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NnD > Lower GI Tract > Flashcards

Lower GI Tract Flashcards

1
Q

Difference between malabsorption and maldigestion vs malassimilation

A

Defective mucosal uptake and transport of adequately digested nutrients vs impaired breakdown of nutrients(mainly in the small intestine), lumenal phase (eg pancreatic insufficiency).
Malassimilation refers to both

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2
Q

What is Zollinger- Elison syndrome

A

When tumours overproduce gastrin and therefore gastric acid, affecting functions of enzymes

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3
Q

What problems can affect fat solubilization

A

Decreased bile salts due to cholestasis or cirrhosis
Bile salt loss due to resection of ileum
Bile salt deconjugation due to bacterial overgrowth

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4
Q

What can affect Lumenal availability of nutrients and what nutrient in particular

A
  • Bacterial consumption of nutrients (bacterial overgrowth) ⇒ B12 deficiency
  • Decreased intrinsic factor (pernicious anaemia) ⇒ B12 deficiency
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5
Q

What are common causes of distruption of epithelial transport?

A

Damaged absorptive surface due to inflammatory diseases like coeliac’s or tropical sprue, Crohn’s. Or ischaemia
Infections like Giardia or SIBO
Lymphoma or amyloid infiltration

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6
Q

What is a post- mucosal cause of malabsorption

A

Problem with post-absorptive processing eg. lymphatic obstruction which affects fat transport. Neoplasms, TB and lymphangectasia are examples.

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7
Q

What are the clinical features of malabsorption

A
  • Diarrhoea and weight loss despite adequate intake
  • Bloating, tense abdomen, distention, cramps, borborygmi ⇒ Abnormal fermentation of nutrients by bacteria in colon
  • Lethargy, malaise
  • Symptoms often mild, non-specific
  • Malabsorption can be global, or specific nutrients
  • Malabsorption syndrome
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8
Q

What is malabsorption syndrome

A

steatorrhoea, distention, weight loss, oedema is a RARE presentation

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9
Q

What is a symptom of vascular insufficiency in gut

A

ntestinal angina
–Abdominal pain after a meal due to vascular insufficiency in gut ( which can also cause malabsorption)

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10
Q

What is one genetic disease that can cause malabsorption

A

Cystic fibrosis

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11
Q

What skin condition is associated with Coeliac’s

A

Dermatitis hepertiformis

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12
Q

What are the neurological symptoms of B12 deficiency

A
  • Peripheral neuropathy
  • Ataxia (posterior column) ⇒ Spinal cord damage
  • Psychosis, dementia
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13
Q

What does microcytosis in malabsorption suggest

A

iron deficiency (common in coeliac, otherwise suspect GI blood loss)

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14
Q

What does macrocytosis in malabsorption suggest

A

B12 and folate deficiency( due to malabsorption??), but also common in coeliac, alcohol

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15
Q

What does elevated ALP in malabsorption suggest

A

Signs of metabolic bone disease, due to Vit D malabsorption

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16
Q

What are the tests for the three most commonest causes of malabsorption

A
  • Tissue Transglutaminase (TTG) ⇒ Antibody test Coeliac disease
  • Faecal elastase ⇒ Enzyme measurement in stools for Pancreatic enzyme insufficiency
  • Glucose H2 breath test ⇒ SIBO
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17
Q

How to test for IBD

A

Faecal calprotectin

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18
Q

How to test for Bile acid malabsorption

A

7alpha-cholestenone or SeHCAT test ( for retention)

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19
Q

How to test for lactase deficiency

A

Lactose H2 breath test

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20
Q

causes of strictures in small bowel and what imaging is done for it

A

MRI ⇒ May find strictures which could be ischaemic, Crohn’s, Neoplastic, TB etc.

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21
Q

use of CT/ CT angiogram in lower GI

A

pancreatic disease, mesenteric ischaemia

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22
Q

What are causes of PEI

A

Chronic pancreatitis => alcohol is most common cause
May be autoimmune
Duct obstruction
Cystic fibrosis that causes thick sticky mucus that clogs the pancreatic ducts
SLE
Autoimmune pancreatitis
- Haemochromatosis ⇒ Rare- abnormal iron deposition in liver and pancreas
- Pancreatic resection ⇒ For cancer or pancreatitis
- Gastric resection ⇒ Can cause changes in acidity and impair enzyme function

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23
Q

Absorption of what nutrient gets affected first in PEI

A

fat

24
Q

Symptoms of PEI

A

Steatorrhea, weight loss, vitamin deficiency (A,D,E,K), also more `minor symptoms

25
Q

How to diagnose PEI

A
  • Pancreatic imaging (CT, MRI)
  • Tests of exocrine pancreatic function
  • Direct – eg Secretin stimulation tests ⇒ stimulates pancreatic secretions (sensitive but cumbersome)
  • Indirect
    • Faecal elastase is the most common ⇒ samples level of enzymes in stool . Not sensitive
    • Pancreolauryl (only reliably detect moderate to severe PEI)
26
Q

Treatment of PEI

A
  • Pancreatic enzyme replacement
  • Taken with meals and snacks
  • Gastric acid suppression since pancreatic enzymes require higher pH
  • Vitamin supplements
27
Q

Are bacteria in ileum and colon gram positive or negative

A

Mostly gram negative in ileum, +ve in colon

28
Q

What happens in SIBO

A

Bacteria from colon moves to SI and ferments food higher up in the gut

29
Q

What are the causes of bacterial overgrowth

A
  • Stasis
    • Strictures (crohn’s, TB)
    • Hypomotility ( old age, opiates, diabetes etc.)
  • Blind loops, Diverticulae (pockets in wall of small intestine)
  • Immunodeficiency ⇒ Cancer drugs, immunosuppresants eg. in Crohn’s
  • ?Obesity
30
Q

Gold standard of diagnosing SIBO and what is more commonly done in practice. What else can be done?

A

Aspiration of jejunal fluid and quantitative culture
Glucose/Hydrogen breath test more practical => Higher hydrogen in SIBO
Can use MRI to check for strictures

31
Q

Treatment for SIBO

A
  • Treatment with 2 weeks of antibiotics e.g. tetracycline(systemic), ciprofloxacin, rifaximin (non-absorbed ideally)
  • Often needs repeat treatment especially for blind loop or stagnant loop
32
Q

What can cause hypomotility in gut

A
  • Old age
  • Immune compromise
  • Opiate analgesics ⇒ slow transit of food through the gut
  • Diabetes
  • Systemic sclerosis
33
Q

How dose giardiasis cause malabsorption

A
  • Malabsorption due to multiple factors
    • Brush border damage
    • Reduction in absorptive surface
    • Bile acid utilization
    • Induction of hypermotility
    • Enterotoxin
34
Q

How to investigate/ diagnose giardiasis

A

Stool samples, but may need microscopy

35
Q

Treatment of choice for giardiasis

A

Metrionidazole

36
Q

Where are bile acids specifically absorbed in??

A

distal ileum

37
Q

What kind of diarrheoa does bile acid malabsorption cause

A

Secretory diarrhoea

38
Q

What causes BAM

A
  • Affected by (terminal) ileal disease, Crohn’s disease or resection of terminal ileum
  • Also impaired in post- cholecystectomy, rapid transit and other malabsorptive states
39
Q

What are the main types of BAM

A
  • Type 1 ⇒ Ileal disease or resection
  • Type 2 ⇒ Idiopathic
    • Secretory diarrhoea from bile acids in colon
  • Type 3 ⇒Assoc with cholecystectomy, rapid transit, coeliac, SIBO, chronic pancreatitis
    • Cholecystectomy ⇒ Bile is being delivered in constant trickle rather than bolus after a meal , results in wasting of bile salts⇒ may cause diarrhoea but may not be severe enough to cause lipid malabsorption
40
Q

Treatment for BAM

A
  • Cholestyramine
  • Colesevelam
41
Q

What is Whipple’s disease

A
  • Uncommon bacterial infection in older men
  • Caused by Tropheryma whippleii ( found in tropics)
42
Q

presentation of whipples

A
  • Presents with diarrhoea, arthritis, fever, cough, headache, muscle weakness
43
Q

Treatment of Whipple’s

A

Antibiotic therapy for months to years.

44
Q

What can IBS be due to

A
  • Over or underactivity of the gut
  • Brain- gut interaction
45
Q

what neurotransmitter is involved in communication between myenteric and submucosal plexus

A

5HT

46
Q

Common history and presentations of IBS

A

May have had gastroenteritis before start of symptoms
Abdominal symptoms, may be colicky pain post prandial, urgent need to move bowels with diarrhoea and mucus ( also post-prandial), but may have tenesmus and sense of incomplete evacuation.
ALternating diarrhoea and constipation
Bloating and discomfort, distention

47
Q

Rome IV criteria for IBS

A
  • Abdominal pain
    AND
  • 2 of:
    • Related to defaecation
    • Change in stool frequency
    • Change in stool form
  • Symptoms over 6/12, on average weekly for last 3/12
48
Q

What is the threshold for classification of IBS

A

25% of BM

49
Q

investigations in IBS

A

FBC, ESR,UnE,LFT,TFTetc.
ESR for markers of inflammation
TTG for coeliac
Stool for microscopy and culture
Faecal calprotectin maybe, for IBD
Abd ultrasound for gallstones

50
Q

Common associations in IBS

A

Migraine, dyspepsia, dyspareunia, bladder problems, fibromyalgia, chronic fatigue

51
Q

When is diarrhea more likely for IBS

A

Morning, if nocturnal may need to exclude other causes

52
Q

Red flag symptoms for IBS

A
  • Weight loss
  • Rectal bleeding,
  • Anaemia, thrombocytosis
  • Persistent diarrhoea (lack of day-day variability)
  • New onset over 50 yrs
  • Frequent nocturnal symptoms
  • FHx bowel cancer/IBD
53
Q

Management of IBS

A

Lifestyle - Dietary, low FODMAP, restrict lactose and gluten
drug therapy
Drug- based on symptoms
Psychological - CBT, hypnotherapy

54
Q

Drug management of IBS

A

Antispasmodic- peppermint oile, TCA very useful for pain ( amitriptyline), loperamide useful for diarrhoea, ispaghula cor constipation, macrogol also as a laxative

55
Q

What arteries supply transverse colon

A

SMA and IMA, anatomical variations

56
Q

Consequences of SIBO

A
  • Vitamin B12 malabsorption
  • Bile acid deconjugation ⇒ Relative bile salt deficiency, affects fat absorption
  • Intraluminal protein utilization
  • Brush border damage
  • Ulceration of mucosa ⇒ inflammatory
  • Bowel dysmotility
57
Q

What type of mucosa exists in the rectum

A

Squamous, instead of columnar

NnD (10 decks)

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