Small and Large Intestinal Disorders Flashcards
What is the function of Trypsin?
Breakdown of proteins to ligopeptides and AAs
What is the function of Lipase?
Breakdown of fats to glycerol and FFAs
What is the function of Amylase?
Breakdown of Carbohydrates (starch/glycogen) to Disaccharides (maltose, sucrose, lactose)
What is the management of SIBO?
- H2 Breath Test (!!!)
- Rotating abx: metronidazole, tetracycline, amoxicillin
- Vitamin + nutritional supplements
What are the symptoms of Small Intestinal disease?
- Malabsorption*
- Weight loss/low or falling BMI
- Increased appetite
- Diarrhoea
- > usually watery
- > sometimes steatorrhoea
- Bloating
- Fatigue
- Steatorrhoea (pale, oily, floating, foul-smelling stools)
What small intestinal disorders is Clubbing associated with?
- Coeliac Disease
- Crohn’s Disease
What small intestinal disorders is Scleroderma associated with?
Systemic Sclerosis
What small intestinal disorders is Aphthous ulceration associated with?
- Coeliac Disease
- Crohn’s Disease
What small intestinal disorder is Dermatitis Herpetiformis associated with?
- Coeliac disease
Blistering, intensely itchy, scalp, shoulders elbows, knees
What is the main sign of Iron, B12 and Folate-deficiency?
- Anaemia!!
What are the signs of Ca2+, Mg2+ and Vitamin D-deficiency?
- Tetany
- Osteomalacia
(all vitamins interlinked -> cause hypocalcaemia)
What are the signs of Vitamin A-deficiency?
- Night Blindness
What are the signs of Vitamin K-deficiency?
- Raised PT time
needed for clotting factor production
What are the signs of Thiamine (Vit B1) deficiency?
- Memory loss
- Dementia
What are the signs of Niacin (vit B3) deficiency?
- Dermatitis
- Unexplained HF
What are the signs of Vitamin C-deficiency?
- Scurvy!
When should you suspect a diagnosis of Coeliac Disease?
Suspect in all those with Diarrhoea + weight loss or anaemia (esp. iron deficiency)
What is Coeliac disease?
It is a T-cell-mediated autoimmune disease of the small intestine in which prolamin
(alcohol-soluble proteins in wheat, barley, rye ± oats) intolerance causes villous atrophy and malabsorption
What is commonly associated with Coeliac Disease?
- HLA-DQ2/8
- Dermatitis Herpetiformis
What are the clinical features of Coeliac Disease?
- Steatorrhoea
- Diarrhoea
- Abdominal pain
- Bloating
- N+V
- Aphthous ulcers
- Angular stomatitis (iron/nutritional deficiency)
- Weight loss
- Fatigue
- Weakness
- Osteomalacia
- Failure to thrive (children)
What are the investigations for Coeliac Disease?
- make sure to investigate while pt. is still taking gluten in their diet!!* also: remember to exclude coeliac disease in all labelled as IBS!
- Coeliac serology: IgA transglutaminase (or IgG if IgA-deficient (always check totak plasma IgA as well!!)) or Anti-Gliadin antibodies
- Endoscopy + distal Duodenal biopsy = gold standard!!
- HLA status: HLA-DQ2/DQ8
(-> to exclude but not confirm coeliac disease)
What are the characteristic histological findings of Coeliac disease?
Villous atrophy !!
(also: increased intra-epithelial lymphocytes)
(found on distal Duodenal biopsy)
What is the treatment of Coeliac Disease?
- Lifelong Gluten-free diet
- MUST refer to state-registered Dietitian!!
What conditions are associated with Coeliac Disease?
basically a lot of autoimmune conditions!!
- Dermatitis Herpetiformis (!!!)
- IDDM → Test ALL pts with Type 1 Diabetes for Coeliac Disease bc these diseases are often linked!!
- Autoimmune thyroid disease
- Autoimmune Hepatitis
- PBC
- Autoimmune Gastritis
- Sjogren’s syndrome
- IgA deficiency
- Down’s Syndrome
What are the complications of Coeliac Disease?
- Anaemia
- Refractory Coeliac disease
- Small bowel Adenocarcinoma
- Small bowel Lymphoma
- Oesophageal cancer
- Colon cancer
What diseases cause malabsorption?
Inflammatory disorders:
- Coeliac disease
- Crohn’s disease
Infection:
- Tropical sprue
- HIV
- Giardiasis
- Whipple’s disease
Infiltration:
- Amyloidosis
Impaired motility:
- Systemic sclerosis
- Diabetes
- Pseudo-obstruction
Iatrogenic:
- Gastric surgery
- Short bowel syndrome
- Radiation
Pancreatic:
- Chronic Pancreatitis
- Cystic Fibrosis
What are the most common infections causing Malabsorption?
- Tropical sprue
- HIV
- Giardiasis
- Whipple’s Disease
What age does IBD typically present in?
15-35yrs
median age at diagnosis is 29.5yrs
What are the different types of IBD?
- UC
- Crohn’s
- IBD-U (Unclassified)
- Microscopic Colitis
- > Collagenous colitis
- > Lymphocytic colitis
What are the causes of IBD?
- > Unknown
- > Possible genetic susceptibility (FDR = 5-20x risk of IBD)
- > altered Microbiome
- > Environmental Factors:
- smokers
- diet
- meds
- hx of infective diarrhoea (gastro-enteritis)
- migration - young asian males 6x inc. risk
What are the extra-intestinal signs of IBD?
- Aphthous oral ulcers
- Skin rashes/lesions: Erythema
Nodosum, Pyoderma Gangrenosum - MSK problems: axial disease (ank. spondylitis, sacroiliitis)
- Eye problems: episcleritis, scleritis, uveitis
- PSC (UC): UC + PSC = inc. risk of CRC (yrly colons)
Why should you perform yearly colonoscopy if a pt. has both UC + PSC?
Because they are at (50%) increased risk of CRC
What are the differential diagnoses of IBD?
Other causes of chronic diarrhoea:
- Malabsorption -> ie. pancreatic insufficiency, bile acid malabsorption, coeliac disease
- IBS
- Overflow Diarrhoea
- Ileo-caecal TB
- Colitis: distinguish from infective, amoebic + ischaemiac colitis
What are the main complications of UC?
- Perforation (!!!)
- Bleeding (!!)
- Toxic dilatation of the colon
- Venous Thrombosis (give prophylaxis to all inpatients)
- CRC -> 15% risk with pancolitis for 20yrs (relates to extent and duration of UC disease)
Describe the screening colonoscopy guidelines for UC
- Screening colonoscopy at 10yrs post-diagnosis of UC for CRC*
- Low risk: extensive colitis with no active inflammation, left-sided colitis = 5 yrly
- Intermediate risk: extensive colitis with mild-active inflammation, FH of CRC in FDR >50 = 3 yrly
- High risk: extensive colitis with moderate/severe active inflammation, PSC, FH of CRC in FDR <50 = 1 yrly
What are the investigations for UC?
- Bloods: FBC, ESR, CRP, U&E, LFT
- Exclude infection: blood culture, stool sample + culture
- Colonoscopy/ Sigmoidoscopy + Biopsy (gold standard!!): inflammatory infiltrate, goblet cell depletion, glandular distortion, mucosal ulcers; crypt abscesses.
- XR: to rule out complications (ie. ?toxic dilatation, ?perforation)
What are the Colonoscopic findings of UC?
- ONLY in the colom and rectum -> spreads proximal*
- Haemorrhagic granular mucosa
- Pseudopolyps (!!)
- Punctate ulcers
- Inflammation NOT transmural!
How do you assess the severity of UC?
using only stools
- Truelove and Witts Criteria*
- Mild: <4 stools/day
- Moderate: 4-6 stools/day
- Severe: ≥6 bloody stools/day
- Fuliminant: 10 stools/day + continuous bleeding
What are the treatment options for inducing remission in UC?
- Mild-Moderate UC: 5-ASAs (Sulfasalazine)
- or oral pred (2nd line)
- Severe UC: IV hydrocortisone
When are topical therapies used for UC?
- for Proctitis!
What are the clinical features of Proctitis?
- Frequency, Urgency, Incontinence, Tenesmus
- Small volume mucus and blood (out of their behinds)
- Proximal faecal stasis (constipation)
What are the side-effects of 5-ASAs?
- Nausea, vomiting, watery diarrhoea
- Headache, indigestion
- Mild allergic reactions
- Rarely: interstitial nephritis, pulmonary fibrosis
What are the treatment options for maintaining remission in UC?
- 5ASAs (1st line!)
- Immunomodulator: Thiopurines (Azathiopurine)
- Monoclonal Abs
What are the side effects of steroids in UC?
- not for long-term use!!
- Diabetes
- Cataracts
- Osteoporosis
- Mood disturbance
- Obesity
What are the side-effects of Azathiopurine?
- Nausea, vomiting, flu-like symptoms
- Leucopoenia
- Hepatotoxicity
- Pancreatitis (check serum amylase if nausea, vomiting)
- Non-Melanoma skin cancer
- Lymphoma
- Requires blood monitoring!!*
What are the side-effects of Monoclonal Abs?
- Psoriasis
- Infections (TB reactivation)
- Worsening HF (hypersensitivity reaction)
- Cancers
- Demyelination (anti-TNFs -> symptoms similar to MS)
What is the first-line investigation for Proctitis?
Rectal swab!
What are the treatment options for inducing remission in Crohn’s?
- Mild-moderate) = oral pred
- Severe = IV hydrocortisone
Why are steroids used in IBD?
To induce remission!!!
What are the treatment options for maintaining remission in Crohn’s?
- Immunomodulators*
- Thiopurine (ie. Azathiopurine) = 1st line
- Methotrexate - for steroid-dependent pts
When should you operate in IBD?
- Failed medical therapy (ie. IV hydrocortisone in the acute setting)
- Perforation
- Massive haemorrhage
- Toxic dilatation
What drug is never used to induce or maintain remission in Crohn’s?
5-ASAs!!! (ie. Sulfasalazine)
What type of surgery is performed in IBD?
- Subtotal Colectomy, rectal preservation + ileostomy
Afterwards…
- Completion Proctectomy
- Pouch procedure
What are the Clinical Features of UC?
- Bloody Diarrhoea
- Abdominal Pain
- Weight Loss
- Fatigue
How to tell if a pt. is having an acute severe colitis attack?
- Life-threatening medical emergency!!!*
- Duration of UC symptoms >10 days
- Infection
What is the management of Acute Severe Colitis?
- IV Hydrocortisone (!!)
- IV hydration -> correct electrolytes to prevent toxic megacolon!
- LMWH -> risk of VTE
- AXR -> complications
- Blood tests
- Stool chart
- 4 stool cultures for C. Diff
- Avoid/stop NSAIDs, opiates, anti-diarrhoeals, anti-cholinergics
What are the immediate investigations for Acute Severe Colitis?
- Bloods -> markers of inflammation
- Stool culture -> (rule out infection)
- Faecal Calprotectin -> >200 = significant
- Colonoscopy + colon mucosal biopsies