Small Bowel Disorders

Question 1

Agammaglobulinemia (IgA), Crohn’s, Amyloidosis, Cryptosporidium, Giardiasis, Intestinal Lymphoma, and Whipple disease can all be doagnosed HOW?

Answer 1

BIOPSY (celiac cannot by biopsy alone)

Question 2

What is the HIGHEST risk factor for CELIAC disease?

Answer 2

Family History

Question 3

How are IL-15 and Zonulin involved in CELIAC disease?

Answer 3

They are directly involved in mucosal injury

Question 4

Does a NEGATIVE SEROLOGY, NEGATIVE Ab’s or NEGATIVE BIOPSY each by themselves mean that a patient is negative for CELAIC disease?

Answer 4

NO, NOT ISOLATED NEGATIVES

Question 5

What are TWO, NON-CLASSIC presentations of CELIAC disease?

Answer 5

IRON-DEFICIENCY ANEMIA, ABNORMAL LFTs (otherwise unexplained) - also ATAXIA, INFERTILITY, NEUROPATHY, PSTEOPOROSIS

Question 6

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?

Answer 6

CELIAC DISEASE

Question 7

Wich TWO extra-intestinal manifestations of CELIAC disease respond to a GLUTEN-FREE diet?

Answer 7

DERMATITIS HERPETIFORMIS
IRON-DEFICIENCY ANEMIA
also, LFTs normalize

Question 8

Which are the TWO SEROLOGIES used to DIAGNOSE CELIAC disease?

Answer 8

IgA anti-TTG OR IgA anti-ENDOMYSIUM Ab’s
(NOT BOTH)

Question 9

Which is the SEROLOGIC TEST used to DIAGNOSE CELIAC disease in an IgA DEFFICIENT patient (such as ANY child < 2 yo)?

Answer 9

IgG - anti-DEAMIDATED GLIADIN PEPTIDES

Question 10

Can a patient be NEGATIVE for HLA DQ2 and DQ8 and have CELIAC disease?

Answer 10

NO

Question 11

Is genetic (HLA DQ2 & DQ8) testing altered by a GLUTEN-FREE DIET?

Answer 11

NO! (but the serologic studies are)

Question 12

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?

Answer 12

HLA DQ2 & DQ8 (genetics)

Question 13

In MARSH 1 classification, you see IntraEpithepial Lymphocytes (IELs), where else are these seen besides CELIAC disease?

Answer 13

SIBO, NSAID use, H.pylori, PUD, viral gastroenteritis, AI disoders

Question 14

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?

Answer 14

Be SCREENED for CELIAC disease

Question 15

What GI disease should a patient with TURNER, DOWN or WILLIAM disease be screened for?

Answer 15

CELIAC disease

Question 16

What is the SINGLE PREFERRED CELIAC disease TEST for patients >2 yo?

Answer 16

IgA-TTG

Question 17

When should a TOTAL IgA be ordered in CELIAC disease testing?

Answer 17

When there is a DEFICIENCY of IgA suspected

Question 18

What do you use for testing for CELIAC disease when IgA deficiency is an issue?

Answer 18

IgG-based testing (IgG-Deaminated Glidin Peptides)

Question 19

If suspicion for CELIAC disease is HIGH and serologies are negative, what MUST be done NEXT?

Answer 19

EGD with BIOPSY

Question 20

Why is testing for CELIAC disease with IgA-TTG in a CVID patient NOT helpful?

Answer 20

Because CVID is the fiding of LOW IMMUNOGLOBUINS of TWO or MORE (IgG, IgA, IgE, IgM)

Question 21

Why is testing for CELIAC disease with IgA-TTG in a patient on a LOW FODMAP diet NOT helpful?

Answer 21

Because LOW-FODMAP is essentially GLUTEN-FREE (so TTG will be normal)

Question 22

Which IMMUNOGLOBULIN is most commonly DEFFICIENT in CVID?

Answer 22

IgA (sinus infections, URI, GI infections)

Question 23

An IMMUNOLOGICAL condition associated with VITILIGO, RA, SLE, ITP, PERNICIOUS ANEMIA (low vit B12) and IBD-like BIOPSIES?

Answer 23

CVID (IgA defficiency most common)

Question 24

In an ADULT with positive IgA-TTG, what test do you do to CONFIRM CELIAC disease?

Answer 24

EGD with MULTIPLE DUODENAL BIOPSIES

Question 25

In a **CHILD** with positive **IgA-TTG**, what test do you do to **CONFIRM CELIAC** disease?

Answer 25

If **IgA >10 x normal**, thats enough Also **IgA-ENDOMYSIAL Ab's** can cofirm Don't NEED EGD in CHILDREN

Question 26

Patient on a **GLUTEN-FREE** diet improves in **ALL** aspects including **DUODENAL** biopsy findings but has persistent **DIARRHEA** what do you do **NEXT**?

Answer 26

**COLONOSCOPY** with **BIOPSIES** (evaluate for **microscopic colitis**)

Question 27

What **COMMON NON-CELIAC GI** finding is noted among GIARDIASIS, **SIBO**, CROHN's, **CVID**, COLLAGENOUS and TROPICAL SPRUE, **OLMESARTAN**, **AUTOIMMUNE ENTEROPATHY**, LYMPHOMA?

Answer 27

**VILLOUS ATROPHY**

Question 28

**ABNORMAL** groupings of **INTRAEPITHELIAL LYMPHOCYTES** that stain **POSITIVE** for **CD3** but **NEGATIVE** for **T-CELL** markers like **CD8**?

Answer 28

**REFRACTORY CELIAC DISEASE**

Question 29

**CELIAC** disease with persistent symtoms of **MALABSORPTION AND VILLOUS ATROPHY** in spite of **12 MONTHS STRICT ADHERENCE** to a **GLUTEN-FREE** diet?

Answer 29

**REFRACTORY CELIAC DISEASE** (**GIB**, fevers, night sweats, bowel **OBSTRUCTION**)

Question 30

If **REFRACTORY CELIAC-DISEASE** is suspected, what should be done **NEXT**?

Answer 30

**EGD** with **6 DUODENAL BIOPSIES** and sent to **FLOW-CYTOMETRY** to evaluate for **LYMPHOMA**

Question 31

**CELIAC** disease where there is **PERSISTENCE** of **GLUTEN-INDEPENDENT VILLOUS ATROPHY** where **BOTH CD3 & CD8** are seen, **INDOLENT COURSE**?

Answer 31

**REFRACTORY CELIAC DISEASE TYPE-I**

Question 32

**CELIAC** disease where there is **LOW-GRADE LYMPHOMA** where **ONLY CD3** remains, no CD8, **AGGRESSIVE COURSE** poor survival?

Answer 32

**REFRACTORY CELIAC DISEASE TYPE-II**

Question 33

Although does **NOT** change course of disease, what are the treatment **OPTIONS** for **REFRACTORY CELIAC DISEASE**?

Answer 33

**BUDESONIDE** and **IMMUNOSUPPRESSIVES**

Question 34

How often do you **MONITOR** a **CELIAC DISEASE** patient?

Answer 34

Every **3-6 MONTHS** for the **FIRST year** then **Every 1-2 YEARS**

Question 35

**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**?

Answer 35

**AUTOIMMUNE ENTEROPATHY** (**anti-ENTEROCYTE Ab's** or anti-GOBLET Ab's)

Question 36

**GI** disease with **CELIAC-TYPE** presentation **BUT** with **MINIMAL INTRA-EPITHELIAL LYMPHOCYTES** and **ABSENT GOBLET** and **PANNETH** cells, **HLA-DQ2.5** positive?

Answer 36

**AUTOIMMUNE ENTEROPATHY** (anti-ENTEROCYTE Ab's or anti-GOBLET Ab's)

Question 37

What is the **TREATMENT** of **AUTOIMMUNE ENTEROPATHY**?

Answer 37

Steroids (**budesonide**), anti-TNF (**Infliximab**), Cyclosporine, Rituximab, Tacrolimus, **STEM CELL** TRANSPLANT (if refractory)

Question 38

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**?

Answer 38

**OLMESARTAN** (benicar) - **STOP** the med

Question 39

What **MEDICATION** can cause a **CELIAC-LIKE ENTEROPATHY**?

Answer 39

**OLMESARTAN** (confused with AIE because positive anti-ENTEROCYTE Ab's)

Question 40

Patient presents with **WATERY DIARRHEA**, **WEIGHT LOSS**, **FEVERS**, **FATIGUE**, **HEADACHES**, **ARTHRITIS**, **ATAXIA**, **SEIZURES**, **MYOCARDITIS**, metabolic **ACIDOSIS**. Diagnosis is made on **BIOPSY**?

Answer 40

**WHIPPLE DISEASE** (treat with **CEFTRIAXONE** or **PENICILLIN G** and **TMP-SMX** or **DOXYCYCLINE** + hydroxychloroquin long-term) - **FOAMY MACROPHAGES**

Question 41

**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**?

Answer 41

**TROPICAL SPRUE** (treat with **TETRACYCLINE** + folic acid)

Question 42

**WHEN** is **DIARRHEA** considered to be **CHRONIC**?

Answer 42

When its **>4 weeks**

Question 43

What is the process that causes **LOOSE STOOLS** with **BLOOD** and **POSITIVE** fecal **CALPROTECTIN**?

Answer 43

**INFLAMMATORY** (IBD, ischemia, neoplasia, radiation) or **INFECTIOUS** (ileocolonic, colonic)

Question 44

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?

Answer 44

**OSMOTIC** (fasting eliminates it) - lactose, sorbitol, mannitol, lactulose, PEG **SECRETORY** (fasting does NOT eliminate it) - endocrine, bile acids, infectious

Question 45

Besides **CELIAC** disease and **PANCREATIC** insufficiency (steatorrhea), what other major **MALABSORPTIVE** diarrhea exists?

Answer 45

**SHORT-BOWEL** syndrome

Question 46

What are the **TWO MAJOR MOTILITY**-caused diarrheal etiologies?

Answer 46

**IBS-D** (fast) **SIBO** (slow)

Question 47

How do you **CALCULATE FECAL OSMOTIC GAP**?

Answer 47

**290 - 2(K + Na)** if **>50** its **OSMPOTIC DIARRHEA**

Question 48

If a patient has **DIARRHEA** and os found to be **OSMOTIC** due to **MAGNESIUM**, **PHOSPHATE** or **SULFATE**?

Answer 48

**FACTITIOUS DIARRHEA**

Question 49

Lact**ose**, Fruct**ose**, Sucr**ose**, Xylet**ol**, other **FODMAPS** (carbohydrates not readily absorbed), **Caffeine**, **Licorice** cause what kind of **DIARRHEA**?

Answer 49

**OSMOTIC** (due to intolerance) - with **BLOATING** and **GAS**

Question 50

If **OSMOTIC DIARRHEA** is found in a patient, what is **FIRST** suggested?

Answer 50

**LACTOSE-FREE** DIET

Question 51

In an **OSMOTIC-DIARRHEA** patient, if lactose-free diet **FAILS**, what is **CHECKED NEXT**?

Answer 51

**Stool pH** if **pH < 6** - **HYDROGEN** breath test if **pH >6** - eliminate **SUGAR ALCOHOLS** if both **NEG** - **FACTITIOUS**

Question 52

**MASTOCYTOSIS**, **CARCINOID** syndrome, **GASTRINOMA**, **VIPoma**, **PHEOCHROMOCYTOMA**, **SOMATISTATINOMA**, **MEDULLARY THYROID cancer**, **HYPERthyroidism** all cause this **TYPE** of **CHRONIC DIARRHEA**?

Answer 52

**SECRETORY**

Question 53

Diarrhea with **ITCHING**, **FLUSHING**, FATIGUE, OSTEOPOROSIS and **KIT-positive**?

Answer 53

**MASTOCYTOSIS** (**allergic** reaction) - serum **TRYPTASE** positive

Question 54

**DIARRHEA** with serum **TRYPTASE** positive?

Answer 54

**MASTOCYTOSIS** (allergic)

Question 55

**Brainerd**, **SIBO**, **Tropical Sprue**, **Post-Infectious IBS** all cause what kind of diarrhea?

Answer 55

**CHRONIC**

Question 56

What determines whether a patient will have **BILE-ACID DIARRHEA** or **FATTY-ACID DIARRHEA** after **ILEAL-RESECTION**?

Answer 56

**BILE-ACID** if **< 100 cm** ILEUM removed **FATTY-ACID** if **>100 cm** removed (steatorrhea with MASSIVE bile acids, low bilirubin, kidney stones, gallstones)

Question 57

Diarrhea post ileal-resection that is associated with **MASSIVE** stool bile acids, kidney stones and gallstones?

Answer 57

**FATTY-ACID** diarrhea (**steatorreha**) when **>100 cm** of ileum have been removed

Question 58

What **TYPE** of **BILE-ACID** diarrhea is seen in those s/p **CHOLECYSTECTOMY**, vagotomy, post-gastric surgery, chronic **PANCRETITIS**, **SIBO**, **MICROSCOPIC** colitis?

Answer 58

**BILE-ACID** diarrhea

Question 59

What **PREVENTS** excess **BILE-ACID** synthesis?

Answer 59

**REABSORPTION** of BILE-ACIDS in **ILEUM** (feedback)

Question 60

**ELEVATED Serum C4**, **LOW** Serum Fibroblast **Growth Factor 19** and **QUANTITATIVE** measurement are all **MAYO** tests avilable for?

Answer 60

**BILE-ACID MALABSORPTION** (SIBO, short SB, etc.)

Question 61

How do you **TREAT BILE-ACID** malabsorption?

Answer 61

**CHOLESTYRAMINE** (colestipol, colesevelam) or **OBETICHOLIC** acid

Question 62

**Crohn**'s, Mesenteric **Ischemia**, Systemic **Sclerosis**, **Mucosal** Diseases, **Bariatric** Surgery and **Volvulus** can all cause this **GI SYNDROME** of malabsorption and diarrhea?

Answer 62

**Short Bowel Syndrome** (lack of FEEDBACK, lack of absorptive surface area, pancreatic enzyme deactiovation by gastric acid)

Question 63

What **DETERMINES INTESTINAL-FAILURE** requiring **LIFE-LONG** **DEPENDENCE** on **TPN** in **SHORT-BOWEL SYNDROME**?

Answer 63

**LENGTH** of BOWEL **< 100 cm** of bowel = **PERMANENT** **PRESENCE** of **TI** (IC **valve**) or **COLON** = better survival and weaning off TPN

Question 64

What happens in the **ACUTE** (**< 4 weeks**) and **ADAPTIVE** (**1-2 years**) phases of **SHORT BOWEL SYNDROME**?

Answer 64

**ACUTE**: **massive** diarrhea, **TPN & IVFs** **ADAPTIVE**: **decreased**, **combine enteral and TPN**

Question 65

Why is **COLON** in continuity of the **SB** so **IMPORTANT** in **SHORT BOWEL SYNDROME**?

Answer 65

Because of **SHORT-CHAIN FATTY ACID** absorption in the colon, preoduced by the colon **MICROBIOME** digestion of carbohydrates - **SALVAGE PATHWAY**

Question 66

**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?

Answer 66

**SHORT BOWEL SYNDROME** (also TPN complications like infection, hepatic failure, electrolyte deficiency)

Question 67

Can patients with **SHORT BOWEL SYNDROME** who **LACK** a **COLON**, develop **OXALATE** kidney stones?

Answer 67

**NO!!** (colon is **REQUIRED** for oxalate absorption)

Question 68

What are the **DIETARY** differences **RECOMMENDED** for patients with **SHORT BOWEL SYNDROME** who have a **COLON** and those who **LACK** a **COLON**?

Answer 68

COLON **PRESENT**: Higher **CARBS**, Less FAT, **NO OXALATES** (fruits, vegetables) COLON **ABSENT**: Higher **FAT**, Less CARBS

Question 69

What **DRUG** can you use to **WEAN** a patient with **SHORT BOWEL SYNDROME** off of **TPN**?

Answer 69

**TEDUGLUTIDE** (**GLP-2** analogue) - increases SB villous height and thus, absorption

Question 70

**TEDUGLUTIDE** (GLP-2 analogue) used to treat **SHORT BOWEL SYNDROME** to wean off **TPN**, has what **ADVERSE EFFECTS** and **MONITORING** requirements?

Answer 70

**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**

Question 71

What can be done for those with **SHORT BOWEL SYNDROME** that are in **IMPENDING FAILURE** and **DEATH** (< 30 cm, liver failure, sepsis, **DESMOID** tumors)?

Answer 71

Small Bowel **TRANSPLANT**

Question 72

**SB Diverticulosis** (pockets for bactera to grow), Dysmotility, **DM**, **SCLERODERMA**, Achlorhydria (not PPI related), **FISTULAS** can all cause this GI disorder?

Answer 72

**SIBO** (seen in **POST-INFECTIOUS IBS**, **IBS-D**)

Question 73

Stomach **ACID**, normal **ABSORPTION**, **BILE ACIDS** and **ENZYMES**, **IMMUNITY**, normal **MOTILITY** and presence of an **IC VALVE** all prevent this disorder?

Answer 73

**SIBO** (opiates can cause this by slowing motility)

Question 74

**Deconjugation** of **BILE ACIDS** (by bacteria) can cause **DIARRHEA** and **STEATORRHEA** in this GI disorder with **PROTEIN** and **Vit B12 LOSS**?

Answer 74

**SIBO**

Question 75

What GI disorder can cause **STEATORRHEA** with **LOW Vit B12**, **HIGH FOLATE** and **HIGH Vit K**?

Answer 75

**SIBO** (bacteria consume the B12 and produce folate and vit K)

Question 76

How is **SIBO** treated?

Answer 76

**Supportive** (supplementation, low FODMAP, MEDIUM chain fatty acids) **ANTIBIOTICS** (single course or ongoing) - **RIFAXIMIN** (550 mg PO BID/TID x 10 days), AUGMENTIN, METRONIDAZOLE

Question 77

What constitutes a **POSITIVE HYDROGEN (diarrhea) BREATH TEST** for **SIBO**?

Answer 77

At **90 MIN >20 ppm** over baseline If **HIGH-METHANE** = **CONSTIPATION** Or **MIXED**

Question 78

**WOMAN**, **HEALTHCARE** worker, **ANOREXIA** sympotms, with **LARGE-VOLUME**, **NOCTURAL** diarrhea, metabolic **ALKALOSIS**, **OIL** droppelts in **STOOL**?

Answer 78

**FACTITIOUS** diarrhea (laxatives, phenolphthalein) - **MUNCHAUSEN** Can't screen for SENNA or CASCARA

Question 79

Stool **OSMOLARITY** (NOT GAP) in **FACTITIOUS** diarrhea?

Answer 79

**< 250** (water **dilution**) or **>400** (**solutes**) **PRESENCE** of **MAG** or **PHOS** in stool electrolytes

Question 80

**CELIAC** disease can present with **WATERY DIARRHEA** due to concomittent presence of what issue?

Answer 80

**MICROSCOPIC COLITIS**

Question 81

What are **CONFUSING** findings in patients with **MICROSCOPIC COLITIS**?

Answer 81

**ASSOCIATED AUTOIMMUNE** conditions and their **POSITIVE Ab's**

Question 82

**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**?

Answer 82

**Microscopic Colitis**

Question 83

What medication is used to obtain **REMISSION** in **MICROSCOPIC COLITIS**?

Answer 83

**BUDESONIDE**

Question 84

**WATERY** diarrhea with **INTRA-EPITHELIAL LYMPHOCYTOSIS** or **THICKENED** SUB-EPITHELIAL **COLLAGEN** band?

Answer 84

**MICROSCOPIC COLITIS**

Question 85

What **DIFFERENTIATES LYMPHOCYTIC COLITIS** from **COLLAGENOUS COLITIS**?

Answer 85

Lymphocytic colitis: **MANY** Intra-Epithelial **Lymphocytes**, THIN collagen band Collagenous colitis: **THICK** **collagen** band, FEW lymphocytes

Question 86

How is **MICROSCOPIC COLITIS** treated?

Answer 86

**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**)