Small Intestinal Disorders and Investigation

Question 1

What is the functions of the small intestine

Answer 1

Digestion

Absorption

Endocrine and neural control (flow of material from stomach to colon)

Barrier functions

Question 2

How does the barriers function work against pathogens

Answer 2

Immune sampling

Monitoring the presence of pathogens

Translocation of Bacteria

Gut Associated Lymphoid Tissue (GALT)

Question 3

What structures and features of the small intestine allow it to perform its function

Answer 3

Large surface area

• Villous architecture
• Constant turnover of cells in crypts & villi

Low Bacterial population
- toxic environment

Motility

Question 4

How and Where does digestion begin

Answer 4

In the stomach by salivary amylase and pepsin

Question 5

Why is there a controlled digestion in the stomach

Answer 5

To avoid osmotic shifts

Question 6

What happens in the digestion of proteins

Answer 6

Breakdown to oligopeptides & amino acids
by Trypsin and chymotrypsin

Final hydrolysis and absorption at brush border

Question 7

What happens in the digestion of fat

Answer 7

Pancreatic lipase breaks don fat into glycerol and free fatty acids
Absorption happens via lacteal and lymphatic system

Question 8

What happens in the breakdown oc carbohydrates

Answer 8

Pancreatic amylase
Breakdown carbohydrate into disaccharides

Final digestion by brush border disaccharidase

Question 9

What is the symptoms of small intestine disease

Answer 9

Weight Loss

Increased appetite

Diarrhoea

Steatorrhoea

Bloating

Fatigue

Question 10

What is the cause of steatorrhoea

Answer 10

Fat malabsorption

causing high fat content on stool

Question 11

What is the presentation of steatorrhoea

Answer 11

Stool less dense and floats

Pale

Foul smelling

May leave an oily mark or oil droplets

Question 12

What is the signs of small intestine disease

Answer 12

Weight loss

Low or falling BMI

Question 13

What deficiencies can occur due to small intestine disease

Answer 13

Iron 
Vitamin B 12 
Vitamin A,C,D,K
Vitamin B complex 
 - Thiamine 
 - Niacin 
Ca2+
Mg2+

Question 14

What does a deficiency of iron and Vitamin b12 cause

Answer 14

Anemia

Question 15

What deficiencies result in tetany osteomalacia (muscle spasms and softening of bones)

Answer 15

Ca2+
Mg2+
Vitamin D

Question 16

What deficiency causes night blindness

Answer 16

Vitamin A

Question 17

What deficiency result in a raised prothrombin time rate (PTR) - the time taken for blood to clot

Answer 17

Vitamin K

Question 18

What is scurvy a deficiency of

Answer 18

Vitamin C

Question 19

What does a thiamine deficiency result in

Answer 19

Memory,

Dementia

Question 20

What does a Niacin deficiency result in

Answer 20

Dermatitis,

Unexplained heart failure

Question 21

What is clubbing and aphthous ulceration (mouth ulcers) a non specific sign of

Answer 21

Coeliac disease

Crohns

Question 22

What is scleroderma a non specific sign on

Answer 22

Systemic sclerosis

Question 23

What is dermatitis herpetiformis a sign of

Answer 23

Is a sign of cutaneous manifestations of coeliac disease

Question 24

What is the presentation of dermatitis herpetiforms

Answer 24

Blistering
Intensely itchy
Scalp, shoulders, elbows, knees
IgA deposit in the skin

Question 25

What are examples of non specific signs of small intestine disease

Answer 25

Clubbing Scleroderma Aphthous Ulceration Dermatitis herpetiformis

Question 26

What are the investigations for the structure of the small intestine

Answer 26

Endoscopy + biopsy Barium swallow CT scan MRI enterography Capsule enterography White cell scan

Question 27

How do you specifically test for bacterial overgrowth in the small intestine

Answer 27

H2 Breath test (H2 is a product of bacterial breakdown of lactulose/glucose so will be increased) or Culture a duodenal or jejunal aspirate

Question 28

How do you test for coeliac disease

Answer 28

Serology - IgA tests (more reliable than IgG) Distal duodenal biopsy HLA status

Question 29

Why should you check the total plasma IgA in diagnosing coeliac disease

Answer 29

Just in case patient has a selective IgA deficiency, so might not make IgA

Question 30

What does distal duodenal biopsy investigate

Answer 30

See if there is villous atrophy | either partial/subtotal/total

Question 31

Why do you investigate HLA (human leukocyte antigen) and why is it not that efficient

Answer 31

As 97% of coeliacs are either HLA DQ2 or DQ8 but so are 30% of the population

Question 32

What causes Coeliac disease

Answer 32

A Sensitivity to Giladin Component of gluten found in Wheat, Rye, Barley

Question 33

What is the pathology of coeliac disease

Answer 33

Produces an inflammatory response that results in Partial or subtotal villous atrophy and Increased intra-epithelial lymphocytes

Question 34

What is the enzyme attacked in coeliac disease

Answer 34

Tissue Transglutaminase

Question 35

What is the investigations for Coeliac disease

Answer 35

Distal duodenal biopsy Serology: + - Anti endomysial IgA - Anti Tissue transglutaminase - Anti Gliadin (help in children but no diagnostic in adults

Question 36

What is the treatment of coeliac disease

Answer 36

``` Withdraw gluten (avoid wheat, + lifelong diet) ``` MUST refer to state registered dietitian

Question 37

What is associated conditions of Coeliac disease

Answer 37

Dermatitis herpetiformis Insulin dependant diabetes mellitus Autoimmune: thyroid disease hepatitis Gastritis Primary Biliary cirrhosis Sjogren syndrome IgA deficiency Downs Syndrome

Question 38

What is the complications of Coeliac disease

Answer 38

Refractory Coeliac Disease Small bowel lymphoma Oesophageal carcinoma Colon Cancer Small bowel adenocarcinoma

Question 39

What is the aetiology of malabsorption

Answer 39

Inflammation: - Crohns - Coeliac disease Infection - Tropical - HIV - Giardia lamblia (unicellular parasite found in contaminated water) Whipples Disease Amyloid (build up of starch/protein) Impaired motility - systemic scerlosis - Diabetes - Pseudo Obstruction Iatrogenic - Gastric surgery - Short bowel syndrome - Radiation Pancreatic - Chronic pancreatitis - Cystic fibrosis

Question 40

What is the treatment of giardia lamblia

Answer 40

Metronidazole

Question 41

What does giardia lamblia result in

Answer 41

Hypogammaglobulinaemia Giardiasis - Causing the symptom of diarrhoea

Question 42

What is the presentation of whiles disease

Answer 42

Middle aged men Skin, brain, joints and cardiac effects Weight loss Malabsorption Abdominal pain PAS material in villi

Question 43

What is the causative organism of whipples disease

Answer 43

Tropheryma whippelii

Question 44

When does small bowel overgrowth happen

Answer 44

When there is a condition that affect the motility, gut structure of the immunity of the small intestine

Question 45

How do you treat small bowel overgrowth

Answer 45

``` Rotating antibiotics: Metronidazole Tetracycline Amoxycillin Each for 2 weeks ``` With Vitamin and nutritional supplements

Question 46

Is it easier to test for the function or structure of the small intestine

Answer 46

Structure