Malabsorption Flashcards
جذب کدوم نوترینت ها محدود به مناطق خاصی از روده س؟
کلسترول ویتامین B12: ترمینال ایلئوم
چه بیماری ای رو میشناسی که diffuse mucosal involvement میده؟
Celiac
Crohn
چربی های unsaturated?
Oleic acid
Linoleic acid
محل بازجذب bile acids?
Terminal ileum with 95% efficiency
What are chylomicrons composed of?
Cholesterol
phospholipids
triglycerides
در داخل سلول های روده باریک اینا باهم دیگه پکیج میشن
Where do most dietary lipids absorb
ژژنوم به همراه ویتامین های DAKE
فرق جذب فروکتور و گلوکز و گالاکتوز از روده؟
گلوکوز و گالاکتوز : با ترنسپورتر سدیم
فروکتوز: Facilitated diffusion
محل تبدیل دی ساکارید ها به مونوساکلرید قابل جذب؟
Brush borders
Where does digestion of proteins start?
In the stomach with pepsin is secreted by the gastric mucosa
ولی عمده ی هیدرولیرش در Proximo small bowel
نحوه ی فعال شدن پروتئاز های پانکراس در روده ؟
Trypsin
elastase
chemo trypsin
carboxypeptidase as inactive pro enzymes
بعد اینا توسط انتروکیناز هایی که از Brush border ترشح میشوند تریپسینوژن تبدیل میشه به تریپسین
و بعد تریپسین بقیه رو فعال میکنه
بخش عمده لومینال فاز در کدوم‌قسمته؟
کدوم انزیما؟
دئودنوم و پروگزیمال ژژنوم
Lipase
Colipase
Trypsin
کدوم بیماری ها با مکانیسم اختلال در فاز لومینال چربی Malabsorption میدن؟
Deficiency in bile salts:
1-Cholestatic liver disorders: Impaired situation of bile
2-BOS: Resulting in luminal bile Salt deconjugation
3-Ileal disease
4-resection
کدوم بیماری ها با مکانیسم اختلال در فاز موکوسال Malabsorption میدن؟ 5
کرون و سلیاک
Decrease in surface area: Surgical resection for a small bowel infarction
Lactase deficiency
abetalipoproteinaemia
کدوم بیماری ها با مکانیسم اختلال در فاز ترنسپورت Malabsorption میدن؟
Vascular conditions
(vasculitis; atheroma)
Lymphatic conditions
(lymphangiectasia; irradiation; nodal tumor, cavitation, or infiltrations)
انمی فقر اهن به تنهایی علامت کدوم بیماری سوجذب میتونه باشه؟
Celiac
علایم Specific
Protein malabsorption چیاس؟
Muscle wasting
Edema
علایم مختص vitamin K deficiency
Gg
Bloating & Soft diarrhoeal movement
ناشی از کدام سوجذبه؟
کربوهیدرات
چه W/U هایی رو برا بیماری که شک به مل ابزوربشن داریم انجام مبدیم؟
Albumin Cobalamin Iron Chol Ca Folic acid PT
برای تشحیص کافی ان ولی برای پیدا کردن اتیولوژی نه
اگر شک‌داشتیم به fat malabsorption چه تستی انجام میدیم که اسون و سریع باشه؟
حساسیت ؟
Gg
How is quantitive fecal test done?
Gg
در تست کمی مدفوع،
مقدار چربی بالای چند باشه بیانگر fat malabsorbtion عه؟
در مورد استئاتوره؟
بیش از ۷ گرم در روز
بیش از ۲۰ گرم در روز
تست کمی مدفوع در کدام Ddx مل ابزوربشن چربی به کارمون میاد؟
Diarrheal illnesses
بهتربن ایندکس عملکرد اگزوکرین پانکراس؟
معایب؟
Aspiration of duodenal contents for evaluation of bicarbonate and enzyme output after stimulation of the pancreas
However, the test is invasive, time-consuming, and performed only in a few specialized centers.
چه W/Uی داریم که ساده و کافی باشه برای تشخیص moderate to severe pancreatic insufficiency?
The measurement of pancreatic enzymes (i.e., fecal elastase 1) in the stool
چه روش imaging رو برای بررسی عملمرد پانکراس استفاده میکنیم و یافته نشخیصی؟
Abdominal Xray or CT
Pancreatic calcifications indicate the presence of chronic pancreatitis.
MRCP & ERCP
چی ان و چه کاربردی دارند؟
حساسیت شون صد در صده؟
Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP)
can help outline abnormal duct anatomy and may supplement CT scanning for diagnostic purposes to evaluate the sequelae of chronic pancreatitis.
However, normal findings on pancreatography do not exclude the presence of pancreatic exocrine insufficiency.
کدوم بیماری ها نمونه برداری از Small bowl تشخیصی عه؟
Whipple disease
Amyloidosis
Eosinophilic enteritis
Lymphangiectasia
Primary intestinal lymphoma
Giardiasis
Abetalipoproteinemia
Agammaglobulinemia
Mastocytosis
کدوم بیماری ها یافته ی بیوپسی روده باریک ابنورماله ولی Diagnostic نیست؟ ۶
Celiac disease
Systemic sclerosis
Radiation enteritis
Bacterial overgrowth syndrome
Tropical sprue
Crohn’s disease
اختصیات barium studies روده باریک در بیماری های سو جذب؟
چیارو ممکنه باهاش پیدا بشه کرد؟
معمولا Nonspecific
jejunal diverticulosis, lymphoma, Crohn’s disease, strictures, or enteric fistulas.
در بیماری بعد از باریوم انما الگوی thin walled و dilated loops دیده شد.
تشخیص؟
Celiac
MR enterography
برای کدام پاتولوژی های روده حساسه؟
active bowel inflammation
mesenteric stranding and edema,
strictures
fibrofatty proliferation of the mesentery
fistula formation.
در کیا نباید capsule endoscopy امجام بدیم؟
in patients in whom a stricture is suspected because of the risk of retention.
عامل حفظ کننده ویتامین B12 در معده و روده؟
gastric parietal cells secrete intrinsic factor, which mixes with the ingested meal.
In the duodenum, pancreatic trypsin hydrolyzes the R-protein, freeing the vitamin to bind with intrinsic factor.
Gg
The vitamin B12–intrinsic factor complex is then absorbed by specific receptors that are found only on enterocytes in the distal ileum. Malabsorption of vitamin B12 can occur because of
The Schilling test quantifies vitamin B12 absorption using radiola- beled vitamin B12 as a marker. The test may be expanded to several stages to amplify its diagnostic spectrum. In stage 1, after the injection of 1000 μg of unlabeled vitamin B12 to saturate hepatic storage, the patient ingests 0.5 μg of radiolabeled vitamin. Urine is then collected for the measurement of radioactivity; reduced radioactivity suggests B12 malabsorption. The test is repeated (stage 2) with the addition of oral intrinsic factor to the ingested vitamin B12. If urinary excretion of the radiolabel is corrected, pernicious anemia is diagnosed. If mal- absorption is still present, the patient is given a short course of oral antibiotics (stage 3), and the test is repeated; correction of radiolabeled B12 excretion establishes bacterial overgrowth. If the test result remains abnormal, oral pancreatic enzymes are given (stage 4) and the test is repeated; correction of the abnormality at this stagei implies pancreatic deficiency. Finally, if all these interventions fail, ileal disease or absence of transcobalamin protein is determined by other diagnostic tests, including assessment for intrinsic factor antibodies or Helicobacter pylori infection. This long outline serves merely as an example of an algorithm of clinical analysis; the usual routine in clinical settings is to administer parenteral vitamin B12 while the etiology is delineated by other modalities.
What are the causes of malabsorption of B12?
lack of intrinsic factor (e.g., pernicious anemia, gastric resection),
pancreatic insufficiency,
bacterial overgrowth,
or ileal resection
or mucosal disease (e.g., Crohn’s disease).
کاربرد تست D-xylose ؟
The d-xylose test serves as an indicator of mucosal absorption in the proximal small bowel and is used to determine whether defects in the epithelium of the intestine are responsible for malabsorption.
روش انجام تست D-xylose ؟
In this test, the subject ingests 25 g of d-xylose, and urine is collected for the next 5 hours.
Healthy subjects excrete more than 4.5 g of d-xylose in 5 hours (or ≥20% of the ingested load).
Excretion of a lower amount of d-xylose suggests abnormal absorption.
در چه بیماری هایی تست دی زایلوز به طور کادب مثبت میشه؟
چه داروهایی؟ ۴
impaired renal excretory function,
gastroparesis,
massive peripheral edema,
ascites,
aspirin, neomycin, indomethacin, and glipizide.
What is pseudo malabsorption in D xylose test?
bacterial overgrowth as a result of bacterial degradation of d-xylose in the lumen,
but this “pseudomalabsorption” may be corrected after treatment with antibiotics serving as a therapeutic trial.
What is the most accurate test for fat malabsorption?
72 hour fecal fat analysis
کاربرد breath test?
لاکتاز دفیشنسی
BOS
Breath tests rely on bacterial degradation of luminal compounds, which releases metabolic byproduct gases (e.g., hydrogen, methane, carbon dioxide) that can be measured in the exhaled breath.
estimate the malabsorption of fat or bile acids and for measurement of bacterial overgrowth (14C-xylose).
بیمار چه علایمی داشته به Carbohydrate malabsorption شک میکنیم؟
Cramps
flatulence
diarrhoea
کدوم تست برای Lactose intolerance
خساس و اختصاصی عه؟
Measurement of breath
Hydrogen
Osmotic gap in fecal
چه کمکی به یافتن اتیولوژی سوجذب میکنه؟
کربوهیدرات و اسید چرب
پایین بودن سطح کاروتن سرم نشوندهنده کدوم سوجذبه؟
Fat malabsorption
بعد از تشخیص Fat malabsorption
با روش ازمایشگاهیی و Qualitative a stool fat
اقدام بعدی؟
دی زایلوز
normal d-xylose test result makes diffuse mucosal disease unlikely and suggests maldigestion, principally pancreatic enzyme or bile salt deficiency.
در کسی که تست fat س النورمال بوده و دی زایلوز نرمال،
سرنخ های تشخیص پانکراتیت مزمن؟
a history of alcohol abuse or previous episodes of pancreatitis.
Unusual causes of pancreatic malabsorption, such as cystic fibrosis,
microlithiasis,
or drug toxicity,
require specific testing and a detailed history.
در کسی که تست fat س النورمال بوده و دی زایلوز نرمال، چه w/u هایی انجام میدبم تا از تشخیص احتمالی مون مطمعن بشیم؟
Serum enzyme tests and abdominal imaging (plain films or, with much greater sensitivity, abdominal CT scans) can be obtained next to identify pancreatic disease.
اگر تست دی زایلوز ابنورمال بود، اقدام بعدی؟
the breath hydrogen test may be used to diagnose bacterial overgrowth using glucose for the carbohydrate load.
اگر دی زایلوز ابنورمال بود و تست هیدروژن هم نرمال بود اقدام بعدی؟
mucosal biopsy
اگر هیچ علتی برای malabsorption پیدا نکردیم؟
careful stool examination for ova and parasites or fecal antigen studies.
such as Giardia lamblia, or ascariasis involvement of the pancreatic duct
What is celiac disease?
intestinal mucosal injury resulting from gluten-related immunologic damage in persons genetically predisposed to this condition.
The exposure initiates a cellular immune response that results in mucosal damage
Particularly in the proximal Intestine
بیس ژنتیکی سلیاک با چه مولکول هایی مرتبطه؟
HLA class ii
HLA-DQ8
HLA-DQ2
کدوم پروتیین گندم در پاتوژنز سلیاک نقش داره؟
Gliadin
What is the auto antigen of celiac disease?
Tissue transglutaminase
What are the atypical manifestations of celiac disease?
💗nonspecific GI symptoms:
▪️bloating,
▪️chronic diarrhea (with or without steatorrhea),
▪️flatulence,
▪️lactose intolerance,
▪️ deficiencies of a single micronutrient (e.g., iron deficiency anemia).
💗Extraintestinal complaints such as ▪️depression, ▪️weakness, ▪️fatigue, ▪️arthralgias, ▪️osteoporosis, ▪️osteomalacia may predominate.
Which diseases are found in significant association with celiac disease? 4
dermatitis herpetiformis
type 1 diabetes mellitus
autoimmune thyroid disease
selective immunoglobulin A (IgA) deficiency
What is the most valuable test in establishing the diagnosis of celiac?
Intestinal biopsy
یافته های کپسول اندوسکوپی در سلیاک؟
may show the typical features of broad and flattened villi
یافته های تشخیصی سلیاک در بیوپسی؟
pathologic changes ranges from normal villous architecture with an increase in mucosal lymphocytes and plasma cells (the infiltrative lesion) to partial blunting or total villous flattening.
چرا باوجود این که بیوپسی سلیاک اسپسفیک نیست، ارزشمند ترین تست تشخیصی ش محسوب میشه؟
particularly because most other conditions that can mimic celiac disease may be distinguished clinically.
Ddx of celiac? 6
Crohn’s disease
gastrinoma
lymphoma
tropical sprue
Graft-versus-host disease
immune deficiency
ایا بعد شروع درمان بازم لازمه بیوپسی چک کنیم واسه اطمینان از اثر بخشی؟
A clinical response to a gluten-free diet establishes the diagnosis and precludes the need, in adults, to document healing by repeated biopsies.
What is the use of serology blood tests in screening of celiac?
1-patients with atypical symptoms
2-asymptomatic relatives of patients with celiac disease.
حساسیت و اختصاصیت تست HLA برای سلیاک؟
حساسیت بالا
اختصاصیت پایین
چه زمانی در بیمار سلیاکی بیوپسی رو تکرار مبکنیم؟
Persistent symptoms despite a gluten-free diet
those who are seronegative
فالو آپ بیماران سلیاکی چطور انجام میشه؟
Follow-up monitoring with serologic testing should be done after 3 to 6 months in the first year
and then yearly thereafter in stable patients clinically responding to a gluten-free diet.
سلیاک ریسک ابتلا به کدام Malignancy را زیاد میکنه؟
Lymphoma
Presents of what additional diseases can lead to refractory celiac disease? 5
1-inflammatory bowel disease, 2-microscopic colitis, 3-lactose intolerance, 4-pancreatic insufficiency, 5-ulcerative jejunitis.
معیار اینکه به یکی بگیم refractory celiac داره؟
persistent celiac disease activity despite adherence to a strict gluten-free diet for 12 months
فرق RCD 1 و ۲ ؟
Type 1 RCD is characterized by normal intraepithelial lymphocytes and a polyclonal T-cell receptor population.
Type 2 RCD is described as having aberrant intraepithelial lymphocytes with monoclonal T-cell receptors.
که طبیعتا پروگنورش بدتره و مورتالیتی ۵ ساله ش بیشتره و More association with lymphoma
If malignancy was suspected in RCD which imaging modality would be our choice?
PET CT
درمان RCD 2?
azathioprine, steroids, methotrexate, cyclosporine, alemtuzumab, cladribine or fludarabine with or without autologous stem cell transplant.
What are the complications of BOS?
Diarrhea
malabsorption
What are the mechanism of bacterial overgrowth syndrome complications? 4
(1) deconjugation of bile salts, which leads to impaired micelle formation and impaired uptake of fat;
(2) patchy injury to the enterocytes
(3) direct competition for the use of nutrients (e.g., uptake of vitamin B12 by gram-negative bacteria or the fish tapeworm Diphyllobothrium latum);
(4) stimulated secretion of water and electrolytes by products of bacterial metabolism, such as hydroxylated bile acids and short-chain (volatile) organic acids.
۳ خط دفاعی gut که مختل شدنشون منجر به BOS میشه؟
gastric acidity
peristalsis
intestinal immunoglobulins (IgA).
Which diseases are associated with impaired peristalsis?
🐥motility disorders
(e.g., scleroderma, amyloidosis, diabetes mellitus) + opiates
🐥anatomic changes
(e.g., surgically created blind loops, obstruction, jejunal diverticulosis).
چه زمانی در بیماری که Chronic pancreatitis داره به BOS شک میکنیم؟
Ongoing weight loss or a steatorrhea
despite enzyme replacement therapy
What is the most definite diagnostic test for BOS?
Direct culture of jejunal aspirate
وقتی شک کردیم به BOS تست انتخابی مون چیه؟
The 14C-xylose breath test is an accurate and sensitive laboratory test;
measurement of breath hydrogen after an oral challenge with glucose is simpler but not as sensitive or as specific.
انتی بیوتیک های انتخابی جهت درمان BOS?
Rifaximin,
amoxicillin-clavulanate,
quinolone,
metronidazole with a cephalosporin or trimethroprim-sulfamethoxazole
طول درمان انتی بیوتیکی BOS؟
۷ تا ۱۰ روز
چه داروهایی با مکانیسم Malabsorption سبب کاهش وزن میشن؟
🦋bile acid–binding resins, such as cholestyramine and colestipol
🦋 lipase inhibitors orlistat (Xenical) and ezetimibe (Zetia).
