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small bowel disorders Flashcards

1
Q

What is celiac disease?

A
  • autoimmune disorder that is triggered by an enviro agent (gliaden component in gluten) in genetically predisposed individuals
  • it occurs primarily in whites of N european ancestry but has not increased in other ethnic groups
  • reported prevalence in most countries: 1:70 to 1:300
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2
Q

2 components of gluten?

A
  • gliadin and glutenin
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3
Q

What studies are used to follow course of CD?

A
  • IgA abs to gliadin
  • IgA abs to endomysium: a structure of smooth muscle CT, presence is nearly pathognomonic for CD
  • gliadin receptors on intestinal epithelial cells may mediate the transport of gliadin peptides into lamina propria where T cell activation occurs - this may someday lead to drug therapy for CD
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4
Q

Mechanism of gluten irritation? Diff in bowel structure?

A
  • gluten triggers release of protein that controls gut permeability
  • intestinal lining cells are pried apart by protein, zonulin
  • undigested food enters blood system
  • immune system cells react by releasing cytokines. Which can trigger inflammation and disruption throughout the body
  • this inflammation attracts more immune cells (macrophages) - just leads to more inflammation
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5
Q

Clinical manifestations of CD: classic?

A
  • diarrhea with bulking, foul smelling, floating stools due to steatorrhea (malabsorption)
  • wt loss
  • vit deficiences: B vitamins, iron, copper, zinc, vit A, D, E and magnesium
  • on small bowel bx: villous atrophy
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6
Q

Atypical disease presentation of CD?

A
  • minor GI sxs
  • can have anemia, osteoporosis, arthritis
  • increased LFTs, neuro sxs, or infertility (due to abs)
  • most show severe mucosal damage and possess the CD ab pattern
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7
Q

What is silent CD?

A
  • recognized incidentally based upon screening for abs
  • often have some changes in mucosa of small bowel
  • they don’t show clinical sxs but many complain of fatigue
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8
Q

Pts with CD have a slight increased risk for what malignancies?

A
  • non-hodgkin lymphoma
  • small intestinal adenocarcinoma
  • hepatocellular carcinoma
  • GI cancer
  • lymphoproliferative disease
  • hodgkin lymphoma
  • decreased risk of breast cancer
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9
Q

Assoc conditions with CD?

A
  • dermatitia herpetifromis (autoimmune rash)
  • type 1 DM
  • down syndrome
  • liver disease
  • autoimmune thyroid disease
  • GERD
  • IBD
  • menstrual and repoductive issues in women
  • infertility in men
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10
Q

How do you dx CD?

A
  • begin with IgA anti-tissue transglutaminase (TTG): autoab against body’s own transglutiminases
    this is used for anyone over the age of 2, it is the single PREFERRED test for detection of CD
  • if high prob of disease and IgA based serology is negative: test total IgA or IgG- deaminated gliadin peptides (DGP)
  • pts with positive serology should undergo a small bowel bx:
  • 1-2 bx from duodenal bulb
  • at least 4 from 2nd and 3rd portion of duodenum
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11
Q

Other dx tests for CD?

A
  • pts on gluten free diet who have negative serology’s should have HLA/DQ1/DQ8 testing: determine if pt is genetically susceptible to disease, if negative CD is ruled out
  • if serology is positive but small bowel bx is negative the pt can be put on high gluten diet and be rebx after 6-12 weeks
  • individuals with low pretest probability (chinese, japanese, adn sub-saharan african descent): recommend - IgA endomysial ab test - it has a higher specifity but it is more costly
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12
Q

What is gluten sensitivity?

A
  • some people are sensitive to gluten w/o having CD

- they get diarrhea, feel ill and bloated and find if they eliminate gluten from their diet they feel better

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13
Q

Tx of CD?

A
  • consult with skilled dietitian
  • education about disease
  • lifelong adherence to gluten free diet
  • Id and tx of nutritional deficiencies
  • access to advocacy group
  • continuous ongoing f/u by multidisciplinary team
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14
Q

What foods should be avoided in gluten free diet? What foods are ok?

A
  • foods containing wheat, barley: avoid
  • soybean or tapioca flours, rice, corn, buckwheat and potatoes are safe
  • read labels: distilled alcohol, vinegar, and wine are gluten free
  • beers, ales and malt vinegars often made with gluten
  • dairy products may not be well tolerated initially since many pts with CD have secondary lactose intolerance - initially dairy should be avoided
  • oats should be introduced into diet with caution (may be some cross reactivity)
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15
Q

How common is lactose intolerance in US - what ethnicities are mostly affected?

A
  • 7-20% caucasian adults
  • 80-90% native americans
  • 55-65% african americans and africans
  • 50% hispanics
  • over 90% of some pops in East Asia
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16
Q

Sxs of lactose intolerance?

A
  • due to low levels of lactase in small bowel:
  • diarrhea
  • abdominal pain
  • flatulence
17
Q

Mechanism of lactose intolerance?

A
  • if you lose lactase - lactoce isn’t being broken down this leads to bacterial fermentation- this is what causes sxs: loose stools, bloating, abd pain
18
Q

Explain what racial/ethnic lactose malabsorption is?

A
  • genetically regulated reduction in lactase activity determined by ethnic factors in healthy individuals
  • majority of caucasians of N. European ancestry maintain elevated lactase levels as adults
  • in US lactase activity is normal in all healthy children until 5
19
Q

Explain what developmental lactase deficiency is?

A
  • results from low lactase levels as result of prematurity
  • infants born at 28-32 wks gestation have reduced lactase activity
  • tx: use elemental (predigested) formula
20
Q

What is congenital lactase deficiency?

A
  • rare autosomal recessive disorder
  • absence of any lactase activity in small intestine
  • largest number of reported cases have been described in Finnish pop
21
Q

What is secondary lactase malabsorption?

A
  • bacterial overgrowth or stasis may be assoc with increased fermentation of dietary lactose in small bowel
  • seen with any mucosal injury to small bowel such as gastroenteritis (avoid dairy products for a couple of weeks to allow mucosa to heal), CD, IBD
22
Q

Clinical manifestations of lacose intolerance?

A
  • abdominal pain: crampy, periumbilical and lower quadrants
  • bloating
  • flatulence
  • diarrhea
  • vomiting: adolescents
23
Q

Dx of lactose intolerance?

A

lactose tolerance test:

  • 50 g test dose given in adults
  • blood glucose levels drawn at 0, 60, and 120 min
  • an increase in blood glucose by less than 20 mg/dL plus sxs is dx
  • this is cumbersome and time consuming

lactose breath hydrogen test:

  • oral lactose given in fasting state (2 gm/kg - max: 25 mg)
  • breath hydrogen levels measured at baseline and 30 min intervals for 3 hrs after lactose ingestion
  • values over 20 ppm dx
24
Q

Tx of lactose intolerance?

A
  • dietary restriction of lactose intake: read labels, usually some lactose containing foods (cheese) can be tolerated
  • substition of alt sources to maintain energy and protein intake
  • admin of commercially available enzyme substrate: lactaid
  • maintenance of Ca and Vit D intake
25
Q

What is ileus?

A
  • temporary absence of normal contractile movements to intestinal wall
26
Q

Etiologies of ileus?

A
  • post op: esp abdominal when the intestine’s have been manipulated
  • drugs: opioids and anticholinergics
  • hypothyroidism
  • lyte disorders: hypokalemia, hypercalcemia
  • intestinal peritonitis: going to have rebound tenderness
  • kidney failure
  • pancreatitis - inflamed pancreas bothersome to bowel
27
Q

Clinical manifestations of ileus?

A
  • bloating
  • N/V
  • crampy abdominal pain: pain precedes vomiting when assoc with acute surgical etiology
  • severe constipation
  • loss of appetite
28
Q

DDx of ileus?

A
  • adynamic (paralytic) ileus (slowed down)
  • intestinal obstruction
  • acute abdomen
  • post-op adhesive disease
29
Q

Dx of ileus?

A
  • xrays
  • lytes
  • CBC
  • CMP including Mg
30
Q

Tx of ileus?

A
  • NPO advancing to clear liquids as tolerated
  • IV fluids to maintain hydration and correct lyte abnorm
  • stop drugs that make ileus worse (use tordol, avoid opioids)
  • occasionally NG tube
  • if post op: get pt up and moving around

GI (21 decks)

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