exocrine pancreatic insufficiency Flashcards
exocrine pancreatic insufficiency
-pancreas is not making EXOcrine enzymes
-common in aging -> cysts, fatty replacement**
-Common Causes: chronic pancreatitis; gastric, pancreatic, or small bowel resection; cystic fibrosis; duct obstruction, fatty replacement
-Symptoms: bloating, diarrhea
-Signs: none or weight loss, anemia
-Lab findings: none or iron deficiency, vitamin A, D, E or K deficiency
-DDX: celiac, lactose intol, SIBO, Giardia**
-Dx: Fecal elastase stool specimen (make sure not falsely diluted with urine)
-if + ->
-Imaging-MRI or CT: fatty replacement/atrophy of pancreas; calcifications, ductal dilatation, enlargement of the pancreas, or peripancreatic fluid collections
-Treatment: Pancreatic enzymes -> dosed based on lipase dose
pancreas
-endocrine and exocrine organ
-insulin, amylase, lipase, protease
bacterial overgrowth
-Small intestine: a small number of bacteria should be
-Bacterial overgrowth in small intestine-> malabsorption:
-Bacterial deconjugation of bile salts
-Bacteria directly damage epithelial cells and brush border
-Microbial uptake of specific nutrients
-colon bacteria goes to small bowel or stomach
Causes of Bacterial Overgrowth
-Gastric achlorhydria- high pH in stomach -> bacteria overgrowth
-Anatomic abnormalities of the small intestine with stagnation - ileocecal valve abnormalities, small intestine diverticulum (things suck and bacteria)
-Afferent limb of Billroth II, resection of ileocecal valve, small intestine diverticula, obstruction, blind loop
-Small intestine motility disorders - slow movements -> bacteria grow, Scleroderma, diabetic enteropathy
-Gastrocolic or coloenteric fistula- Crohn’s disease, malignancy, surgical resection
-Miscellaneous disorders - AIDS, chronic pancreatitis
clinical findings in Bacterial Overgrowth
-Many patients asymptomatic
-Bloating, gas, abdominal pain, diarrhea
-Severe overgrowth: malabsorption symptoms and signs (RARE):
-Distention, weight loss, and steatorrhea
-Watery diarrhea is common
-Megaloblastic anemia or neurologic signs
-Testing: *Noninvasive breath tests (hydrogen, methane or both) vs empiric tx with nonabsorbable antibiotic 2 weeks 3x day
treatment for bacterial overgrowth***
-Correct the anatomic defect
-Nonabsorbable antibiotic- Rifaximin 500 mg three times daily x 14 days
-Cyclic therapy may be used for pts with scleroderma
-maintain on Probiotics
short bowel syndrome
-Malabsorptive condition that arises secondary to removal of significant segments of the small intestine.
-Most common causes in adults:
-Crohn’s disease
-Mesenteric infarction
-Radiation enteritis
-Volvulus- bowel is twisted on itself
-Tumor resection
-Trauma
primary lactase deficiency
-Lactase is a brush border enzyme- hydrolyzes the disaccharide lactose (milk sugar) into glucose and galactose (simple sugars that can be absorbed)
-lactose cannot be absorbed in whole form -> if its not broken down it draws fluid into bowel
-The concentration of lactase enzyme levels is high at birth
-Declines steadily in most people of non-European ancestry
-Degree is genetically determined
secondary lactase deficiency
-disease that washes away the lactase enzyme on the brush border
-it can be produced though -> once bowel heals it will come back
-Crohn’s disease
-Celiac ds
-Gastroenteritis
-Short bowel syndrome
-Malabsorbed lactose is fermented by intestinal bacteria, producing gas and organic acids- Increased stool osmotic load and fluid loss
-osmotic diarrhea
lactase deficiency S&S
-Great variability in clinical symptoms
-Severity of deficiency
-Amount ingested
-Symptoms:
-Bloating, abdominal cramps, and flatulence
-Osmotic diarrhea will result with higher lactose intake
lactase deficiency diff dx
Inflammatory bowel disease, mucosal malabsorptive disorders, irritable bowel syndrome, and pancreatic insufficiency
-secondary to other gi disorders!
-treat underlying
lactase deficiency dx and tx
-Diagnosis:
-Hydrogen breath test- ingest lactose -> blow -> hydrogen produced by bacteria that digests lactose -> differentiate primary and secondary
-Blood test- many sticks :(
-Bx
-Empiric trial- lactaid pills
-Treatment:
-Lactaid pills
-should never avoid dairy
-pts find their own dairy threshold
-Patient comfort is the goal
-Calcium and vitamin D supplement
tumors of small bowel
-Benign and malignant tumors-rare
-Often incidental finding and no symptoms/signs
-May cause acute or chronic gi bleed
-May cause obstruction
-act like a lead Intussusception- can cause telescoping bowel fold on itself
-Usually ID CT Scan or Small Bowel Series- Require bx
-Most are single
-Multiple polyps suggestive of hereditary polyposis syndrome
-With the exception of lipomas, surgical or endoscopic excision!
benign tumors of small bowel
-Adenomatous polyps-most common: can turn into cancer so must be removed
-Majority asymptomatic +/- bleeding
Endoscopic or surgical resection warranted
-act like a lead Intussusception- telescoping, ulcer
-Lipomas occur commonly in ileum:
Most asymptomatic, incidental finding
Rarely obstruction with intussusception
-lipoma common on iliocecal valve- bx
gastrointestinal stromal tumors
-GST tumors
-Begin within the autonomic system of the GI tract so can be anywhere
-Stomach MC, Small bowel 2nd
-Most are asymptomatic but can ulcerate and cause acute or chronic bleeding or obstruction (acts like a lead)
-Benign stromal tumors:
-Submucosal, fibroid like
-soft tissue tumors
-Intraluminal, intramural, or extraluminal
-Malignant stromal tumors:
-1% of GI tumors
-Type of soft tissue sarcoma
