malabsorption 2 W7

Question 2

risk factors for malabsorption

Answer 2

surgery, radiotherapy
autoimmunity, DM
medications, alcohol
travel history

Question 3

management of malabsorption?

Answer 3

nutritional support - introduce in measured way to mitigate risk of refeeding syndrome

Question 4

coeliac disease definition?

Answer 4

chronic autoimmune-mediated gluten-sensitive enteropathy

Question 5

what is coeliac disease caused by

Answer 5

exposure to cereal prolamins in genetically susceptible individuals:
-wheat
-rye
-barley

Question 6

presentation of coeliac disease - GI?

Answer 6

chronic or intermittent diarrhoea, bloating, weight loss, fatigue, failure to thrive, lactose intolerance
any unexplained persistent GI symptoms
‘coeliac crisis’

Question 7

presentation of coeliac disease - extra-GI?

Answer 7

signs of specific micronutrient deficiencies
neuro symptoms, particularly ataxia
dermatitis herpetiformis
raised liver enzymes
subfertility
metabolic bone disease

Question 8

diagnosis of coeliac disease?

Answer 8

requires ongoing gluten exposure
serology - TTG IgA most widely used
endoscopy, duodenal biopsies

Question 9

what is the most common nutrient deficiency in coeliac disease

Answer 9

iron deficiency

Question 10

when isn’t a colonoscopy required for Coeliac disease diagnosis?

Answer 10

TGA IgA > 50 and symptoms leads to no biopsy diagnosis of Coeliac disease

Question 11

management of coeliac disease?

Answer 11

gluten free diet (lifelong, GF products can be prescribed, adherence is an issue)

annual review (dietary compliance, weight and symptoms, bone health, vaccination status, bloods)

Question 12

what is non-responsive coeliac disease?

Answer 12

ongoing symptoms 12 months after GFD implemented

Question 13

what to do for non-responsive coeliac disease?

Answer 13

rule out other possibilities - slow responder? non-compliance?

is this an associated condition, mimic or refractory coeliac disease?
-repeat OGD and duodenal biopsies - is there atrophy?

Question 14

non-responsible coeliac disease repeat biopsy - results with atrophy could be caused by?

Answer 14

coeliac histological mimics
inadvertent gluten contamination
slow healing
‘supersensitivity’
refractory coeliac sprue (RCD1 and 2)

Question 15

non-responsible coeliac disease repeat biopsy - results with no atrophy could be caused by?

Answer 15

SIBO
microscopic colitis
lactose intolerance
IBD
thyroid disease
DM
PEI
BAM
infection
IBS

Question 16

what is non-responsive coeliac disease if no explanation is found?

Answer 16

refractory coeliac disease (bad news!!)

Question 17

refractory coeliac disease type 1?

Answer 17

normal IEL phenotype. treat with tight diet and steroids (budesonide). good 5yr survival

Question 18

refractory coeliac disease type 2?

Answer 18

aberrant and/or clonal IEL cell lines
can progress to malignancy
treat with aggressive immune suppression (steroids)
poor 5yr survival

Question 19

what malignancies can RCD progress to

Answer 19

enteropathy-associated T cell lymphoma
non-Hodgkin’s lymphoma
small bowel adenocarcinoma

Question 20

infectious enteropathies?

Answer 20

tropical sprue
Whipple’s disease
giardiasis
HIV/TB enteropathy

Question 21

other enteropathies?

Answer 21

drug-induced enteropathy
autoimmune enteropathy
radiation enteropathy
Crohn’s disease

Question 22

tropical sprue features?

Answer 22

recent prolonged travel or living in endemic area.
very rare
presents with malabsorption syndrome (may or may not follow traveller’s diarrhoea. whole small bowel affected. weight loss and folate/B12 deficiency common)
diagnosis - D2 Bx showing villous atrophy, lymphocytic infiltrate. travel history and negative screen for other causes.
antibiotics 3-6 months

Question 23

Whipple’s disease features?

Answer 23

affects middle aged men, farmers.
malabsorption syndrome, GI bleeding, migratory arthritis, sacroiliitis, pericarditis/endocarditis, confusion, ataxia, extrapyramidal signs. endoscopy - yellow, dotty. treat with antibiotics

Question 24

giardiasis features?

Answer 24

flagellated protozoan infection
malabsorption
stool microscopy, stool antigen ELISA.
D2 Bx showing loss of brush border, villous shortening, trophozoites.
treat with metronidazole

Question 25

drug induced enteropathy caused by which drugs? how is it resolved?

Answer 25

caused by NSAIDs, olmesartan, MMR, methotrexate resolved with drug withdrawal

Question 26

autoimmune enteropathy features?

Answer 26

rare villous atrophy, deep crypt lymphocytosis, minimal intra-epithelial lymphocytosis treat with systemic steroids, nutrition support

Question 27

radiation enteropathy features?

Answer 27

dysmotility, villous atrophy, telangiectasia, strictures, SIBO treatment - treat coexisting SIBO. low fat, high protein, MCT diet. enteral +/- parenteral support.

Question 28

Crohn's disease features?

Answer 28

malabsorption mediated by mucosal disease, fistulae, surgical resection. treatment - treat inflammation, treat coexisting SIBO, nutrition support, surgery.

Question 29

SIBO stands for what?

Answer 29

small intestinal bacterial overgrowth

Question 30

SIBO definitions?

Answer 30

normally 10^3 bacteria/ml present in small bowel colon has up to 10^12 bacteria/ml mostly gram negative aerobic bacteria in ileum, and gram positive anaerobes in colon. in SIBO this balance is lost.

Question 31

SIBO presentation?

Answer 31

risk factors maldigestion, bloating, diarrhoea B12 deficiency common (folate normal/high)

Question 32

aetiology of SIBO?

Answer 32

loss of protective mechanisms stasis: -blind loop/post-UGI surgery -stricture -diverticulum -dysmotility (opioids, diabetes, systemic sclerosis, parkinson's) systemic immunodeficiency local mucosal disease (coeliac, crohns, NSAIDs etc) PPI PEI

Question 33

diagnosis of SIBO?

Answer 33

>10^3/mL quantitative culture of jejunal fluid (gold standard) more practical - glucose/hydrogen breath test (rise of >20ppm hydrogen from baseline considered +ve) consider radiology for anatomical abnormalities and testing for risk factors or secondary causes

Question 34

treatment of SIBO?

Answer 34

rifaxamin 550mg TDS for 10-14 days

Question 35

pancreatic exocrine insufficiency definition

Answer 35

insufficient secretion or function of pancreatic enzymes or sodium bicarbonate for normal digestion

Question 36

pancreatic exocrine insufficiency aetiology

Answer 36

results from impaired production or drainage of pancreatic enzymes, reduced entero-hormonal stimulation of the exocrine pancreas, or asynchronous digestion due to dysmotility or abnormal anatomy.

Question 37

pancreatic exocrine insufficiency - associated conditions?

Answer 37

Chronic pancreatitis (21-94%) Pancreatic cancer, (20-92%) Cystic fibrosis (85%) Pancreatic resection (11-100%) Acute pancreatitis (30% at 6 months) Untreated coeliac (11%) Refractory coeliac (30%) HIV on ARVs (32%), Type 1 Diabetes (38%) Type 2 Diabetes (10-28%) UGI surgery (9-31%) Alcohol Smoking

Question 38

pancreatic exocrine insufficiency - making the diagnosis?

Answer 38

history - diarrhoea, abdominal pain, bloating, weight loss FE1 nutritional blood tests pancreatic imaging

Question 39

management of pancreatic exocrine insufficiency?

Answer 39

pancreatic enzyme replacement therapy (PERT) refer to dietician smoking and alcohol cessation