Patient Presentation: Malabsorption Flashcards
What processes need to occur for proper absorption to be achieved?
- Mechanical breakdown
- chewing
- gastric churning
- intestinal mixing
- Enzymatic breakdown
- salivary
- gastric
- pancreatic
- biliary
- Absorption
- Transported in teh Portal Circulation
What absorptive avenue by-passes the portal circulation?
sublingual
What are the normal functions of the following components of the GI tract with relation to digestion?
mouth
stomach
duodenum
jejunum
ileum
colon
- mouth
- salivary amylase
- stomach
- intrinsic factor
- HCl
- Pepsinogin
- Chymosin
- duodenum
- Pancreatic enzymes released
- biliary Salts released
- jejunum
- primary site of absorption of nutrients
- folate, iron, calcium (FIC)
- ileum
- B12 absorption
- ADEK
- Bile salt absorption
- B12 absorption
- colon
How is fat digested and absorbed?
- fat globule will be bound to the bile salts
- creates emulsion
- placed in micelles cross epithelial cell wall
- enter into the lympatics
How are carbohydrates digested and absorbed?
- glucose polymers that use amylase in salivary gland
- broken down into dissacharides and monosaccharides
- transported across gastric mucosa
- enter blood stream
What is the major enzyme involved in protein digestion adn absorption?
trypsin
If malabsorption occurs affecting either the mechanical breakdown or enzymatic reakdown, what phase is this?
Absorption?
Transportion into the Portal Circulation?
- Mechanical breakdown & Enzymatic Breakdown
- Luminal Phase
- can’t get nutrients out of the lumen
- Absorption
- mucosal phase
- problem w/ mucosa & your not able to transport into portal veinous system
- Transported in the portal circulation
- Transport Phase
- in the liver, or passes through the liver and systemic
10 signs and symptoms of Chronic Diarrhea?
- Abdominal pain
- cramping
- diarrhea
- foul smelling stool
- Bulk Stools
- Nausea
- Vomiting
- Weakness
- Fatgue
- Pale Colored Stools
If malabsortion is suspected, what are some tests you would immediately run?
If there are no other clues, what is the next step?
If you notice bacterial overgrowth?
If you notice pancreatic disease?
If you notice mucosal disease?
- History, Physical Examination
- Laboratory Tests
- Electrolyte panel
- B12, Folate
- No other clues
- Quantitative fecal fat
- Bacterial overgrowth
- Hydrogen, C-xylose breath test
- Empiric therapy
- Pancreatic disease
- Stool, serum pancreatic enzymes
- response to Enzyme supplementation
- Ultrasonography +/- CT scan +/- ERCP
- Mucosal disease
- duodenal biopsy
- Upper GI barium series
- Stool, serum pancreatic enzymes
If the Quantitative fecal fat test is normal, what is the next step?
Abnormal?
- Normal
- evaluate for chronic diarrhea
- Abnormal
- D-Xylose test
- normal
- pancreatic disease
- abnormal
- mucosal disease
- normal
- D-Xylose test
What are teh 10 most common malabsorption diagnoses?
- Celiac Sprue
- Tropical Sprue
- Whipple’s Disease
- Eosinophilic Gastroenteritis
- Short Bowel Syndrome
- Systemic Mastocystosis
- Radiation Enteritis
- Small Intestine Bacterial Overgrowth
- Intestinal Lymphangiectasia
- pancreatic Insufficiency
What causes Celiac Disease?
Most common presentation?
rare, late complication?
What are the four diagnostic factors of Celiac?
- immune-mediated process secondary to gluten
- associated with other autoimmne issues
- associatd with HLA-B8
- most common presentation
- iron deficiency anemia (loss of brush border, not absorbing)
- Late complication
- primary intestinal lymphoma (b/c chronic inflammation)
- Treatment
- Gluten-free diet (very strict)
What are the Four Diagnostic Factors of Celiac Disease?
- Diagnostic Factors
- Evidence of malabsorption
- Abnormal Small Bowel Biopsy
- Usually (not necessarily) a positive antiendomysial antibodt or tissue transglutaminase antibody test
- (IgA) TTG
- Response to a gluten-free diet (clinical, chemical and histological)
Where is Tropical Sprue most common?
It is characteristic of malabsorption of which nutrients?
What type of disease it it?
How is it treated?
Diagnostic for the disease?
- endemic in equatorial areas
- malabsorption
- folic acid
- vitamin B12
- likely infectious etiology
- Treatment
- tetracycline or TMP/SMX for 3-6 months (alter microbiome)
- folic acid replacement
- Diagnostic
- unexpected, significant, positive response to folate
- ie. if they were anemic & with folate they start to improve
What causes Whipple’s Disease?
What is the Cardinal Tetrad for the disease?
Is it more common in males or females?
Treatment?
- caused
- Tropheryma whippelii
- gram + actinomycete
- Tropheryma whippelii
- cardinal teterad
- Arthralgias (most common symptom)
- Abdominal pain (not as much)
- Weight loss
- Diarrhea
- 87% patients are male
- EGD with small intestine biopsy - procedure of choice to diagnosse, looking for
- foamy macrophages
- positive for PAS staining bacterial remnants
- Periodic Acid Schiff (PAS)– for polysaccharides
Eosinophilic Gastroenteritis mimics which other two diseases?
Diagnostic Criteria?
Treatment?
- mimics intestinal lymphoma and regional enteritis
- Diagnostic
- histologic demonstration of increased gastric, intestinal or colonic mucosal or mural eosinophilic infiltration of eosinophilic ascites
- Treatment
- oral corticosteroids and avoidance of the causative foods
- might have to do an elimination diet to determine what the causative agent is
Under what conditions is short bowel syndrome likely?
- likely
- <2 feet of small bowel
- the proximal jejunum remaining small bowel is <100cm
- loss of ileocecal valve
- treatment
- low-fat diet
- vitamin supplements
- TPN (total parenteral nutrition) may be needed after large resection wile waiting for bowel adaptation
What is systemic mastocytosis?
Diagnostic criteria?
- demonstration of increased mucosal mast cells (>20 per high-power field) in stomach, small bowel, colon
- Diagnostic
- elevated serum typtase
In what conditions should you consider radiation enteritis?
Features?
What complication may occur?
- consider
- cancer patients with history of radiation
- Features
- mucosal teangiectasias
- obliterative endarteriolitis
- fibrosis
- strictures
- complication
- small intestinal bacterial overgrowth may develop
What is small intestinal bacterial overgrowh associatd with?
Diagnostic criteria?
Treatment?
- Associated with small bowel surgery
- Diagnostic
- positive breath test (lactose, glucose)
- OR
- Culture of jejunal aspirate if available
- Responds to antibiotics
Diagnostic criteria for intestinal lymphangiectasia?
- Diagnostic
- hypoproteinemia,
- lymphopenia,
- evidence of
- protein-losing enteropathy
- increased fecal loss of alpha 1-antitrypsin
What three diseases are caused by pancreatic insufficiency?
Diagnosis?
What extra step must happen for patients over 55 with pancreatic insufficiency?
- Pancreatic Insufficiency
- Chronic Pancreatitis
- Pancreatic Cancer
- Cystic Fibrosis
- Confirms diagnosis?
- positive response to treatment with pancreatic enzymes
- xylose absorption test normal
- must rule out pancreatic cancer if therse is evidence of pancreatic insufficiency in patients > 55 years old
Bile Acid Deficiency
In what conditions would you see a decreased production of bile acid?
In what conditions would you expect to see decreased bile acid uptake?
What would cause in increased breakdown of bacterial growth?
- decreased production
- severe liver disease
- deceased bile acid uptake
- ileal resection (> 100cm)
- Zollinger Ellison syndrome (ZES)- increased acidity precipitates the bile acid
- Associated symptom
- increased breakdown
- bacterial overgrowh
