Small Intestine Flashcards
Celiac Dz
Whipple Dz
Tropical Sprue
Lactose Deficiency
Bacterial Overgrowth
Short bowel syndrome
Malabsorption syndorme
IRON
Calcium
Copper
Magnesium
Phosphorus
Riboflavin
Thiamin
Absorbed in Duodenum
Vitamins ADEK
Folate
Jejunum
Vit B12
Bile salts/acids
Ileum
What are the BIG THREE clinical manifestations of malabsorption?
Steatorrhea
Microcytic/macrocytic anemia
Dairy intolerance
Bulky, greasy stools that typically float
Sign of increased fat
Steatorrhea (sign of malabsorption)
Lab = low serum iron
Microcytic anemia (malabsorption sign)
Lab = low B12, low folate
Macrocytic anemia (malabsorption sign)
Consider tropical sprue OR bacterial overgrowth
Typical symptoms: weight loss, chronic diarrhea, abdominal distention, growth
retardation.
Atypical symptoms: dermatitis herpetiformis, iron deficiency anemia, osteoporosis.
Abnormal serologic test results. Abnormal small bowel biopsy.
Clinical improvement on gluten-free diet.
Celiac dz
Diffuse damage to the proximal small intestine
Celiac dz
Immunological response to gluten
Usually diagnosed in late childhood/early adulthood
Grossly underdiagnosed
Celiac disease
(1
Most important step is to consider the diagnosis
SSx are variable for Celiac (Depends on small intestine into element). What are the classic symptoms?
Dyspepsia
Diarrhea
Steatorrhea
Wt loss
Flatulence/abd distention/bloating
Borborygmi
(Weakness/muscle wasting if severe)
Many adults may present asymptomatically/atypically w/ with what ssx?
“Extraintestinal manifestations”
Fatigue
Depression
Iron deficiency anemia
Osteoporosis
Transaminitis
Dermatitis herpetiforims
Regarded as a cutaneous variant of celiac dz
Skin rash w/pruritic papulovesicles over the extensor surfaces
Dermatitis herpetiformis
Most cases of Celiac dz are unremarkable on PE
However, nutrient deficiencies maybe present due to malabsorption , such as?
Loss of muscles mass, bruising (due to def. in. Vit K), hyperkeratosis (Vit A def.), bone pain, neuro deficit is (def. in Vit B)
Labs (such as CBC/CMP/UA) may produce non specific results … What’s the test of choice for Celiiac?
IgA trans glutaminase (IgA tTG)
If IgA tTG is negative for celiac, but still a strong clinical suspicion for celiac.. what’s your next move?
Obtain serum IgA levels
Then do an anti-DGP test
If a patient has IgA deficiency what Follow up test could be performed to asses for celiac?
Deamidated gliadin peptides(anti-DGP)
Confirmatory test in pts w/ a Celiac positive serological test?
Endoscopic mucosal biopsy of proximal/distal duodenum
Normal biopsy excludes Celiac
Histology exam reveals blunting and/or atrophy of the intestinal villi
(Near absence of villi = flat mucosa)
Celiac
Biopsy after pos serology
Diff Dx for celiac?
IBS
chronic diarrhea
Tropical sprue
Lactose intolerance
Gastroenteritis
Diagnostic approach to Celiac…
Diagnostic suspicion… Serologic testing… trial of gluten free diet…
Mucosal biopsy
Celiac
Tx of Celiac?
Removal of all gluten products including oats
Should see improvement in 2-3 weeks…
(REFER TO DIETICIAN)
Most common reason for tx failure in celiac?
W/ celaic, Any risk for cnacer?
Most common reason for failure is dietary noncompliance
SLIGHT increase in risk for adenocarcinoma and lymphoma
No need for retesting if dietary measures are effective… However…
If symptoms persist, refer
Multisystem dz
Fever/lymphadenopathy/arthralgias
Wt loss
Duodenal biopsy w/ Periodic Acid Schiff (PAS) positive macrophages w/ bacillus
Whipple Dz
In whom is whipple dz most common?
How’s it spreads?
Most common in white males, age 30-50
No human-human spread.. Contact w/ sewage/waste water
Fatal if untreated
White males 30 -50 Waste Water With human to human (fecal) With migrating arthralgia *first sign if present* WEIGHT LOSS - MOST common* With fever With lymphadenopathy Whippelii trophoryme WILL KILL YA! Will DIAGNOSE with EGD and find "foamy macrophages"
Common/class presentation of Whipple?
**MIGRATORY arthralgias - first sign
Diarrhea
Abd pn
Wt loss - MOST COMMON
FEVER OF UNKNOWN ORIGIN
Less common signs… What diseas?
Skin hyperpigmentation
Generaliazed lymphadenopathy
Ophthalmoplegia
Whipple dz
Diagnosis of Whipple dz is usually performed how?
Endoscopic biopsy w/ evidence of bacterium
“Foamy macrophages”
TX for whipple dz?
IV ceftriaxone for 2 weeks
THEN
TMP-SMX 1 tab PO BID for ONE YEAR
Environmental enteropathy
Occurs in narrow Tropical band
Chronic diarrhea (often after acute diarrhea)
Involves entire small intestine
CHaracterized by malabsorption (esp folic acid//B12)
Tropical sprure
Tropical malabsopriton
Chronic diarrhea
Steatorrhea
Wt loss
Malaise
B12/Folate deficiency (glossitis/cheilitis)
tropical sprue
CBC would show megaloblastic anemia
Endoscopy w/ biopsy would show flattened duodenal folds
Tropical sprue
Microscopic findings of blunted villi and ELONGATED CRYPTS
Prevention of tropical sprue?
Tx?
Prevention : boiled/bottled water; peel fruits
Tx: TMP-SMX x 6 mos; folate/B12 supps
Diarrhea, bloating, flatulence, and abdominal pain after ingestion of milk-
containing products.
Diagnosis supported by symptomatic improvement on lactose-free diet.
Diagnosis confirmed by hydrogen breath test.
LactAse deficiency
BRush border enzyme that hydrolysis lactose in glucose and galactose
Lactase deficiency
Malabsrobed lactose is fermented by intestinal bacteria producing gas and organic acids
Cool
LactAse deficiency
Top three lactase deficient populations?
Asian (95-100%)
American Indians (80-100%)
Black people (60-80)
Ssx of lactose are variable and dose dependent…
- Small intake?
- Mod intake?
- Large intake?
- Maybe asymptomatic
- Bloating, cramps, flatulence
- OSMOTIC DIARRHEA
Other signs of malabsorption SHOULD NOT be present in lactase deficiency… so if wt loss is present then what?
LOOKK FOR ANOTHER ETIOLOGY
Tx for Lactase deficiency
Presumptive diagnosis of lactase deficiency?
Diagnostic test for lactase deficiency?
Presumptive -> 2-3 week of lactose free diet
Diagnostic test = hydrogen test
Symptoms of distention, flatulence, diarrhea, and weight loss.
Increased qualitative or quantitative fecal fat.
Advanced cases associated with deficiencies of iron or vitamins A, D, and B12.
Diagnosis suggested by breath tests using glucose, lactulose, or 14C-xylose as
substrates.
Diagnosis confirmed by jejunal aspiration with quantitative bacterial cultures.
Bacterial overgrwoth
Consider what dz in these following pts:
Pts on chronic PPI
Pts who have an anatomical abnormality Or motility disorder of small intestine
Pts who have gastrocolic/coloenteric fistula (e.g., Crohn, malignancy, surgical resection)
Bacterial overgrwoth
Bacterial overgrwoth is an important cause of malabsorption in what pt population?
Olds
Bacterial overgrowth can often be a symptomatic… What would be the ssx?
Flatulence
Wt loss
Abd pn
Diarrhea
Steatorrhea
Macrocytic anemia
Specific diagnosis for bacterial overgrowth can be establish by aspirate and culture (but this is expensive and difficult) So what do we use?
Can use a noninvasive breath test but many clinicians use an empiric approach w/ abx
Thx for bacterial overgrwoth?
Empiric tx w/ antibiotics… Cipro, Amoxicllin-clavulanate, Rifaximin
Short bowel syndrome
Due to removal of significant segments of small intestine
What does the degree of malabsorption depend on?
Length
Site
Degree of adaptation of remaining bowel
Precipitating factors: surgery, peritonitis, electrolyte abnormalities, medications,
severe medical illness.
Nausea, vomiting, obstipation, distention.
Minimal abdominal tenderness; decreased bowel sounds.
Plain abdominal radiography with gas and fluid distention in small and large
bowel.
Acute paralytic ileus
Types of intestinal motility disorders?
Acute paralytic ileus
Chronic intestinal pseudo-obstruction
Small bowel obsutrcion
Ileus considered in hospitalized pts as results of?
- Intrabdominal processes (surgery/peritoneal irritation)
- Severe medical illness (pneumonia, respiratory failure, etc.)
- Medications that affect motility (opioids, anticholinergics, phenothiazines)
Failure or loss of intestinal peristalsis WITHOUT mechanical obstruction
Acute paralytic ileus
Diffuse, CONSTANT abd pn
Nausea and vomiting
LACK OF ABDOMINAL TTP (no signs of peritoneal irritation)
Abdominal distension
Diminished/absent bowel sounds
Acute paralytic ileus
Though lab findings in acute paralytic ileus are non-specific, they should be obtained why?
To exclude abnormalities as contributing factors
What would you see on a X-ray of acute paralytic ileus?
Gas-filled loops of the small/large intestine (air fluid levels may be present)
Ilues must be distinguished from mechanical obstruction. How might you tell
Pain from obstruction is typically intermittent w/ cramping and profuse vomiting.
Ileus is CONSTANT
Treatment for acute paralytic ileus?
Tx underlying dz
Pn mgmt/fluid maintenance/electrolyte replacement
Nasogastric decompression for severe distension
Severe abdominal distention.
Arises in postoperative state or with severe medical illness.
May be precipitated by electrolyte imbalances, medications.
Absent to mild abdominal pain; minimal tenderness.
Massive dilation of cecum or right colon.
Acute Colonic pseudo-obstruction (Ogilvie syndrome)
Similar to gastroparesis
Intermittent signs of obstruction in the absence of a physical obstruction
Chronic intestinal pseudo obstruction
Involvement of the small bowel results in….
Abd distension
Vomiting
Diarrhea
Varying degrees of malutrition
Chronic intestinal pseudo obstruciton
In a work up of chronic intestinal pseudo obstruciton, what must you exclude? With what type of imaging?
Exclude mechanical obstruction with CT or endoscopy
Tx for chronic intestinal pseudo obstruciton?
Acute exacerbation require NG decompression and IV fluid/electrolyte replacement
Refer to GI
What are most small bowel obstructions attributed to?
Postop adhesions or hernias
(Other causes include neoplasm, strictures, foreign body , intussusception, gallstones
Prior abd/ pelvic surgery
Abd/groin hernia
Intestinal inflmmation
Hx of neoplasm
Prior radiation
Hx of foreign body ingestion
RISK factors for SBO
How would a SBO clinically present?
ABRUPT onset of:
COLICKY pn
Nausea
Profuse vomiting
Obstipation
PE findings for SBO?
Abd distension (tympany)
HYPERactive bowel sounds early, then progress to HYPOactive later
Signs of dehyration
Labs for SBO include CBC, CMP, Urinalysis, and what?
If surgery is indicated?
Type and cross match for surgery
What type of radiographs for SBO?
What do you expect to see?
Plain abdominal films…
Upright and supine…
DILATED LOOPS OF SMALL BOWEL W/ AIR FLUID LEVELS
When should you perform a CT scan for a suspected SBO/?
If pat has fever, tachy, localized abd pn, or leukocytosis
To dx a strangulated obstruciton
Thx for SBO?
Early surgical consultation
ADMISSION
Flui resuscitation
Bowel decompression w/ NG
Pain control
Antiemetic meds
Complications of SBO?
Dilation -> comprised intramural vessels -> ischemia -> necrosis
Rare
Due to impaction of gallstone in the ileum after passing through fistula
Common in whom?
Gallstone ileus, more common in females/older patients
Female/Fat/Forty/Fertile
Segment of intestine invaginates into adjoining intestinal lumen…
Common in whom and what’s the stool look like?
Intussusception more common in kids and causes currant jelly stool
Though rare, primary malignancy of the small bowel can cause what?
Intussusception (obstruciton)
If small intestinal, Adenocarcinoma are most commonly in the Duodenum or proximal jejunum. How would it present?
Obstruciton, chronic GI bleed, wt loss
What populations have increased incidents of small intestinal lymphomas?
AIDS/immunosuppressed, Crohn dz
Side Note: Small intestinal Neoplasms - mainly adenocarcinoma and lymphomas*
Intestinal carcinoid,
Sarcoma
Small intestinal neoplasm possibilites
Usually a result of an already established GI order
Causes excess loss of serum protein into GI tract (hypoalbuminemia)
Protein losing enteropathy
Thx of protein losing enteropathy?
treat underlying condition
Dietary therapy and if severe, albumin replacemtn
Interruption of blood to the bowel
Acute arterial occlusion (emboli or thrombotic)
Non-occlusive -> vasospasm, low cardiac output
Ischemia -> necrosis (emergency)
Mesenteric ischemia
Classically… pain out of proportion w/ PE
DIagnose w/ CT angiography
Mesenteric ischemia
Tx for mesenteric ischemia?
Admit!
Papaverine (smooth muscle relaxant)
Thrombolytics
Surgical referral
Most common CONGENITAL abnormality of the GI tract?
Rule of twos….
Meckel’s diverticlum
2% of population.
2:1 male to female
2 feet of ileocecal valve
2 types of mucosa
SSx before age 2
Males 2:1 Manifests 2/yo (although under 10 y/o and adults less than 40 must suspect for different reasons) Maybe 2% of pop Most 2' w/i ileocecal valve 2 types of mucosa
Variable presentation… but can see
GI bleeding
Abd Pain (similar to appendicitis)
Meckel’s diverticula
Suspect Meckel’s in whom?
Children under 10 who present w painless GI bleeding w/o ssx of gastroenteritis or IBD
Adult pts less than 40 w GI bleeding but ID’ed source on endoscopy
How to diagnose Meckel’s?
Capsule endoscopy
Meckel’s scan (nuke medciine w/ 99m technetium)
Tx for Meckel’s?
Referral for surgical eval if ASYMPTOMATIC
Symptomatic? Stabilize bleed and removal diverticula
pruritic papulovesicles or rash that appears as:
Extremely itchy bumps or blisters appear on both sides of the body, most often on the forearms near the elbows, as well as on knees and buttocks, and along the hairline.
Dermatitis herpetiformis
