Krause 28: lower GI Flashcards
celiac disease also called:
gluten sensitive enteropathy
peak in diagnosis of celiac happens in ____ decade
4th to 6th
classic GI symptoms of celiac?
bloating, diarrhea, steatorrhea, malodorous stools, apathy, fatigue, poor wt gain
nutritional symptoms and conditions associated with celiac:
anemia, osteomalacia, lactase deficiency, delayed growth, dental enamel hypoplasia, coagulopathies
extraintestinal symptoms and conditions associated with celiac
lassitude, malaise, arthritis, arthralgia, dermatitis, infertility, hepatic steatosis, neuro symptoms, psych syndromes
disorders associated with celiac:
autoimmune disease, GI malignacy, IgA deficiency
celiac frequently misdiagnosed as :
IBS, lactase deficiency, gallbladder disease
a manifestation of CD that presents as itchy skin rash:
dermatitis herpetiformis
celiac is characterized by these 4 factors:
1) genetic susceptibility 2) exposure to gluten 3) enviro trigger 4) autoimmune response
specific peptide fractions of proteins found in wheat
gluten
why gluten problem in celiac?
resist complete digestions, reach small intestine intact and translocate from lumen, across epithelium, into lamina propria and trigger inflamm response–>flatten villi and systemic immune response triggered
term used to descibe ppl with nonspecific symptoms, without immune response of CD or intestinal damage
gluten sensitivity
term to describe ppl who have symptoms and may/may not have CD
gluten intolerance
why not follow GF diet until have workup to exclude/confirm diagnose CD?
1) underlying med condition for which GF diet is not treatment 2) after following GF diet for a while it is difficult to diagnose CD 3) GF diet expensive and restrictive
celiac mostly affects ___ sections of small bowel
proximal/mid
gold standard for celiac diagnosis?
biopsy
refractory celiac ppl may respond to:
steroids, cyclosporine, azathioprine
newly diagnosed celiac should have these lab values checked:
vit D, ferritin, red blood cell folate
2 types of antibodies considered in celiac:
antigluten and antiself
2 major forms of IBD
crohn’s and UC
onset of IBD usually occue in pt ____ yrs
15-30
shared clinical characteristics of crohn’s and colitis:
diarrhea, fever, wt loss, anemia, food intolerance, malnutrition, growth failure, extraintestinal manifestations
malnutrition more a concern in crohn’s or colitis?
crohn’s
enviro factors to IBD?
resident and transient microorganisms in GI tract, diet components
strictures and fistulas very rare in ___ and common in ___
UC; crohn’s
rectum always involved in ___
ulcerative colitis
___ is continuous whereas ___ can occur anywhere along GI
UC; crohn’s
which has more inflamm, crohn’s or UC?
crohn’s
deeper ulcers in UC or colitis?
UC
thin wall in ___ and thick wall in ___
UC; crohn’s
granulomas in crohn’s or UC?
crohn’s
bleeding more common uc or crohn’s
uc
goals of treatment in IBD are to induce and maintain ____ and to improve ___
remission; nutr status
___ normally used in severe Crohn’s but not UC
Anti-TNF
in terms of MNT for IBD, shown these 4 things:
1) nutr support may bring about some clinical remission when used solely 2) complete bowel rest using PN not necessarily required 3) EN potential to feed intestinal epithelium and alter GI flora and is preferred 4) EN may temper some inflamm and serve as valuable nutr source, steroid sparing 5) kids benefit from EN as sole or supplement
malnutrition compromises digestive and absorptive fxn cuz increases ____ of GI and potential ___ agents
permeability ;inflammatory
PN may need in pt with:
persistent bowel obstruction, fistulas, major GI resections (SBS)
___g/kg/d of pro recommended
1.3-1.5
use of omega 3s helpful?
yes (reduce disease activity and med sparing effect, ^ remission)
pt with _____ benefit from reduced fibre and smaller food particle size
strictures or partial bowel obstruction
when fat malabsorption likely, supplement with foods made with:
MCTs
___ probiotic supplements shown to be beneficial in maintaining remission in pt with UC who had ____
multistrain; pouchitis (inflamm of ileal pouch acter colectomy)
using pro and prebiotics may prevent ___ and be used to treat ____
SIBO; diarrhea
___ colitis characterized by inflammation not visible by inspection of colon during colonoscopy and apparent only when lining biopsied
microscopic
types of microscopic colitis:
lymphocytic colitis and collagenous colitis
what is SBS
inadequate absorptive capacity resulting from reduced length or decreased functional bowel after resection
SBS is ___cm of small bowel without colon or ___cm with colon
100-120; 50
jejunal enterohormones:
CCK (pancreatic secretion/gallbladder contraction), secretin (bicarbonate), gastric inhibitory peptide, vasoactive inhibitory peptide
after jejunal resection, ___ adapts to replace fxn
ileum
_____ is only site for absorption of bile salts and vit B12 - intrinsic factor complex, also a lot of fluid
distal ileum
probs with malabsorbing bile salts?
can’t emulsify lipids so poorly absorbed and lead to malabsorb fat soluble vits as well, fats form f.a.-mineral soaps with Ca, Zn, and Mg so they are poorly absorbed as well, oxalate stones
preservation of colon essential for ___ status
hydration
malabsorption of bile salts can act as ____ which increases colonic motility with fluid and electrolyte losses
mucosal irritant
high fat diet + ileal resection + retained colon =
hydroxy fatty acids (^ fluid loss)
dependence on __ ^ risk of biliary sludge
PN
primary gut slowing meds?
loperamide and narcotics
most pt with significant bowel resection requires ___
PN
__ is preferred fuel for small intestinal enterocytes
glutamine
___ are major fuels for colon epithelium
SCFAs
severity of SBS depends on:
length/anatomy of bowel resected, health of remaining mucosa, presence of intact stomach/pancreas/liver
intestinal adaptation evidenced by:
hyperplasia of intestinal cells, ^ villus height, deepening of crypts, ^ transporter proteins
hormones to help intestinal adaptation?
recombinant human growth hormone, glucagon-like peptide 2
syndrome characterized by overproliferation of bacteria normally found in large intestine within small intestine
SIBO
causes of SIBO?
chronic use of meds suppressing gastric acid, liver disease/chronic pancreatitis, gastroparesis, bowel dysmotility, surgical resection of distal ileum and ileocecal valve
one of the most common symptoms of SIBO
chronic diarrhea (fat maldigestion)
what does bacteria in SIBO do?
toxic effects of bacterial products to brush border, use available vit B12 and make host deficient, produce folic acid, bloating/distention
rare neurologic complication of SIBO:
d-lactic acidosis (malabsorption of large CHO load)
treatment for SIBO?
therapeutic trial of antibiotics when suspicion is high (broad-spectrum)
diet for SIBO?
limit readily fermented carbohydrates (refined starch/sugar), more vit B12, MCTs, fat sol vits
abnormal passage of organ to another organ, skin, or wound called:
fistula
what is enterocutaneous fistula?
abnormal passage from portion of intestinal tract to skin or to wound
ECF classified how?
volume of output per day, cause (surgical vs spontaneous), site of origin, # fistula tracts
majority of ECF develops cuz of __
surgery
gold standard for identifying location and route of fistulous tract:
fistulogram
surgically created opening between intestinal tract and skin
intestinal ostomy
colostomies and ileostomies categorized either ___ or ___
loop (more temp); end
output from ileostomy is termed ___ whereas output from colostomy is ___
effluent; stool
stool from colostomy on __ side of colon is firmer than on ___ side
left; right
should we wait to feed when bowel functions again?
no, can start early
diet for ostomy:
low fibre diet
controlling flatus/odour more concern for ____ pt than ___ pt
colostomy; ileostomy
risk of ____ for ileostomy, so chew food well
blockage
ostomy output may become elevated, more common with ___
ileostomy
a high output stoma is output > ___ mL/day over 3 consecutive days
2000
reasons for high output stoma?
c diff, meds, intraab sepsis, obstruction, drinking too much, IBD
managing HOS?
correction of depleted electrolytes and minerals, initiate oral rehydration solution, avoid hypertonic/simple sugar, reduce insoluble fibre, separate solids and liquids at meals, small frequent meals
two classes of meds recommended to reduce HOS:
antidiarrheal, antisecretory
surgery of choice for pt with medically refractory UC and familial adenomatous polyposis
proctocolectomy with ileal pouch anal anastomosis
what does proctocolectomy with IPAA involve?
removal of entire colon and rectum while preserving anal sphincter
most common pouch in IPAA?
ileal J-pouch (two limbs of bowel)
why J pouch preferred?
efficiency of construction and optimal functional results
alternatives to J pouch:
S and W
type of applianceless ileostomy that uses internal reservoir with one way valve, constructed from loop of intestine attached to ab wall with skin level stoma
koch pouch
non specific inflamm of mucosal tissue forming ileal pouch and is most frequent long term complication of IPAA in pt with UC
pouchitis
why pouchitis?
SIBO, unrecognized crohn’s, immun changes, bile salt malabsorb, insufficient SCFA production
presenting symptoms pouchitis:
stool frequency/urgency, incontinence, nocturnal seepage, ab cramps, pelvic discomfort
main treatment for pouchitis?
antibiotics
IPAA people need supplement vit B12 cuz:
reduced absorb capacity cuz distal ileal resection, bacterial overgrowth, insufficient intake