Malabsorption syndromes- Pales Flashcards
Bristol Stool Chart
Type 1- little nuts
Type 2- sausage-shaped but lumpy
Type 3- sausage with cracks
Type 4- snake, smooth and soft
Type 5- soft blobs with clear-cut edges
Type 6- fluffy pieces with ragged edges, a mushy stool
Type 7 - watery, no pieces, entirely liquid
Diarrhea definition
Subjective definition:
Decrease in stool consistency (increased fluidity)
Presence of fecal urgency and abdominal discomfort
Increase in the frequency of stool.
Objective definition:
24 hr stool weight of more than 200 g (misses 20% of diarrheal symptoms)
Acute vs. chronic diarrheas
Acute – less than 6 to 8 weeks (typically under 2 weeks)
Chronic – more than 6 to 8 weeks.
tenesmus
constant feeling of having to go
clue that COLON is involved, and points to inflammation (colitis)
diarrhea from colon vs intestine
colon- small amounts, painful
small intestine- large amounts, crampy
absence of weight loss and appetite issues tells us what about the diarrhea?
cancer, malabsorption less likely
appetite is controlled by the brain and related to upper GI tract; you can exclude it from consideration in the dx
asthma relating to diarrhea?
think about eosinophils
sinusitis relating to diarrhea?
taking abx can –> diarrhea
Mechanisms of Diarrhea
Osmotic
Secretory
Exudative
Altered motility
Types of chronic diarrhea
Inflammatory
Watery non-inflammatory
Malabsorptive (fatty)
stool description: inflammatory diarrhea
Inflammatory (blood and pus) – positive hemoccult and fecal leukocytes, fecal calprotectin, painful, and may be febrile
Inflammatory Infectious Diarrheas
Enteropathogenic and enteroadherentE. coli Giardia Cryptosporidium Entamoeba Isospora Microsporidia Strongyloides Clostridium Dificille Breinerd Diarrhea (unknown causative agent)
Inflammatory Non-infectious Diarrhea
Inflammatory Bowel Disease
- Chrohn’s
- UC
Eosinophylic Gastroenteritis
Collagenous/Microscopic Colitis
Food Allergy
Radiation enteritis
Protein loosing gastro-enteropathy
“Board-related conditions”
- inflammatory diarrhea
Chronic mesenteric vascular ischemia Gastrointestinal tuberculosis Gastrointestinal histoplasmosis Behçet syndrome Churg-Strauss syndrome Neutropenic enterocolitis
Malabsorption. Impaired lipolysis.
Deficiency in pancreatic lipase
- Congenital absence of pancreatic lipase
- Destruction of the pancreatic gland
\+ Alcohol-related pancreatitis
\+ Cystic fibrosis
\+ Pancreatic cancer
- Denaturation of lipase by excess secretion of gastric acid
+ Zollinger-Ellison syndrome
Malabsorption. Impaired mixing.
Gastrectomy with gastrojejunostomy (Billroth II anastomosis)
Gastrointestinal bypass surgeries for obesity
Malabsorption. Impaired Micelle Formation
Due to decreased Bile salt concentrations
- decreased bile salt synthesis
+ severe liver disease
- decreased bile salt delivery
\+ Cholestasis
\+ Removal of luminal bile salts
- bacterial overgrowth
- terminal ileal disease or resection
- cholestyramine therapy
- acid hypersecretion
Malabsorption. Impaired Mucosal Absorption
Lactase Deficiency Congenital Enteropeptidase (Enterokinase) Deficiency Abetalipoproteinemia Celiac Disease Tropical Sprue Whipple Disease Graft-versus-Host Disease Short-Bowel Syndrome
Malabsorption.Impaired Nutrient Delivery
Impaired Lymphatic Drainage - Primary congenital lymphangiectasia (malunion of intestinal lymphatics) - Secondary lymphangiectasia \+ Lymphoma \+ Tuberculosis \+ Kaposi sarcoma \+ Retroperitoneal fibrosis \+ Severe heart failure
Steatorrhea. Diagnostic work up.
A qualitative test for fecal fat:
Sudan stain for fat
The test depends on an adequate fat intake (100 g/day).
High sensitivity (90%) and specificity (90%) if significant malabsorption (fat >10 g/24 hr)
Quantitative test for fecal fat:
Gold standard test of fat malabsorption
Requires ingestion of a high-fat diet (100 g) for 2 days before and during the collection.
Stool is collected for 3 days.
Over 14 g/ 24 hr is diagnostic for fat malabsorption
Secretin stimulation test for pancreatic insufficiency:
The gold standard test of pancreatic function.
Requires duodenal intubation with a double-lumen tube and collection of pancreatic juice in response to intravenous secretin.
Measures of bicarbonate (HCO3−) and pancreatic enzymes.
Very labor intensive and invasive and rarely done.
Fecal elastase-1 test:
Stool test for pancreatic function
Enteroscopy with biopsy
- Best test for malabsorption due to decreased intestinal absorption
Diagnosis by treatment
- Pancreatic enzymes improve symptoms with pancreatioc insufficiency
Probiotics
- Improve symptoms with bacterial overgrowth
where can ALP come from besides liver?
bone
treatment for short bowel and malabsorption of vitamin B
Patient went through course of antibiotics, then was started on probiotics and bile acid binder cholestyramine.
Low fat diet is started as well
Also started on Vitamin B12 shots
Symptoms improved
stool for osmotic gap (SOG)
290 − 2 x (stool Na + stool K)
watery diarrhea
Osmotic defined by:
Osmotic gap > 100 mOsm/kg
< 1 liter/day
Intermittent and relieved by fasting
Secretory defined by:
Osm gap < 50 mOsm/kg
Continuous and interrupts sleep
> 1 liter/day
Osmotic diarrhea
relieved by fasting
SOG > 100
from carbs- lactase deficiency, other disaccharidase deficiency, sorbitol ingestion
poorly absorbed salts (Mg++, Al3+, etc.)
secretory diarrhea
not relieved by fasting
SOG under 50
From bile acids Neuroendocrine tumors - carcinoid - VIPoma Increased motility - postvagotomy - DM - meds - IBS villous adenoma, microscopic colitis infections (Giardia, Cryptosporodiosis, Cyclospora, Cystoisosporiasis (eosinophilia), amebiasis)
Lactase deficiency (Lactose intolerance) testing
Hydrogen breath test
- after ingestion of 50 g of lactose, a rise in breath hydrogen of more than 20 ppm within 90 minutes is a positive test
Empiric trial of a lactose-free diet for 2 weeks.
- Resolution of symptoms is suggestive of lactase
Celiac Sprue Diagnosis
Serologic tests
- IgA tissue transglutaminase (IgA tTG) antibody
95% sensitivity and 95% specificity
- Antigliadin antibodies have low specificiity and sensitivity and not recommended
- IgA antiendomysial antibodies are no longer recommended due to the lack of standardization among laboratories.
- Endoscopic mucosal biopsy of duodenum (gold standard)
golden standard for diagnosis of celiac
Endoscopic mucosal biopsy of duodenum – golden standard for diagnosis
Usually shows
- intraepithelial lymphocytosis
- extensive infiltration of the lamina propria with lymphocytes and plasma cells
- hypertrophy of the intestinal crypts
- blunting or complete loss of intestinal villi
Partial or complete reversion of these abnormalities occurs within 3–24 months after the start of gluten-free diet
What dermatological complication is associated with Celiac disease?
Dermatitis Herpetiformis
What other disease can present similarly to celiac disease but has an infectious etiology and doesn’t get worse with gluten?
Tropical sprue
Tropical sprue
associated with the overgrowth of predominantly coliform bacteria
In residents or travelers to the tropics
Diarrhea is associated with megaloblastic anemia secondary to vitamin B12and folate deficiency
Treatment is a prolonged course of tetracyclines, folic acid, and vitamin B12injections (1000 µg weekly)
What is the cause of malabsorption when it’s associated with fevers, migratory arthralgia, and neurological and cardiac complications?
Whipple’s Disease
Whipple’s Disease
Caused by Tropheryma whipplei.
Symptoms include arthralgias, diarrhea, abdominal pain, weight loss, intermittent low-grade fever, generalized lymphadenopathy.
Myocardial or valvular involvement may lead to heart failure or valvular regurgitation.
Central nervous system involvement may cause dementia, lethargy, coma, seizures, myoclonus or cranial nerve palsy.
Irritable Bowel Syndrome
Functional GI disorder characterized by abdominal pain and altered bowel habits in the absence of a specific and unique organic pathology
Prevalence – 10-20%
some thoughts: Increased fecal serine protease activity, probably from an altered fecal flora!” You have 23,000 genes, but your microbiome has 8,000,000 genes. Increased bowel permeability - LPS. Associated with flu like symptoms, e.g.. fatigue, myalgia, arthralgia, fogginess.
IBS and breath test
Hydrogen or methane breath test (LBT) – will rise before 90 minutes when given lactulose (normal rise at 120 – 180 minutes). Indicates SIBO partially from decreased phase III intestinal housekeeper wave.
Complications of change in intestinal bacteria
Obesity – altered fat absorption and storage –fecal transplant – the new bacteria produce more LPL = fat storage.
high fat diet – different microbiome increases LPS absorption – endotoxemia, inflammation, metabolic disorder (metabolic syndrome)
Red meat – carnitine – altered microbiome produces trimethylamine N-oxide (TMAO) – atherosclerosis
Anxiety
Medication malabsorption
Aging – bacterial overgrowth
IBS and hypersensitivity
Bacterial antigen –>
visceral hypersensitivity.
Hypersensitivity in IBS similar to hypersensitivity of chronic fatigue syndrome and interstitial cystitis.
Bacterial translocation immune activation (CD25), –>increased sympathetic activity, anxiety.
IBS. Symptoms
Diarrhea, constipation, or both
Abdominal pain and distention, usually diffuse, worse after meals, better after defecation, dull or sharp
Postprandial urgency
Clear or white mucorrhea of a noninflammatory etiology
Dyspepsia, heartburn
Nausea, vomiting
Sexual dysfunction (including dyspareunia and poor libido)
Urinary frequency and urgency
Worsening of symptoms in the perimenstrual period
Comorbid fibromyalgia
Stressor-related symptoms
Inconsistent with IBS symptoms
Onset in middle age or older Acute, rather than chronic, symptoms Progressive symptoms Nocturnal symptoms Anorexia or weight loss Fever Rectal bleeding Painless diarrhea Steatorrhea Gluten intolerance
IBS. Diagnosis. The Rome III Criteria
Recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months associated with 2 or more of the following:
- Relieved by defecation
- Onset associated with a change in stool frequency
- Onset associated with a change in stool form or appearance
- Altered stool passage (straining and/or urgency)
- Mucorrhea
- Abdominal bloating or subjective distention
Four bowel patterns
- IBS-D (diarrhea predominant)
- IBS-C (constipation predominant)
- IBS-M (mixed diarrhea and constipation)
- IBS-U (unclassified; the symptoms cannot be categorized into one of the above three subtypes)
IBS. Management.
Psychological support
- cognitive-behavioral therapy, dynamic psychotherapy, and hypnotherapy
Dietary measures
- Fiber supplementation may improve the symptoms of constipation and diarrhea
- Judicious water intake is recommended in patients who predominantly experience constipation
- Caffeine avoidance may limit anxiety and symptom exacerbation
- Legume avoidance may decrease abdominal bloating
- Lactose, fructose, and/or FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) should be limited or avoided in patients with these contributing disorders
- Probiotics
Pharmacologic agents:
Anticholinergics (e.g., dicyclomine, hyoscyamine)
Antidiarrheals (e.g., diphenoxylate, loperamide)
Tricyclic antidepressants (e.g., imipramine, amitriptyline)
Prokinetics
Bulk-forming laxatives
Serotonin receptor antagonists (e.g., alosetron)
Chloride channel activators (e.g., lubiprostone)
Guanylate cyclase C (GC-C) agonists (e.g., linaclotide)
Antispasmodics (e.g., peppermint oil, pinaverium, trimebutine, cimetropium/dicyclomine)[4]
Potentially, rifaxamin (this is still investigational and not FDA approved)
HIAA
test for carcinoid tumor
Dumping syndrome
After surgeries
- distal esophagectomy
- Nissan wrap
- Gastrojejunostomy
- Roux-en-Y gastric bypass
- Duodenal switch gastric bypass
Delivery of concentrated sugars and food into the duodenum and jejunum
Results in
- altered insulin regulation
- Maldigestion
- osmotic movement of fluid into the intestinal lumen
- rapid transit insufficient for absorption of nutrients.
Dumping Syndrome. Symptoms
Early dumping:
abdmonial cramping and diarrhea (fatigue, sweating, rapid heart rate, decreased blood pressure, flushing, dizziness, shortness of breath)
Late dumping (shakiness, cold sweats, fatigue, decreased blood pressure, headache)
Short Bowel Syndrome
Less than 100 cm of ileal involvement or resection – liver able to keep
up with bile acid synthesis, so enough bile acid for fat absorption.
But, the bile lost to the colon produces a secretory diarrhea, so it
needs to be bound to control the diarrhea.
* Treated with Bile Acids Binders
Greater than 100 cm of ileal involvement – not enough micelle
formation (steatorrhea), so treated with * low fat diet, vitamin replacement, and medium-chained triglycerides.
