Small intestine disease and malabsorption (not including coeliac disease) Flashcards
What are symptoms of GI malabsorption?
- Diarrhoea
- Weight loss
- Lethargy
- Steatorrhoea
- Bloating
What signs are common in GI malabsorption disorders?
Signs of deficiencies
- Anaemia
- Bleeding disorders
- Oedema - protein deficeincy
- Pathological fractures
- Neurological features - neuropathy
What are disorders of the small intestine which can cause malabsorption?
- Coeliac disease/dematitis herpatiformis
- Tropical sprue
- BActerial overgrowth
- Intestinal resection
- Whipple’s Disease
- Radiation enteropathy
- Parasitic infestation
What investigaitons would you consider doing in someone who was displaying features of GI malabsorption?
- Bloods - FBC, Ca2+, Iron Studies, B12 + folate, INR, Lipid profile, Coeliac screen
- Imaging - Endoscopy + SB biopsy
- Other - Stool culture, Hydrogen breath test
What is tropical sprue?
A condition presenting with chronic diarrhoea and malabsorption that occurs in residents or visitors to affected tropical areas.
The term is reserved for severe malabsorption (2 or more substances) accompanied by diarrhoea and malnutrition
What is the cause of tropical sprue?
Unknown aetiology - likely to be infective
How would you approach investigating someone with suspected tropical sprue?
Investigations as for malabsorption (bloods, endoscopy etc.) - exclude infectious causes of diarrhoea
How would you manage someone with tropical sprue?
- Remove from spure area
- Consider Folic acid/B12
- Consider Abx
What is bacterial overgrowth?
A disorder of excessive bacterial growth in the small intestine. Unlike the colon (or large bowel), which is rich with bacteria, the small bowel usually has fewer than 10,000 organisms per millilitre
What are the main features of bacterial overgrowth?
- Diarrhoea/steatorrhoea
- Features of B12 deficiency
What investigation is used to confirm bacterial overgrowth?
Hydrogen breath test
What is involved in the hydrogen breath test?
- Mouth rinsed out with an antiseptic mouthwash beforehand.
- Take samples of end-expired air before giving lactulose
- Appearance of a breath hydrogen peak after oral lactulose is used to estimate mouth to caecum transit time
- An earlier rise in the breath hydrogen after lactulose indicates bacterial breakdown in the small intestine.
What result on hydrogen breath test indicates bacterial overgrowth?
Early increase in exhaled hydrogen = overgrowth
How would you manage someone wit bacterial overgrowth?
- Treat cause - e.g. resect stricture
- Consider rotatiing course of Abx
What can happen if too much small bowel is resected?
Small bowel syndrome
What nutrient abnormalities occur in ileal resection?
B12
What problems can occur in ileal resection?
- Bile-salt induced diarrhoea
- Steatorrhoea
- Gallstone
- Urinary stones formation
- B12 deficiency
What is short-bowel syndrome?
Intestinal failure resulting from obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance
What is the major problem that can occur if small bowel is resected and a terminal small bowel stoma is put in place?
Sodium and fluid depletion - majority of patients with ≤100 cm of jejunum remaining will require parenteral supplements of fluid and electrolytes, often with nutrients.
What do those with shortened small intestine with terminal small bowel stoma need to manage sodium and fluid losses?
- Increased salt intake
- Restriction of hypotonic fluids between meals
- Oral glucose-electrolyte mixture
What is Whipple’s Disease?
A rare infection caused by trophyeryma whipplei
What organism is implicated in Whipples disease?
Tropheryma Whipplei
How can those with Whipples disease present?
Starts insidiously
- Arthralgia - chronic, migratory, seroneagative
- Colicky abdominal pain
- Weight loss
- Diarrhoea/Steatorrhoea
- Chronic cough
- Fever/sweats
- Lymphadenopathy
- Skin hyperpigmentation
- Neurological features - reversible dementia, opthalmoplegia, facial myoclonus
What neuological features can present in whipples disease?
- Reversible dementia
- Opthalmoplegia
- Facial myoclonus
- Hypothalamic syndrome - hyperphagia, polydipsia, insomnia
What are systemic features of whipples disease?
- Fever
- Arthralgia
- Chornic cough
- Sweats
- Lymphadenopathy
- Skin hyperpigmentation
What investigations would you perform if you suspected whipples disease?
- Tests for malabsorption
- Jejunal biopsy - Stunted villi + macrophage deposition in lamina propria + positive periodic acid-Schiff stain
What can be present in whipples disease on biopsy?
- Positive Periodic acid-Schiff stain macrophages
- Trilaminar cell wall of T. Whipplei
What might you use to confirm whipples disease following biopsy?
PCR of bacterial RNA
How would you manage whipples disease?
ABx which crosses BB barrier
- IV ceftriaxone - 2 weeks
- Oral co-trimoxazole - 1 year
What is giardiasis?
Small intestinal disease which is caused by giardia lamblia
How is giardiasis spread?
Faecal-oral spread - water food/fomites
How does giardiasis present?
Asymptomatic in most, but can have:
- Diarrhoea
- Flatulence
- Bloating
- Pain
- Malabsorption
How long does it take for symptoms to develop in giardiasis?
1-3 weeks
How long does it take to symptoms to pass in giardiasis?
2-6 weeks
How would you diagnose giardiasis?
- Stool microscopy - cysts and trophozoites
- Faecal immunoassay
- PCR
- Duodenal aspirate - from biopsy
Would a negative stool sample in someone with suspected giardiasis exclude it as a diagnosis?
No - Intermittent shedding means it is excreted at irregular intervals
How would you manage someone wtih giardiasis?
- Improve hygeine
- Oral Metranidazole - 2g dose three days in a row
What can occur as a result of giardia infestation?
Lactose-intolerance
What is regarded as the gold standard for confirmation of bacterial overgrowth?
Culture of small intestinal fluid
What must you advise someone getting a hydrogen breath test to stop doing before the test is done?
Smoking
