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Small Bowel Disorders Flashcards

1
Q

What are the small bowel disorders?

A

Diarrhea
Malabsorption
Celiac Disease

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2
Q

define diarrhea

A
  1. Increased frequency or volume of stool

A. 3 or > liquid or semi-solid stools qd for at least 2-3 consecutive days

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3
Q

What is acute diarrhea?

A

≤ 14 days duration

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4
Q

What is persistent diarrhea?

A

> 14 days duration

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5
Q

What is chronic diarrhea? >

A

> 30 days duration

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6
Q

What is the etiology of diarrhea?

A 
1. Infectious
A. Most cases of acute diarrhea due infections w/virus or bacteria → self-limited
2. Bacterial Toxins
3. Dietary
A. Laxative use
4. Other GI disease
A. HIV
5. Noninfectious etiology more common as diarrhea persists & becomes chronic
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7
Q

What are the viral causes of acute infectious diarrhea?

A
  1. Norovirus
  2. Rotavirus
  3. Adenoviruses
  4. Astrovirus
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8
Q

What are the bacterial causes of acute infectious diarrhea?

A
  1. Salmonella
  2. Campylobacter
  3. Shigella
  4. Enterotoxic E. coli
  5. C. difficile
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9
Q

What are the protozoa causes of acute infectious diarrhea?

A
  1. Cryptosporidium
  2. Giardia
  3. Cyclospora
  4. Entamoeba
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10
Q

What is secretory diarrhea?

A
  1. Large volumes w/out inflammation
  2. Indicative of:
    A. Pancreatic insufficiency
    B. Ingestion of bacterial toxins
    C. Laxative use
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11
Q

What is inflammatory diarrhea?

A
  1. Bloody diarrhea w/out fever
  2. Indicative of:
    A. Invasive organisms
    -Salmonella, Shigella, Campylobacter (3 most common US)
    B. Inflammatory bowel disease (IBD)
    -Crohn’s Dz
    -Ulcerative Colitis
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12
Q

What is antibiotic asst. diarrhea?

A
  1. Primary organism A. Clostridium difficile
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13
Q

What are the dx studies for diarrhea?

A 
1. Stool WBC’s
A. Inflammatory process
2. Stool C&S
A. Identifies bacterial pathogens
3. Stool O&P (ova and parasite)
A. Microscopy
B. Identifies parasites
C. Diarrhea > 10 days
D. Recent travel to endemic region
E. Community water borne outbreak
4. Toxin identification
A. Used to identify enterotoxic E. coli or C. difficile
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14
Q

What are the indications for dx studies for diarrhea?

A
  1. Diarrhea > 7 days
  2. Fever > 38.5°C (101.3°F)
  3. Bloody diarrhea
  4. Abd pain
  5. IBD
  6. Profuse watery diarrhea w/dehydration
  7. Frail or elderly
  8. Immunocompromised
  9. Hospital acquired diarrhea
  10. Systemic illness w/diarrhea, especially pregnant women (R/O listeriosis)
  11. Food handlers
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15
Q

Where is listeria found?

A
  1. Listeria monocytogenes
    A. Bacteria inwater & soil
    B. Found in uncooked meats & vegetables, unpasteurized milk, & processed foods* (hot dogs & deli meats)
    *Contamination may occur aftercooking & before packaging
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16
Q

How long is the incubation period for listeria?

A

Incubation 2-30 days

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17
Q

What are the sxs of listeria infection in pregnancy?

A
  1. Mild flu-like symptoms, headaches, myalgias,fever, N/V
  2. Can cause meningitis, endocarditis, bacteremia, brain abscess, osteomyelitis
  3. Most common 3rd trimester
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18
Q

What are the complications of listeriosis in pregnancy?

A
  1. Miscarriage
  2. Prematuredelivery
  3. Infection to newborn
  4. Death to newborn
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19
Q

What are the non abx treatment options for diarrhea?

A 
1. Supportive therapy
A. Hydration- (water, salt, sugar)
2. BRAT diet
A. Rest bowel
3. Antidiarrheal
A. Loperamide (Imodium)
B. Acute diarrhea w/o fever or hematochezia
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20
Q

What are the abx treatment options for diarrhea?

A
  1. Empiric Tx for moderate to severe travelers’ diarrhea
  2. Elderly
  3. (+) signs & sx’s of invasive bacterial diarrhea such as fever and bloody diarrhea
  4. NO antibiotic Tx w/enterohemorrhagic E. coli (unless severe)
21
Q

What abx are indicated for shigella caused diarrhea?

A

Fluoroquinolone (Cipro 500 mg po bid x 7 days)

22
Q

What abx are indicated for campylobacter caused diarrhea?

A

Fluoroquinolone (Cipro 500 mg po bid x 7 days)

23
Q

What abx are indicated for C. difficle caused diarrhea?

A

Metronidazole 500 mg po tid x 10-14 days

24
Q

What abx are indicated for Giardia caused diarrhea?

A

Metronidazole 250 mg po tid x 10 days

25
Q

What abx are indicated for Listeria caused diarrhea?

A
  1. 1st line: ampicillin ≥ 6 g/d IV 7–14 d; if fetus survives, longer Tx
  2. 2nd line: erythromycin 4 g/d IV, 7–14 d; if fetus survives, longer Tx
26
Q

What may malabsorption involve?

A

May involve a single nutrient, enzyme deficiency, or global

27
Q

What are examples of malabsorption?

A
  1. Pernicious anemia – Vit B12 def
  2. Lactase deficiency – inability to digest lactose products
  3. Celiac disease
28
Q

What is the etiology of malabsorption?

A
  1. Digestion problem
  2. Absorption problem
  3. Impaired blood flow & lymph flow
29
Q

What are the more common sxs of malabsorption?

A
  1. Diarrhea
    A. Usually 1° complaint
  2. Bloating
  3. Abd pain
30
Q

What are the less common sxs of malabsorption?

A
  1. Weight loss
  2. Steatorrhea
    A. Large, greasy, foul smelling stools
  3. Specific deficiencies can cause:
    A. Bone demineralization
    B. Bleeding
    C. Anemia
31
Q

What are the dx studies for malabsorption?

A
  1. Fecal fat test
    A. Measures fat content in stool
    B. If (+) fat in stool → not digested or absorbed
  2. If 72 hr fecal fat test is normal
    A. R/O pancreatic insufficiency
    B. R/O abnormal bile salt metabolism
  3. D-Xylose Absorption test (Monosaccharide) 25 g po
32
Q

What is D-Xylose Absorption test (Monosaccharide)?

A
  1. Now redundant due to Ab tests
  2. Does not require enzyme (amylase) for digestion prior to absorption
  3. Result determined by absorptive function of small intestine
    A. Normal=Urine D-Xylose 4.5 g in 5 hr
    B. Abnormal < 4.5 g in 5 hr
  4. Polymerase chain reaction (PCR) based assay
  5. EGD w/duodenal Bx to detect bacteria
  6. CBC & vitamin assays
    A. Vit B12 def
  7. Hydrogen breath test
33
Q

What is the purpose of D-Xylose Absorption test?

A
  1. Differentiates maldigestion vs malabsorption
    A. Maldigestion=pancreatic insufficiency or bile salt deficiency or bacterial* overgrowth
    -*Whipple’s Dz-responds to antibx
    B. Malabsorption=Celiac Dz
34
Q

What is the the PCR assay for malabsorption?

A
  1. DNA sequencing test
  2. PCR of saliva, gastric, intestinal fluid, stool are highly sensitive, but not specific (use like D-Dimer to R/O bacteria)
  3. (-) PCR=healthy
35
Q

What is the hydrogen breath test for malabsorption?

A
  1. Used to diagnose lactase deficiency
    A. After ingesting 50 g lactose, ↑ breath hydrogen
    B. > 20 ppm w/in 90 min = (+) test
36
Q

How is lactase deficiency treated?

A

Lactose free diet

Lactaid pills

37
Q

How is celiac dz treated?

A

Gluten free diet

38
Q

How is pancreatic insufficiency treated?

A

Pancreatic enzyme replacement

39
Q

How is pseudomembranous colitis?

A

Metronidazole 500 mg po bid x 10-14 days

40
Q

What are the general characteristics of celiac dz?

A
  1. Permanent dietary disorder caused by immunologic response to gliadin (gluten protein)
    A. Storage protein found in certain grains
    B. Wheat, barley, rye, sometimes oats
  2. Characterized by mucosal inflammation, villous atrophy & crypt hyperplasia
  3. Results in diffuse damage to proximal small intestinal mucosa -> malabsorption of nutrients
41
Q

What is the epidemiology of celiac dz?

A

Most cases undiagnosed

More prevalent in Northern Europeans

42
Q

What is the etiology of celiac dz?

A 
1. May be genetic
A. HLA-DQ2 or HLA-DQ8
2. Immunologic 
A. T-cell mediated response in intestinal mucosa
B. B-cell response
C. Ab to gluten
43
Q

What are the classic sxs of celiac dz?

A
  1. Diarrhea
  2. Steatorrhea
  3. Weight loss
  4. Abd pain
  5. Distention
  6. Weakness
  7. Muscle wasting
44
Q

What are the atypical sxs of celaic dz?

A
  1. Fatigue
  2. Depression
  3. Iron def anemia
  4. Osteoporosis
  5. Amenorrhea
  6. Dermatitis herpetiformis
    A. Pruritic papules & vesicles occurring in groups
    B. Elbows, dorsal forearms, knees, scalp, back, & buttocks
45
Q

What are the dx studies for celiac dz?

A 
1. Serologic tests 
A. > 90% sensitivity & > 95% specificity 
-IgA endomysial Ab
-IgA tTG Ab
2. (-) test excludes celiac disease
3. False (-) & (+)
  1. Ab undetectable after 6-12 mo gluten free diet
  2. Mucosal tissue Bx of distal duodenum or proximal jejunum
46
Q

What is the gold standard for dx celiac dz?

A
  1. Mucosal tissue Bx of distal duodenum or proximal jejunum
  2. Done if
    A. (+) serology to confirm Dx
    B. (-) serology w/high suspicion
47
Q

What are the ddx for celaic dz?

A
  1. IBS
  2. Bacterial overgrowth
    A. Pseudomembranous colitis
    B. Whipple’s Dz
  3. Lactose intolerance
48
Q

What is the tx for celaic dz?

A
  1. Gluten free diet
  2. Dietary guides
  3. Support groups
  4. Lactose free diet
    A. Many pts with celiac disease have co-existing lactose intolerance
  5. Dietary supplements early in disease
    A. Iron, folate, Ca, Vit A, B12, D, E
49
Q

What is the prognosis for celaic dz?

A
  1. Excellent prognosis with Dx & Tx
  2. Most common cause recurrent sx’s is dietary noncompliance
  3. Celiac disease refractory to dietary management may be result of intestinal T cell lymphoma

Gen Med: GI (16 decks)

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