Malabsorption syndrome and Coeliac disease Flashcards
Define malabsorption
Failure of GI tract to absorb one or more nutrients causing weight loss or nutritional deficiencies
List 4 key clinical features of malabsorption
- Abdominal bloating
- Crampy abdominal pain
- Diarrhoea
- Steatorrhoea
- Weight loss
List 3 conditions affecting digestion which cause malabsorption
- Exocrine pancreatic insufficiency
- Disaccharidase deficiency
- Lactose intolerance
List 3 conditions causing pancreatic insufficiency
- Chronic pancreatitis
- Pancreatic cancer
- Cystic fibrosis
Treatment of pancreatic insufficiency?
Pancreatin - Creon
Lactase breaks down lactose into ______ and ______
What is the pathology of lactose intolerance?
Glucose and galactose
Deficiency in Lactase enzymes means lactose gets fermented by normal gut bacteria into gases (H2) - hence symptoms of bloating
Treatment of lactose intolerance
Dietary modifications: lactose free
List 4 conditions affecting absorption which cause malabsorption
- Cholecystectomy
- Crohn’s
- Amyloidosis
- Bile acid malabsorption
- Coeliac disease
List 4 infective causes affecting absorption which cause malabsorption
- Parasites: Giardiasis, worm infestation
- Tropical sprue
- Cholera
- Gastroenteritis: salmonella
- Small Intestine Bacterial Overgrowth (SIBO)
- C difficile
- Ileocolonic TB
- Whipple’s ds
What is Tropical sprue?
How do we treat it?
Rare GI disease resulting in malabsorption (unknown cause)
More prevalent in tropical countries so must ask about ‘travel history’
Treat with Antibiotics eg. tetracycline (check?)
List 3 risk factors for SIBO
poor gut motility due to
- strong pain killers
- elderly patients
- post surgical patients
What bacteria causes Whipple’s disease?
List 3 key clinical features of this condition
Tropheryma whipplei (+)
- Malabsorption: diarrhoea, weight loss
- Large-joint arthralgia
- Lymphadenopathy
What would a jejunal biopsy of Whipple’s disease show?
Foamy macrophages containing Periodic acid-Schiff (PAS) granules
List 4 Systemic diseases affecting GI tract which can cause malabsorption
- Diabetes
- Thyroid disorders (hyperthyroidism)
- Zollinger Ellison syndrome
- Carcinoid syndrome
- Cancer related: chemotherapy, advanced malignancies
How does Diabetes lead to Malabsorption?
- Autonomic neuropathy can cause diarrhea
- Metformin can cause diarrhea
What is Zollinger Ellison syndrome and how does it lead to malabsorption?
Gastrin secreting tumour of the pancreas
Excess gastrin → excess HCl → ulceration of mucosa → malabsorption
a) What is a Carcinoid tumour?
b) What is Carcinoid syndrome?
a) Tumours of enterchromaffin cells, producing serotonin
b) Group of symptoms (i.e. diaerhoea, SOB, flushing, abdo pain) due to hepatic involvement of carcinoid tumour
CHECK
How does Carcinoid syndrome lead to malabsorption?
Increased serotonin → increases peristalsis → less time for fluid absorption
Why does chemotherapy cause malabsorption?
Chemotherapy aims to reduce rate of rapidly diving cells
Villi in small bowel have a very high cell turnover rate, hence are affected signifcantly by chemotherapy
What LFT finding may be indicative of malnutrition?
Why?
Low Albumin due to deficient protein intakec(required for albumin synthesis
Raised faecal calprotectin aids in diagnosis of what?
IBD
Raised fecal elastase is indicative of what?
Pancreatic insufficiency
What is Urinary 5- HIAA and what condition does it aid diagnosis of?
Main metabolite of serotonin
Aids diagnosis of carcinoid tumors
What is the D-xylose absorption test?
Aid diagnosis of conditions related to mucosal defects in the small intestine, presenting with malabsorption
D-xylose is a sugar that is absorbed across the intestinal mucosa. Test involveds administering and measuring amount in urine or blood
Low levels = abnormality of the mucosa
What is the SeHCAT test used for?
Test for bile acid malbsorption
List 3 supportive measures for malabsorption
- IV fluids – replace electrolytes
- Nutritional support to treat deficiencies
- In-patient treatment required for severe malabsorption
What is coeliac disease?
Autoimmune condition where exposure to gluten causes a T cell-mediated rxn resulting in inflammation of the small intestine
List 3 important associations of coeliac disease?
- Positive family history
- HLA-DQ2 allele
- Other autoimmune disease
Which part of the GIT is most affected by coeliacs disease?
Jejunum
List 4 GI symptoms of Coeliacs disease
- Abdominal pain and cramping
- Distension, excessive flatus
- Nausea and vomiting
- Diarrhoea and constipation
- Steatorrhoea
Note: it is often asymptomatic, so low threshold for testing required
What is the dermatological manifestation of coeliacs disease?
Describe it
Dermatitis herpetiformis - pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk
List 4 systemic symptoms of Coeliac disease
- Fatigue
- Weight loss or failure to thrive in children
- Pallor (secondary to anaemia)
- Bruising (Vit K deficiency secondary to malabsoption)
List 4 complications of coeliacs disease
- Anaemia (Iron, B12, folate deficiency) and other Vitamin deficiencies
- Osteoporosis
- Increased risk lymphoma (NHL) and small bowel cancer
- Increased risks of other autoimmune diseases
- Infertility
What is essential to do when undergoing testing for Coeliacs?
It is ESSENTIAL that patients eat a gluten containing diet while undergoing testing to avoid false negatives
How is a diagnosis of Coeliacs disease made?
Highlight the gold standard
- Total IgA levels to exclude IgA deficiency
- Check for coeliac disease-specific antibodies: Anti- TTG asnd EMA
- OGD and duodenal/jejunal biopsy ☆ ‘Marsh classification’
List 3 antibodies raised in coeliacs disease?
(serology)
- Anti-tissue transglutaminase (anti-TTG)
- Serum and total IgA
- Anti-endomysial (anti-EMA)
What 3 findings are seen on endoscopy and intestinal biopsy in coeliacs disease?
- Sub-total Villous atrophy
- Crypt Hyperplasia
- Intra-epithelial Lymphocytes
Management of Coeliacs disease
Lifelong gluten-free diet are curative
How can we measure disease progression of Coeliacs
Checking coeliac antibodies
What is recommended by the BSG for maintaining and monitoring bone health in adults with coeliac disease?
- At least 1000mg calcium/day.
- DEXA scan on diagnosis to assess BMD
- Weight bearing activity, avoiding smoking and ensuring adequate vit D
Why are patients with coeliacs at an increased risk of BMD
- Late or delayed diagnosis
- Chronic malabsorption of calcium prior to diagnosis
- ↓ intake of calcium post diagnosis (bread and cereal foods)
- Lapses in the gluten free diet
- Persistent villus atrophy
- Lactose intolerance
- Low BMI
What is Non-coeliac gluten sensitivity (NCGS)?
Represents a large patient group who get symptoms upon eating gluten despite negative serological tests and duodenal biopsy
No specific diagnostic test available, do FODMAPs to check if other components are to blame or if it placebo effect
