Malabsorption

Question 1

What are the characteristics of steatorrhoea?

Answer 1

Pale, bulky, offensive, fat >17mmol/day, float in the toilet, difficult to flush away

Question 2

What are the investigations needed for small bowel disease?

Answer 2

Full blood count (anaemia macro/micro) (dimorphic) (MCV low= ferritin and transferrin receptor) (MCV high= B12, folate) (MCV low in coeliac and crohn’s)
Albumin
Low calcium and high ALP (osteomalacia)
Autoantibodies (tissue transglutaminase, reticulin, gliadin= coeliac)

Question 3

When are B12 absorption studies used?

Answer 3

Pernicious anaemia 
Ileal disease (when oral vitamin B12 given with intrinsic factor will show malabsorption)
Bacterial overgrowth (measurement of vitamin B12 plus intrinsic factor absorption is repeated after antibiotics)

Question 4

What are diseases of the small intestine which cause malabsorption?

Answer 4

Coaliac disease
Dermatitis herpetiformis 
Tropic sprue
Bacterial overgrowth 
Intestinal resection 
Whipples disease 
Radiation enteritis 
Parasite infestation (guardia intestinalis)

Question 5

What is coeliac disease?

Answer 5

Inflammation of the jejunal mucosa decreasing in severity towards the ileum that improves when patient doesn’t eat gluten
Pure oats aren’t harmful
Absence of villi, crypt hyperplasia with chronic inflammatory cells in the lamina propria
Can present at any age
Tiredness, malaise, associated anaemia
Diarrhoea, steatorrhea, bloating, weight loss
Mouth ulcers and angular stomatitis
Infertility and neuropsychiatric problems
Associated diseases include- IBD, chronic liver disease, epilepsy, fibrosing allergic alveolitis

Question 6

What investigations are done for coeliacs disease?

Answer 6

EMA, tissue transglutaminas (tTg) antibodies (IgA)
Anti-reticulin antibodies (ARA)- less sensitive also used for crohn’s
Duodenal/jejunal biopsy (smoothness of mucosa)
Haematology- anaemia, folate deficiency,
Radiology- dilation of the small bowel with a change in fold pattern
Bone densitometry
Bone chemistry

Question 7

What complications can occur in coeliacs?

Answer 7

ntestinal lymphoma 
Ulcerative jejunitis (fever, abdo pain, perforation)

Question 8

What occurs with ileal resection?

Answer 8

Malabsorption of water and electrolytes leading to diarrhoea
Steatorrhoea, lithogenic bile and gallstone formation
Renal oxalate stones
Low serum B12 and macrocytosis
Low GLP-2

Question 9

What is pernicious anaemia?

Answer 9

Autoimmune parietal cell destruction 
More common in females 
Middle to old age 
More common in blood group A
results in vitamin B12 deficiency
associated with thyroid disease, diabetes, Addison's, rheumatoid and vitiligo
predisposes to gastric carcinoma

Question 10

What are the features of pernicious anaemia?

Answer 10

Lethargy, weakness
dyspnoea
paraesthesia
also: mild jaundice, diarrhoea, sore tongue
possible signs: retinal haemorrhages, mild splenomegaly, retrobulbar neuritis

Question 11

What immunisations do patients with coeliac disease require?

Answer 11

Have a degree of functional hyposplenism
For this reason, all patients with coeliac disease are offered the pneumococcal vaccine
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
Currrent guidelines suggest giving the influenza vaccine on an individual basis.

Question 12

What are the complications in coeliacs disease

Answer 12

Iron, folate and vit B12 deficiency
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies