Small Bowel Disorders Flashcards
Agammaglobulinemia (IgA), Crohn’s, Amyloidosis, Cryptosporidium, Giardiasis, Intestinal Lymphoma, and Whipple disease can all be doagnosed HOW?
BIOPSY (celiac cannot by biopsy alone)
What is the HIGHEST risk factor for CELIAC disease?
Family History
How are IL-15 and Zonulin involved in CELIAC disease?
They are directly involved in mucosal injury
Does a NEGATIVE SEROLOGY, NEGATIVE Ab’s or NEGATIVE BIOPSY each by themselves mean that a patient is negative for CELAIC disease?
NO, NOT ISOLATED NEGATIVES
What are TWO, NON-CLASSIC presentations of CELIAC disease?
IRON-DEFICIENCY ANEMIA, ABNORMAL LFTs (otherwise unexplained) - also ATAXIA, INFERTILITY, NEUROPATHY, PSTEOPOROSIS
DERMATITIS HERPETIFORMIS, IDDM (type-I), AUTOIMMUNE THYROID DISEASE, selective IgA DEFFICIENCY, MICROSCOPIC COLITIS, TURNER, DOWN and WILLIAM syndromes, AIH, PSORIASIS, LUPUS are all associated with this GI DISEASE?
CELIAC DISEASE
Wich TWO extra-intestinal manifestations of CELIAC disease respond to a GLUTEN-FREE diet?
DERMATITIS HERPETIFORMIS
IRON-DEFICIENCY ANEMIA
also, LFTs normalize
Which are the TWO SEROLOGIES used to DIAGNOSE CELIAC disease?
IgA anti-TTG OR IgA anti-ENDOMYSIUM Ab’s
(NOT BOTH)
Which is the SEROLOGIC TEST used to DIAGNOSE CELIAC disease in an IgA DEFFICIENT patient (such as ANY child < 2 yo)?
IgG - anti-DEAMIDATED GLIADIN PEPTIDES
Can a patient be NEGATIVE for HLA DQ2 and DQ8 and have CELIAC disease?
NO
Is genetic (HLA DQ2 & DQ8) testing altered by a GLUTEN-FREE DIET?
NO! (but the serologic studies are)
PRIOR to a gluten challenge on a patient already on a GLUTEN-FREE diet, PT does NOT want to do a GLUTEN CHALLENGE, VILLOUS atrophy on biopsy but TTG-IgA NEGATIVE, what’s the best test?
HLA DQ2 & DQ8 (genetics)
In MARSH 1 classification, you see IntraEpithepial Lymphocytes (IELs), where else are these seen besides CELIAC disease?
SIBO, NSAID use, H.pylori, PUD, viral gastroenteritis, AI disoders
Patients with CLASSICAL symptoms of CELIAC disease (malabsorption, weight loss, chronic diarrhea, bloating, abdominal pain, steatorrhea), LABORATORY evidence, SYPTOMATIC and ASYMPTOMATIC patients with POSITIVE 1st DEGREE RELATIVES should all have what done?
Be SCREENED for CELIAC disease
What GI disease should a patient with TURNER, DOWN or WILLIAM disease be screened for?
CELIAC disease
What is the SINGLE PREFERRED CELIAC disease TEST for patients >2 yo?
IgA-TTG
When should a TOTAL IgA be ordered in CELIAC disease testing?
When there is a DEFICIENCY of IgA suspected
What do you use for testing for CELIAC disease when IgA deficiency is an issue?
IgG-based testing (IgG-Deaminated Glidin Peptides)
If suspicion for CELIAC disease is HIGH and serologies are negative, what MUST be done NEXT?
EGD with BIOPSY
Why is testing for CELIAC disease with IgA-TTG in a CVID patient NOT helpful?
Because CVID is the fiding of LOW IMMUNOGLOBUINS of TWO or MORE (IgG, IgA, IgE, IgM)
Why is testing for CELIAC disease with IgA-TTG in a patient on a LOW FODMAP diet NOT helpful?
Because LOW-FODMAP is essentially GLUTEN-FREE (so TTG will be normal)
Which IMMUNOGLOBULIN is most commonly DEFFICIENT in CVID?
IgA (sinus infections, URI, GI infections)
An IMMUNOLOGICAL condition associated with VITILIGO, RA, SLE, ITP, PERNICIOUS ANEMIA (low vit B12) and IBD-like BIOPSIES?
CVID (IgA defficiency most common)
In an ADULT with positive IgA-TTG, what test do you do to CONFIRM CELIAC disease?
EGD with MULTIPLE DUODENAL BIOPSIES
In a CHILD with positive IgA-TTG, what test do you do to CONFIRM CELIAC disease?
If IgA >10 x normal, thats enough
Also IgA-ENDOMYSIAL Ab’s can cofirm
Don’t NEED EGD in CHILDREN
Patient on a GLUTEN-FREE diet improves in ALL aspects including DUODENAL biopsy findings but has persistent DIARRHEA what do you do NEXT?
COLONOSCOPY with BIOPSIES (evaluate for microscopic colitis)
What COMMON NON-CELIAC GI finding is noted among GIARDIASIS, SIBO, CROHN’s, CVID, COLLAGENOUS and TROPICAL SPRUE, OLMESARTAN, AUTOIMMUNE ENTEROPATHY, LYMPHOMA?
VILLOUS ATROPHY
ABNORMAL groupings of INTRAEPITHELIAL LYMPHOCYTES that stain POSITIVE for CD3 but NEGATIVE for T-CELL markers like CD8?
REFRACTORY CELIAC DISEASE
CELIAC disease with persistent symtoms of MALABSORPTION AND VILLOUS ATROPHY in spite of 12 MONTHS STRICT ADHERENCE to a GLUTEN-FREE diet?
REFRACTORY CELIAC DISEASE (GIB, fevers, night sweats, bowel OBSTRUCTION)
If REFRACTORY CELIAC-DISEASE is suspected, what should be done NEXT?
EGD with 6 DUODENAL BIOPSIES and sent to FLOW-CYTOMETRY to evaluate for LYMPHOMA
CELIAC disease where there is PERSISTENCE of GLUTEN-INDEPENDENT VILLOUS ATROPHY where BOTH CD3 & CD8 are seen, INDOLENT COURSE?
REFRACTORY CELIAC DISEASE TYPE-I
CELIAC disease where there is LOW-GRADE LYMPHOMA where ONLY CD3 remains, no CD8, AGGRESSIVE COURSE poor survival?
REFRACTORY CELIAC DISEASE TYPE-II
Although does NOT change course of disease, what are the treatment OPTIONS for REFRACTORY CELIAC DISEASE?
BUDESONIDE and IMMUNOSUPPRESSIVES
How often do you MONITOR a CELIAC DISEASE patient?
Every 3-6 MONTHS for the FIRST year
then
Every 1-2 YEARS
CHRONIC large volume DIARRHEA, WEIGHT loss, ANEMIA, LOW VIT A, D, HIGH INR, STEATORRHEA, SMALL BOWEL EDEMA, SEVERE VILLOUS ATROPHY NOT responding to a GLUTEN-FREE diet and has MINIMAL INTRA-EPITHELIAL LYMPHOCYTES?
AUTOIMMUNE ENTEROPATHY (anti-ENTEROCYTE Ab’s or anti-GOBLET Ab’s)
GI disease with CELIAC-TYPE presentation BUT with MINIMAL INTRA-EPITHELIAL LYMPHOCYTES and ABSENT GOBLET and PANNETH cells, HLA-DQ2.5 positive?
AUTOIMMUNE ENTEROPATHY (anti-ENTEROCYTE Ab’s or anti-GOBLET Ab’s)
What is the TREATMENT of AUTOIMMUNE ENTEROPATHY?
Steroids (budesonide), anti-TNF (Infliximab), Cyclosporine, Rituximab, Tacrolimus, STEM CELL TRANSPLANT (if refractory)
Patient with IBS symptoms, DIARRHEA, WEIGHT loss, MESENTERIC LYMPHADENOPATHY, SB wall thickening. EGD with MUCOSAL ULCERATION and VILLOUS BLUNTING, POSITIVE anti-ENTEROCYTE Ab’s). What MEDICATION do you LOOK FOR?
OLMESARTAN (benicar) - STOP the med
What MEDICATION can cause a CELIAC-LIKE ENTEROPATHY?
OLMESARTAN (confused with AIE because positive anti-ENTEROCYTE Ab’s)
Patient presents with WATERY DIARRHEA, WEIGHT LOSS, FEVERS, FATIGUE, HEADACHES, ARTHRITIS, ATAXIA, SEIZURES, MYOCARDITIS, metabolic ACIDOSIS. Diagnosis is made on BIOPSY?
WHIPPLE DISEASE (treat with CEFTRIAXONE or PENICILLIN G and TMP-SMX or DOXYCYCLINE + hydroxychloroquin long-term) - FOAMY MACROPHAGES
LONG-TERM Caribbean EXPOSURE with CHRONIC diarrhea, FOUL-SMELLING stools, WEIGHT LOSS, BLOATING, CRAMPING with GLOSSITIS, PITTING EDEMA, DISTENDED abdomen, LOW-FOLATE & B12 (distal SB), STEATORRHEA (SUDAN-STAIN), MACROCYTIC (MCV >100) ANEMIA and often (50%) associated with AUTOIMMUNE GASTRITIS?
TROPICAL SPRUE (treat with TETRACYCLINE + folic acid)
WHEN is DIARRHEA considered to be CHRONIC?
When its >4 weeks
What is the process that causes LOOSE STOOLS with BLOOD and POSITIVE fecal CALPROTECTIN?
INFLAMMATORY (IBD, ischemia, neoplasia, radiation)
or
INFECTIOUS (ileocolonic, colonic)
What is the process that causes LOOSE STOOLS without blood, negative calprotectin, less volume and FASTING eliminates it? What if same but FASTING does NOT eliminate it?
OSMOTIC (fasting eliminates it) - lactose, sorbitol, mannitol, lactulose, PEG
SECRETORY (fasting does NOT eliminate it) - endocrine, bile acids, infectious
Besides CELIAC disease and PANCREATIC insufficiency (steatorrhea), what other major MALABSORPTIVE diarrhea exists?
SHORT-BOWEL syndrome
What are the TWO MAJOR MOTILITY-caused diarrheal etiologies?
IBS-D (fast)
SIBO (slow)
How do you CALCULATE FECAL OSMOTIC GAP?
290 - 2(K + Na)
if >50 its OSMPOTIC DIARRHEA
If a patient has DIARRHEA and os found to be OSMOTIC due to MAGNESIUM, PHOSPHATE or SULFATE?
FACTITIOUS DIARRHEA
Lactose, Fructose, Sucrose, Xyletol, other FODMAPS (carbohydrates not readily absorbed), Caffeine, Licorice cause what kind of DIARRHEA?
OSMOTIC (due to intolerance) - with BLOATING and GAS
If OSMOTIC DIARRHEA is found in a patient, what is FIRST suggested?
LACTOSE-FREE DIET
In an OSMOTIC-DIARRHEA patient, if lactose-free diet FAILS, what is CHECKED NEXT?
Stool pH
if pH < 6 - HYDROGEN breath test
if pH >6 - eliminate SUGAR ALCOHOLS
if both NEG - FACTITIOUS
MASTOCYTOSIS, CARCINOID syndrome, GASTRINOMA, VIPoma, PHEOCHROMOCYTOMA, SOMATISTATINOMA, MEDULLARY THYROID cancer, HYPERthyroidism all cause this TYPE of CHRONIC DIARRHEA?
SECRETORY
Diarrhea with ITCHING, FLUSHING, FATIGUE, OSTEOPOROSIS and KIT-positive?
MASTOCYTOSIS (allergic reaction) - serum TRYPTASE positive
DIARRHEA with serum TRYPTASE positive?
MASTOCYTOSIS (allergic)
Brainerd, SIBO, Tropical Sprue, Post-Infectious IBS all cause what kind of diarrhea?
CHRONIC
What determines whether a patient will have BILE-ACID DIARRHEA or FATTY-ACID DIARRHEA after ILEAL-RESECTION?
BILE-ACID if < 100 cm ILEUM removed
FATTY-ACID if >100 cm removed (steatorrhea with MASSIVE bile acids, low bilirubin, kidney stones, gallstones)
Diarrhea post ileal-resection that is associated with MASSIVE stool bile acids, kidney stones and gallstones?
FATTY-ACID diarrhea (steatorreha) when >100 cm of ileum have been removed
What TYPE of BILE-ACID diarrhea is seen in those s/p CHOLECYSTECTOMY, vagotomy, post-gastric surgery, chronic PANCRETITIS, SIBO, MICROSCOPIC colitis?
BILE-ACID diarrhea
What PREVENTS excess BILE-ACID synthesis?
REABSORPTION of BILE-ACIDS in ILEUM (feedback)
ELEVATED Serum C4, LOW Serum Fibroblast Growth Factor 19 and QUANTITATIVE measurement are all MAYO tests avilable for?
BILE-ACID MALABSORPTION (SIBO, short SB, etc.)
How do you TREAT BILE-ACID malabsorption?
CHOLESTYRAMINE (colestipol, colesevelam) or OBETICHOLIC acid
Crohn’s, Mesenteric Ischemia, Systemic Sclerosis, Mucosal Diseases, Bariatric Surgery and Volvulus can all cause this GI SYNDROME of malabsorption and diarrhea?
Short Bowel Syndrome (lack of FEEDBACK, lack of absorptive surface area, pancreatic enzyme deactiovation by gastric acid)
What DETERMINES INTESTINAL-FAILURE requiring LIFE-LONG DEPENDENCE on TPN in SHORT-BOWEL SYNDROME?
LENGTH of BOWEL
< 100 cm of bowel = PERMANENT
PRESENCE of TI (IC valve) or COLON = better survival and weaning off TPN
What happens in the ACUTE (< 4 weeks) and ADAPTIVE (1-2 years) phases of SHORT BOWEL SYNDROME?
ACUTE: massive diarrhea, TPN & IVFs
ADAPTIVE: decreased, combine enteral and TPN
Why is COLON in continuity of the SB so IMPORTANT in SHORT BOWEL SYNDROME?
Because of SHORT-CHAIN FATTY ACID absorption in the colon, preoduced by the colon MICROBIOME digestion of carbohydrates - SALVAGE PATHWAY
SIBO, D-lactic acidosis, OXALATE stones (increased absorption due to calcium binding to long-chain fatty acids rather than oxalate for excretion), GALLSTONES are all complications of this GI malabsorptive syndrome with diarrhea?
SHORT BOWEL SYNDROME (also TPN complications like infection, hepatic failure, electrolyte deficiency)
Can patients with SHORT BOWEL SYNDROME who LACK a COLON, develop OXALATE kidney stones?
NO!! (colon is REQUIRED for oxalate absorption)
What are the DIETARY differences RECOMMENDED for patients with SHORT BOWEL SYNDROME who have a COLON and those who LACK a COLON?
COLON PRESENT: Higher CARBS, Less FAT, NO OXALATES (fruits, vegetables)
COLON ABSENT: Higher FAT, Less CARBS
What DRUG can you use to WEAN a patient with SHORT BOWEL SYNDROME off of TPN?
TEDUGLUTIDE (GLP-2 analogue) - increases SB villous height and thus, absorption
TEDUGLUTIDE (GLP-2 analogue) used to treat SHORT BOWEL SYNDROME to wean off TPN, has what ADVERSE EFFECTS and MONITORING requirements?
AE: cholecystitis, adenomatous colon POLYPS
Cannot be used if pt has GIT CANCERS
Monitoring: COLONOSCOPY 6 MONTHS before starting, then 1 yr and if NEG, 5 yrs
What can be done for those with SHORT BOWEL SYNDROME that are in IMPENDING FAILURE and DEATH (< 30 cm, liver failure, sepsis, DESMOID tumors)?
Small Bowel TRANSPLANT
SB Diverticulosis (pockets for bactera to grow), Dysmotility, DM, SCLERODERMA, Achlorhydria (not PPI related), FISTULAS can all cause this GI disorder?
SIBO (seen in POST-INFECTIOUS IBS, IBS-D)
Stomach ACID, normal ABSORPTION, BILE ACIDS and ENZYMES, IMMUNITY, normal MOTILITY and presence of an IC VALVE all prevent this disorder?
SIBO (opiates can cause this by slowing motility)
Deconjugation of BILE ACIDS (by bacteria) can cause DIARRHEA and STEATORRHEA in this GI disorder with PROTEIN and Vit B12 LOSS?
SIBO
What GI disorder can cause STEATORRHEA with LOW Vit B12, HIGH FOLATE and HIGH Vit K?
SIBO (bacteria consume the B12 and produce folate and vit K)
How is SIBO treated?
Supportive (supplementation, low FODMAP, MEDIUM chain fatty acids)
ANTIBIOTICS (single course or ongoing) - RIFAXIMIN (550 mg PO BID/TID x 10 days), AUGMENTIN, METRONIDAZOLE
What constitutes a POSITIVE HYDROGEN (diarrhea) BREATH TEST for SIBO?
At 90 MIN >20 ppm over baseline
If HIGH-METHANE = CONSTIPATION
Or MIXED
WOMAN, HEALTHCARE worker, ANOREXIA sympotms, with LARGE-VOLUME, NOCTURAL diarrhea, metabolic ALKALOSIS, OIL droppelts in STOOL?
FACTITIOUS diarrhea (laxatives, phenolphthalein) - MUNCHAUSEN
Can’t screen for SENNA or CASCARA
Stool OSMOLARITY (NOT GAP) in FACTITIOUS diarrhea?
< 250 (water dilution) or >400 (solutes)
PRESENCE of MAG or PHOS in stool electrolytes
CELIAC disease can present with WATERY DIARRHEA due to concomittent presence of what issue?
MICROSCOPIC COLITIS
What are CONFUSING findings in patients with MICROSCOPIC COLITIS?
ASSOCIATED AUTOIMMUNE conditions and their POSITIVE Ab’s
NSAIDs, CHECKPOINT-INHIBITORS (nivolumab, pembrolizumab), SSRIs, H2-blockers, Statins, ACE-I, ARBs, Cephalosporins and PPIs are often ASSOCIATED with this FINDING that causes WATERY DIEARRHEA?
Microscopic Colitis
What medication is used to obtain REMISSION in MICROSCOPIC COLITIS?
BUDESONIDE
WATERY diarrhea with INTRA-EPITHELIAL LYMPHOCYTOSIS or THICKENED SUB-EPITHELIAL COLLAGEN band?
MICROSCOPIC COLITIS
What DIFFERENTIATES LYMPHOCYTIC COLITIS from COLLAGENOUS COLITIS?
Lymphocytic colitis: MANY Intra-Epithelial Lymphocytes, THIN collagen band
Collagenous colitis: THICK collagen band, FEW lymphocytes
How is MICROSCOPIC COLITIS treated?
Anti-DIARRHEALS, then BUDESONIDE (if no response, PREDNISONE, if still no response, MESALAMINE or BISMUTH SUBSALICYLATE, if STILL no response, AZATHIOPRINE or 6MP, or DIVERTING ILEOSTOMY)
