٢ Flashcards
(21 cards)
Diarrhea+ nystagmus + polyarthritis+ pas positive foamy macrophage + negative acid fast + weight loss
*Diagnosis… Whipple disease
*Other cause of Pas positive..
MAC
*Treatment… اسبوعين…سنتين
Ceftriaxone 2gm iv /24 hours for 2 weeks then sulpha -trimethoprim DS twice /day for 1-2 years
Mnemonics of whipple disease
Weight loss
Hyperpigmentation
Infection by trophyrema whipplei
PAS macrophage positive, positive sudan stain
Polyarthritis
Lymphadenopathy
Eye,,, nystagmus (oculomasticatory myorrhetmia
Diarrhea+ pas positive+ acid fast positive
MAC
Young age+diarrhea+ataxia+ lipid containing vaccules in enerocytes of small bowel biopsy
Diagnosis.. Abetalipoproteinemia
Treatment
-High fiber diet and low fat
- lipid soluble vitamins supplement especially vit E
Diarrhea
+
Stool electrolyte Na 15
K 30
Stool Ph 5
Lactose intolerance
عرفت ازاي
Fecal osmotic gap =90 -2(na +k)
If less than 50= secretory diarrhea
If more than 50 or 100= osmotic diarrhea في مية كتير يعني
ساعتها شوف ph stool
If >5 = lactose intolerance
If «5 = non carbohydrate ingested osmoles as lacteluse
Diarrhea+heart failure+ focal white spots (lacteals) in small intestine
Intestinal lymphangiectasia
Diarrhea+ Increase Mcv+ decrease b12 + increase folate
SIBO
Chrons then developed diarrhea +increase folate
SIBO
Treatment of SIBO
Treatment:
1- Treat underlying etiologies.
x2-Diet: high fat, low carbohydrate, and low fiber diet. Avoid sorbitol and artificial sweeteners.
3- If SIBO is considered based on symptoms and risk factors, and if diagnostic tests are not available, it is
reasonable to give a treatment trial for 7-10 days. Antibiotic choices include:
Amoxicillin-clavulanic acid 625mg13
Doxycycline 100 mg 12., metronidazole 250-mg 13, ciprofloxacin 500 mg 12., trimethoprim-
sulfamethoxazole 160/800 mg 12
Rifaximin 550 mg 13 t is the safest due to its low intestinal absorption, but it is significantly
more expensive than other antibiotics
Probiotics have not been found to consistently improve SIBO and are not recommended.
Recurrence after treatment is common.
o Patients can be given repeated courses of antibiotics as needed for symptom control.
o Change the antibiotic type to decrease the rate of bacterial resistance.
Diagnosis of SIBO
1-Gold standard: proximal jejunal aspirate of ≥ 103
colony forming units/mL.
2- Hydrogen breath test
General concept: anaerobic bacteria ferment a test substrat
producing hydrogen that is detected in breath samples.
The test is abnormal if there is a rise in hydrogen concentration: (PPM: parts per million)
o > 20 PPM within 2 hours after ingestion of lactulose.
o > 12 PPM within 3 hours after ingestion of glucose.
3-c14 breath test
4- increase mcv
With decrease b12 and increase folate
What is SIBO
an increase in the number or change in the type
of bacteria in the small intestine resulting in symptoms of excessive gas formation and malabsorption.
most common bacteria types causing SIBO is gram negative organisms,enterococci and anerobes
Causes of SIBO
1-Motility disorders..DM, scleroderma
2-Structural abnormalities…
- surgery as short bowel syndrome
- chrons disease complications as fistula or strictures
-diverticuosis
3- hypocholohyrda or achlorohydra
4- hypo or agammaglobulinemia
تاريخية….
عيان عنده Crohn’s وعمل عملية وشال 50سم من terminal ileum
What happened? How to treat?
لو شال اقل من 100سم يبقي لسا في فرصة bile salt يحصل لها reabsorption بس هنا هيحصل بصورة اكبر عشان طول القولون قل وده هيعمل secretory diarrhea
Treatment…cholestyamine
تاريخية….
عيان عنده Crohn’s وعمل عملية وشال
120 سم من terminal ileum
What happened? How to treat?
لو اتشال اكتر من 100 سم من القولون يبقي مش هيحصل bile salts reabsorption وكمان هيحصل fat malabsorption
Treatment ..medium chain triglycerides
What is short bowel syndrome
Short bowel syndrome (SBS) is defined as malabsorption and intestinal failure resulting from the decrease in the normal intestinal length (or surface area) to < 30%, or 200 cm in adults.
x The presence of the colon partially compensates for malabsorption by increasing its absorption of water
and electrolytes.
Causes of short bowel syndrome
1-post operative,,Io-volvoulus- strangulated bowel
2- mesenteric vascular thrombosis,,Sma ,smv occlusion
3- chrons disease
4-Radiation enteritis
جزء من الأمعاء زي قلته
Treatment of short bowel syndrome
1- Diet: encourage hyperphagia. Give elemental and low-fat diet. Add medium chain fatty acids.
2-Parenteral IVF and TPN.
امتي؟
3-Micronutrient, vitamin, and mineral supplementation.
4- pharmacological
*Loperamide (2-4 mg every 8 hours).
o Octreotide (50-100 mcg subq or IV b.i.d. or t.i.d.).
o PPIs are given to inhibit excess gastric secretion.
*Medications to enhance bowel adaptation (trophic agents)
Somatropin (Zorbtive®) is recombinant growth hormone that is FDA approved for treatment of SBS.
Teduglutide had FDA approved for the treatment of SBS.
o Teduglutide is a long acting GLP-2 analogue given s.c to improves intestinal adaptation and proliferation.
5- Intestinal transplantation
SBS is the most common indication for intestinal transplant.
The 1-year patient survival after intestinal transplant is 90%
امتي تفكر تعمل TPN لعيان عنده short bowel syndrome
1-Small bowel length < 50-100 cm.
2- Low plasma citrullin levels. Citrullin is an amino acid produced by enterocytes.
3-Absence of ileocecal valve.
4-Absence of an intact and functional colon.
x5-Residual small bowel mucosal disease.
A 46 year old woman with scleroderma presents with frequent watery diarrhea, bloating
and weight loss. Colonoscopy is normal with no abnormality found on biopsy histology.
Coeliac serology is negative, thyroid function normal and stool culture negative. Bacterial
overgrowth is suspected.
A-What would you expect to see on blood analysis to support this diagnosis?
Low albumin
Increase mcv
High folate
B-What is your treatment advice?
Doxycycline 100mg 12
Rifaximin 550mg 13
Amox/clav 625 mg 1*2
Diet rich in fibers
