malabsorption 2 W7 Flashcards
risk factors for malabsorption
surgery, radiotherapy
autoimmunity, DM
medications, alcohol
travel history
management of malabsorption?
nutritional support - introduce in measured way to mitigate risk of refeeding syndrome
coeliac disease definition?
chronic autoimmune-mediated gluten-sensitive enteropathy
what is coeliac disease caused by
exposure to cereal prolamins in genetically susceptible individuals:
-wheat
-rye
-barley
presentation of coeliac disease - GI?
chronic or intermittent diarrhoea, bloating, weight loss, fatigue, failure to thrive, lactose intolerance
any unexplained persistent GI symptoms
‘coeliac crisis’
presentation of coeliac disease - extra-GI?
signs of specific micronutrient deficiencies
neuro symptoms, particularly ataxia
dermatitis herpetiformis
raised liver enzymes
subfertility
metabolic bone disease
diagnosis of coeliac disease?
requires ongoing gluten exposure
serology - TTG IgA most widely used
endoscopy, duodenal biopsies
what is the most common nutrient deficiency in coeliac disease
iron deficiency
when isn’t a colonoscopy required for Coeliac disease diagnosis?
TGA IgA > 50 and symptoms leads to no biopsy diagnosis of Coeliac disease
management of coeliac disease?
gluten free diet (lifelong, GF products can be prescribed, adherence is an issue)
annual review (dietary compliance, weight and symptoms, bone health, vaccination status, bloods)
what is non-responsive coeliac disease?
ongoing symptoms 12 months after GFD implemented
what to do for non-responsive coeliac disease?
rule out other possibilities - slow responder? non-compliance?
is this an associated condition, mimic or refractory coeliac disease?
-repeat OGD and duodenal biopsies - is there atrophy?
non-responsible coeliac disease repeat biopsy - results with atrophy could be caused by?
coeliac histological mimics
inadvertent gluten contamination
slow healing
‘supersensitivity’
refractory coeliac sprue (RCD1 and 2)
non-responsible coeliac disease repeat biopsy - results with no atrophy could be caused by?
SIBO
microscopic colitis
lactose intolerance
IBD
thyroid disease
DM
PEI
BAM
infection
IBS
what is non-responsive coeliac disease if no explanation is found?
refractory coeliac disease (bad news!!)
refractory coeliac disease type 1?
normal IEL phenotype. treat with tight diet and steroids (budesonide). good 5yr survival
refractory coeliac disease type 2?
aberrant and/or clonal IEL cell lines
can progress to malignancy
treat with aggressive immune suppression (steroids)
poor 5yr survival
what malignancies can RCD progress to
enteropathy-associated T cell lymphoma
non-Hodgkin’s lymphoma
small bowel adenocarcinoma
infectious enteropathies?
tropical sprue
Whipple’s disease
giardiasis
HIV/TB enteropathy
other enteropathies?
drug-induced enteropathy
autoimmune enteropathy
radiation enteropathy
Crohn’s disease
tropical sprue features?
recent prolonged travel or living in endemic area.
very rare
presents with malabsorption syndrome (may or may not follow traveller’s diarrhoea. whole small bowel affected. weight loss and folate/B12 deficiency common)
diagnosis - D2 Bx showing villous atrophy, lymphocytic infiltrate. travel history and negative screen for other causes.
antibiotics 3-6 months
Whipple’s disease features?
affects middle aged men, farmers.
malabsorption syndrome, GI bleeding, migratory arthritis, sacroiliitis, pericarditis/endocarditis, confusion, ataxia, extrapyramidal signs. endoscopy - yellow, dotty. treat with antibiotics
giardiasis features?
flagellated protozoan infection
malabsorption
stool microscopy, stool antigen ELISA.
D2 Bx showing loss of brush border, villous shortening, trophozoites.
treat with metronidazole
drug induced enteropathy caused by which drugs? how is it resolved?
caused by NSAIDs, olmesartan, MMR, methotrexate
resolved with drug withdrawal
autoimmune enteropathy features?
rare
villous atrophy, deep crypt lymphocytosis, minimal intra-epithelial lymphocytosis
treat with systemic steroids, nutrition support
radiation enteropathy features?
dysmotility, villous atrophy, telangiectasia, strictures, SIBO
treatment - treat coexisting SIBO. low fat, high protein, MCT diet. enteral +/- parenteral support.
Crohn’s disease features?
malabsorption mediated by mucosal disease, fistulae, surgical resection.
treatment - treat inflammation, treat coexisting SIBO, nutrition support, surgery.
SIBO stands for what?
small intestinal bacterial overgrowth
SIBO definitions?
normally 10^3 bacteria/ml present in small bowel
colon has up to 10^12 bacteria/ml
mostly gram negative aerobic bacteria in ileum, and gram positive anaerobes in colon.
in SIBO this balance is lost.
SIBO presentation?
risk factors
maldigestion, bloating, diarrhoea
B12 deficiency common (folate normal/high)
aetiology of SIBO?
loss of protective mechanisms
stasis:
-blind loop/post-UGI surgery
-stricture
-diverticulum
-dysmotility (opioids, diabetes, systemic sclerosis, parkinson’s)
systemic immunodeficiency
local mucosal disease (coeliac, crohns, NSAIDs etc)
PPI
PEI
diagnosis of SIBO?
> 10^3/mL quantitative culture of jejunal fluid (gold standard)
more practical - glucose/hydrogen breath test (rise of >20ppm hydrogen from baseline considered
+ve)
consider radiology for anatomical abnormalities and testing for risk factors or secondary causes
treatment of SIBO?
rifaxamin 550mg TDS for 10-14 days
pancreatic exocrine insufficiency definition
insufficient secretion or function of pancreatic enzymes or sodium bicarbonate for normal digestion
pancreatic exocrine insufficiency aetiology
results from impaired production or drainage of pancreatic enzymes, reduced entero-hormonal stimulation of the exocrine pancreas, or asynchronous digestion due to dysmotility or abnormal anatomy.
pancreatic exocrine insufficiency - associated conditions?
Chronic pancreatitis (21-94%)
Pancreatic cancer, (20-92%)
Cystic fibrosis (85%)
Pancreatic resection (11-100%)
Acute pancreatitis (30% at 6 months)
Untreated coeliac (11%)
Refractory coeliac (30%)
HIV on ARVs (32%),
Type 1 Diabetes (38%)
Type 2 Diabetes (10-28%)
UGI surgery (9-31%)
Alcohol
Smoking
pancreatic exocrine insufficiency - making the diagnosis?
history - diarrhoea, abdominal pain, bloating, weight loss
FE1
nutritional blood tests
pancreatic imaging
management of pancreatic exocrine insufficiency?
pancreatic enzyme replacement therapy (PERT)
refer to dietician
smoking and alcohol cessation
