Non-Surgical bowel disorders

Question 1

Celiac Disease

Answer 1

Also known as Gluten-Sensitive Enteropathy or Celiac Sprue, this is a chronic
digestive disorder characterized by the inability to tolerate Gliadin, an alcohol
soluble fraction of gluten. Gluten is found in the endosperm of the grain.

Question 2

Gluten is a protein found in the grains ____

Answer 2

wheat, rye, and barley.

Question 3

Celiac Disease pathophysiology

Answer 3

○ Gliadin is absorbed into the lamina
propria and is often bound by Tissue
Transglutaminase (tTG).
○ Two Human Leukocyte Antigens
(HLA-DQ2 and HLA-DQ8- can test for
the genes for these) on the surface of
antigen-presenting cells bind the
Gliadin and present it to helper T cells,
which mediate the inflammatory
response and production of antibodies
against Gliadin and tTG.
○ The inflammatory cytokines released into
the intestinal epithelium, as well as the
presence of antibodies against Gliadin and
tTG, trigger epithelial invasion by
Lymphocytes, which results in destruction
of the absorptive surface of the intestine.
○ Intestinal villi are mostly or totally lost as a
result, leading to maldigestion and
malabsorption syndrome.

Question 4

Celiac Disease classic presentation

Answer 4

■ Diarrhea (45-85%) -
■ Flatulence
■ Weight loss or failure to thrive (45%)
■ Weakness or fatigue
■ Abdominal pain or bloating

Question 5

Extraintestinal symptoms of celiac disease:

Answer 5

■ Anemia (~10%) - iron or folate deficiency
■ Neurologic symptoms (8-14%)- headache, paresthesias, ataxia
■ Osteopenia and osteoporosis
■ Skin problems (10-20%)- Dermatitis
Herpetiformis is characteristic
■ Hormonal disorders- including
amenorrhea or infertility

Question 6

Celiac Disease diagnosis

Answer 6

○ Serologic testing is generally the initial testing:
■ Anti-Tissue Transglutaminase (tTG) IgA
● Most common and best predictive value
■ IgA levels are helpful: Anti-Endomysial (EMA IgA)
■ Individuals with positive serology require a small bowel biopsy to confirm the diagnosis
○ Upper Endoscopy with at least 6 duodenal
biopsies is confirmatory and gold standard.

Question 7

Associated lab studies for celiac disease1

Answer 7

■ Ferritin, serum iron, TIBC, Vitamin D, Vitamin B12
■ TSH w/ reflex to T4
■ Genetic testing for HLA-DQ2 or DQ8

Question 8

What will an upper endoscopy show in celiac disease?

Answer 8

Shows Reduced mucosal folds, atrophic
mucosa (blunted or absent villi), visible
fissures

Question 9

Management of celiac disease

Answer 9

A completely Gluten-Free Diet is essential to treatment.
■ Can be a difficult thing in US- Consider nutritionist consult
○ It takes generally 4-8 weeks of a Gluten-Free diet for patients
to notice a difference in their symptoms.
○ In refractory cases, a short course of prednisone may be needed

Question 10

Lactose Intolerance

Answer 10

● Lactose is a disaccharide sugar that is found in the milk of mammals.
● It cannot be absorbed in the intestines unless it is broken down into simple sugars.
● Intolerance occurs with the inability to digest lactose into glucose and galactose due to low levels of lactase (enzyme)

Question 11

Primary vs. Secondary lactose intolerence

Answer 11

● Primary lactose intolerance is secondary to deficiency of lactase, which develops naturally after childhood.
● Secondary lactose intolerance can develop in a healthy person after an acute illness. (Mucosal damage or meds)

Question 12

Lactose Intolerance pathophysiology

Answer 12

○ In order to be absorbed, ingested lactose must be hydrolyzed into the simple sugars Glucose and Galactose by Lactase.
○ The Lactase enzyme is normally produced by
the intestinal villi in young humans, but
production decreases with age.
○ Lactose that is not broken down remains in the gut and acts like an osmotic laxative, pulling
fluid into the lumen.
○ Lactose is also fermented by colonic bacteria,
producing hydrogen gas.

Question 13

Lactose Intolerance presentation

Answer 13

■ Nausea
■ Bloating
■ Flatulence
■ Diarrhea
■ Abdominal cramping
○ IBS and Lactose Intolerance can present in
a similar fashion

Question 14

Lactose Intolerance diagnosis

Answer 14

○ Generally, lactose intolerance is a clinical diagnosis, based on the history and clinical clues.
○ If testing is desired, the Breath Hydrogen Test is the diagnostic study of choice.
○ EGD with biopsy (rarely performed and not usually necessary) may reveal low lactase activity on assays.

Question 15

Lactose Intolerance management

Answer 15

○ Dietary adjustments to exclude lactose containing foods is the treatment of choice.
■ Prehydrolized milk or milk alternatives are available
○ Commercially available lactase enzyme
preparations are available over the counter and
are usually effective in decreasing symptoms.
■ Lactaid, lactrase
■ Taken 30-45 min prior to ingestion of foods
containing dairy

Question 16

Common Causative Foods causing allergies:

Answer 16

● Fish/seafood
● Peanuts/tree nuts
● Allergy to cow’s milk proteins

Question 17

Epidemiology of food allergies

Answer 17

Over 8% of children and around 5% of adults
● Most food allergies develop in early childhood, with highest prevalence around age 1.
● Up to 15% of allergies develop in adulthood.

Question 18

Food Allergies pathophysiology

Answer 18

● Usually, the first ingestion of a new food does not result in a reaction. During that first ingestion, the body become “sensitized” and then reacts on subsequent exposures.
● IgE-mediated: immediate (within seconds to minutes) activation of mast cells and basophils

Question 19

Food Allergies symptoms

Answer 19

● Pruritus, urticaria, flushing
● Swelling of the lips, face, or throat
● Nausea/vomiting, cramping, diarrhea
● Wheezing, lightheadedness, syncope, hypotension

Question 20

T/F Many childhood allergies naturally resolve

Answer 20

T

Question 21

Food Sensitivities (Intolerance)

Answer 21

Difficulty digesting or metabolizing a particular food. It is a digestive problem, not an immunologic reaction.

Question 22

Food Sensitivities S/S

Answer 22

● Depends on the reaction, but often includes excessive intestinal gas, bloating,
abdominal pain, and diarrhea.
● When a larger amount of the food is ingested, symptoms are generally worse

Question 23

Dx of food sensitivities

Answer 23

● Often, it requires elimination of varies foods to determine these

Question 24

Irritable Bowel Syndrome (IBS)

Answer 24

● A functional GI disorder characterized by abdominal pain and altered bowel
habits in the absence of a specific organic pathology
● Women are 2-3 times more likely to
develop IBS.
● It is thought to be a combination of
altered intestinal motility, visceral
hyperalgesia, and psychological distress.

Question 25

Used to be considered Dx of exclusion, but ROME IV criteria is generally diagnostic for

Answer 25

IBS

Question 26

Irritable Bowel Syndrome (IBS) Pathophysiology

Answer 26

○ Four IBS-Subtype patterns are seen with the disease. They include: ■ IBS-D: Diarrhea predominant disease ■ IBS-C: Constipation predominant disease ■ IBS-M: Mixed diarrhea and constipation ■ IBS-A: Alternating diarrhea and constipation

Question 27

Irritable Bowel Syndrome (IBS) presentation

Answer 27

○ Altered bowel habits: Constipation or diarrhea. Postprandial urgency is common. Small volume stools. ○ Abdominal pain: Diffuse without radiation. Lower abdomen is common. Defecation commonly improves it ○ Abdominal distention ○ Fibromyalgia is a common comorbidity ○ Symptoms may be induced by excessive stress.

Question 28

Rome Criteria IV for IBS:

Answer 28

IBS is defined as recurrent abdominal pain, averaging 1 day/week in the last 3 months, and associated with 2 of the following: ■ Symptoms related to defecation (Prev. Improved by defecation-Rome III) ■ Onset associated with a change in stool frequency ■ Onset associated with a change in stool form or appearance

Question 29

Symptoms that are inconsistent with IBS and warrant further investigation:

Answer 29

■ Onset in middle or older age ■ Acute symptoms (IBS is a chronic, recurrent issue) ■ Progressively worsening symptoms ■ Nocturnal symptoms ■ Anorexia or weight loss ■ Fever ■ Rectal bleeding- Remember a Hemoccult Test ■ Family Hx of Colon Ca ■ Recent Use of Antibiotics ■ Gluten-intolerance or Lactose-intolerance

Question 30

Irritable Bowel Syndrome (IBS) Managmeent (non-pharm)

Answer 30

○ Treatment of IBS primarily consists of providing psychological support and recommending dietary measures. ○ Helpful dietary measures may include: Keep a food journal ■ Fiber supplementation ■ Citrucel or Metamucil ■ Caffeine avoidance ■ Lactose avoidance ■ Probiotics are often helpful ○ Psychological interventions, cognitive-behavioral therapy (CBT), and hypnotherapy have been shown to be very effective for some with IBS

Question 31

Irritable Bowel Syndrome (IBS) Managmeent - Pharm

Answer 31

○ Pharmacologic therapy is considered adjunctive for patients with IBS and should be directed at specific symptoms. ■ Antidiarrheals, such as Loperamide or Diphenoxylate. ■ Tricyclic Antidepressants, such as Imipramine and Amitriptyline, have been well documented to help those with depressive symptoms and fibromyalgia accompanying IBS. (Anticholinergic and analgesic) ■ Linaclotide (Linzess) is a type of laxative indicated for IBS-C. ■ Rifaximin (Xifaxan) x 2 wks , an antibacterial drug indicated for IBS-D ■ Dicyclomine (Bentyl) and Hyoscyamine (Anaspaz) are antispasmodics indicated for abdominal pain associated with IBS. (Smooth m. Relaxation

Question 32

Acute Paralytic Ileus

Answer 32

Ileus is a medical condition in which the intestine is suffering from neurogenic failure or loss of peristalsis, in the absence of any mechanical obstruction.

Question 33

There are three main etiologies of Acute Paralytic Ileus:

Answer 33

○ Intra-abdominal process, such as surgery of peritoneal irritation (pancreatitis, appendicitis, ruptured viscus, hemorrhage, peritonitis). ○ Severe medical illness, such as respiratory failure, sepsis, DKA, electrolyte abnormalities (hypokalemia, hypercalcemia, etc). ○ Medications that affect intestinal motility, such as opioids, anticholinergics, phenothiazines.

Question 34

Acute Paralytic Ileus presentation

Answer 34

○ Conscious patients often report the following symptoms: ■ Mild, diffuse, continuous abdominal pain ■ Nausea, often with vomiting ■ Abdominal distention without flatulence ○ In comatose patients, watch for abdominal distention. ○ Characteristically, bowel sounds are very diminished or absent with paralytic ileus

Question 35

Acute Paralytic Ileus Dx

Answer 35

○ Plain film abdominal X-ray is the go-to radiologic imaging study. ■ Will reveal distended gas-filled loops of large and small intestine. ■ Sometimes, may be difficult to tell between ileus and small bowel obstruction. ○ CT scan of the abdomen can quickly exclude mechanical obstruction. ○ Laboratory studies: ■ Should check CMP to evaluate electrolytes.

Question 36

Acute Paralytic Ileus management

Answer 36

○ The primary treatment of paralytic ileus is to focus treatment on the underlying, precipitating condition. ■ Electrolytes, severe illness, ruptured viscus, etc. ○ Most cases respond to restriction of oral intake, IV hydration, and gradual liberalization of diet as bowel function returns. ○ Alvimopan (Entereg) is a PO medication that acts as a peripheral mu-opioid receptor antagonist. ○ It reverses opioid-induced inhibition of intestinal motility and is FDA approved for post-op ileus. Not used longer than 7 days. Shown ↑in MIs (relationship?)

Question 37

Gastroparesis

Answer 37

a delay in gastric emptying, generally accompanied by nausea, vomiting, bloating, and/or upper abdominal pain

Question 38

Pathophysiology of gastroparesis

Answer 38

● Idiopathic: no detectable underlying abnormality. The most common form. ● Diabetic: Due to chronic uncontrolled glucose levels (usually greater than 5 years) leading to autonomic dysfunction and/or damage to the intrinsic nervous system ● Postsurgical: gastric stasis due to injury to the vagus nerve

Question 39

Gastroparesis S/S

Answer 39

● Nausea (~ 90%) and vomiting (~70%) ● Abdominal pain (>50%) or Bloating ● Early satiety or fullness (~70%) ● Severe cases: weight loss

Question 40

Gastroparesis Diagnosis

Answer 40

Often diagnosed clinically ● Diagnosis can be confirmed using gastric emptying scintigraphy. ○ The patient eats food (often eggs and toast) that contains a tracer (radioactive material) ○ Images are taken over the next few hours to watch the food move

Question 41

Gastroparesis treatment

Answer 41

● Dietary modification and treatment of causative factors is considered first-line therapy ● Prokinetics, like metoclopramide or domperidone, can be used to increase the rate of gastric emptying ● Other treatments of symptoms can be utilized