated with h pylori)
-T cell lymphoma (associated with celiac)

17
Q

malignant small bowel tumors: carcinoid

A

-30% in small intestine, most commonly in ileum
-Indolent with slow spread
-can have carcinoma associated but dont need to