Malabsorption syndrome and Coeliac disease

Question 1

Define malabsorption

Answer 1

Failure of GI tract to absorb one or more nutrients causing weight loss or nutritional deficiencies

Question 2

List 4 key clinical features of malabsorption

Answer 2

1. Abdominal bloating
2. Crampy abdominal pain
3. Diarrhoea
4. Steatorrhoea
5. Weight loss

Question 3

List 3 conditions affecting digestion which cause malabsorption

Answer 3

1. Exocrine pancreatic insufficiency
2. Disaccharidase deficiency
3. Lactose intolerance

Question 4

List 3 conditions causing pancreatic insufficiency

Answer 4

1. Chronic pancreatitis
2. Pancreatic cancer
3. Cystic fibrosis

Question 5

Treatment of pancreatic insufficiency?

Answer 5

Pancreatin - Creon

Question 6

Lactase breaks down lactose into ______ and ______

What is the pathology of lactose intolerance?

Answer 6

Glucose and galactose

Deficiency in Lactase enzymes means lactose gets fermented by normal gut bacteria into gases (H2) - hence symptoms of bloating

Question 7

Treatment of lactose intolerance

Answer 7

Dietary modifications: lactose free

Question 8

List 4 conditions affecting absorption which cause malabsorption

Answer 8

1. Cholecystectomy
2. Crohn’s
3. Amyloidosis
4. Bile acid malabsorption
5. Coeliac disease

Question 9

List 4 infective causes affecting absorption which cause malabsorption

Answer 9

1. Parasites: Giardiasis, worm infestation
2. Tropical sprue
3. Cholera
4. Gastroenteritis: salmonella
5. Small Intestine Bacterial Overgrowth (SIBO)
6. C difficile
7. Ileocolonic TB
8. Whipple’s ds

Question 10

What is Tropical sprue?

How do we treat it?

Answer 10

Rare GI disease resulting in malabsorption (unknown cause)

More prevalent in tropical countries so must ask about ‘travel history’

Treat with Antibiotics eg. tetracycline (check?)

Question 11

List 3 risk factors for SIBO

Answer 11

poor gut motility due to

1. strong pain killers
2. elderly patients
3. post surgical patients

Question 12

What bacteria causes Whipple’s disease?

List 3 key clinical features of this condition

Answer 12

Tropheryma whipplei (+)

1. Malabsorption: diarrhoea, weight loss
2. Large-joint arthralgia
3. Lymphadenopathy

Question 13

What would a jejunal biopsy of Whipple’s disease show?

Answer 13

Foamy macrophages containing Periodic acid-Schiff (PAS) granules

Question 14

List 4 Systemic diseases affecting GI tract which can cause malabsorption

Answer 14

1. Diabetes
2. Thyroid disorders (hyperthyroidism)
3. Zollinger Ellison syndrome
4. Carcinoid syndrome
5. Cancer related: chemotherapy, advanced malignancies

Question 15

How does Diabetes lead to Malabsorption?

Answer 15

1. Autonomic neuropathy can cause diarrhea
2. Metformin can cause diarrhea

Question 16

What is Zollinger Ellison syndrome and how does it lead to malabsorption?

Answer 16

Gastrin secreting tumour of the pancreas

Excess gastrin → excess HCl → ulceration of mucosa → malabsorption

Question 17

a) What is a Carcinoid tumour?
b) What is Carcinoid syndrome?

Answer 17

a) Tumours of enterchromaffin cells, producing serotonin
b) Group of symptoms (i.e. diaerhoea, SOB, flushing, abdo pain) due to hepatic involvement of carcinoid tumour

CHECK

Question 18

How does Carcinoid syndrome lead to malabsorption?

Answer 18

Increased serotonin → increases peristalsis → less time for fluid absorption

Question 19

Why does chemotherapy cause malabsorption?

Answer 19

Chemotherapy aims to reduce rate of rapidly diving cells

Villi in small bowel have a very high cell turnover rate, hence are affected signifcantly by chemotherapy

Question 20

What LFT finding may be indicative of malnutrition?

Why?

Answer 20

Low Albumin due to deficient protein intakec(required for albumin synthesis

Question 21

Raised faecal calprotectin aids in diagnosis of what?

Answer 21

IBD

Question 22

Raised fecal elastase is indicative of what?

Answer 22

Pancreatic insufficiency

Question 23

What is Urinary 5- HIAA and what condition does it aid diagnosis of?

Answer 23

Main metabolite of serotonin

Aids diagnosis of carcinoid tumors

Question 24

What is the D-xylose absorption test?

Answer 24

Aid diagnosis of conditions related to mucosal defects in the small intestine, presenting with malabsorption

D-xylose is a sugar that is absorbed across the intestinal mucosa. Test involveds administering and measuring amount in urine or blood

Low levels = abnormality of the mucosa

Question 25

What is the SeHCAT test used for?

Answer 25

Test for bile acid malbsorption

Question 26

List 3 supportive measures for malabsorption

Answer 26

1. IV fluids – replace electrolytes 2. Nutritional support to treat deficiencies 3. In-patient treatment required for severe malabsorption

Question 27

What is coeliac disease?

Answer 27

Autoimmune condition where exposure to gluten causes a T cell-mediated rxn resulting in inflammation of the small intestine

Question 28

List 3 important associations of coeliac disease?

Answer 28

1. Positive family history 2. HLA-DQ2 allele 3. Other autoimmune disease

Question 29

Which part of the GIT is most affected by coeliacs disease?

Answer 29

Jejunum

Question 30

List 4 GI symptoms of Coeliacs disease

Answer 30

1. Abdominal pain and cramping 2. Distension, excessive flatus 3. Nausea and vomiting 4. Diarrhoea and constipation 5. Steatorrhoea ## Footnote Note: it is often asymptomatic, so low threshold for testing required

Question 31

What is the dermatological manifestation of coeliacs disease? Describe it

Answer 31

**Dermatitis herpetiformis** - pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk

Question 32

List 4 systemic symptoms of Coeliac disease

Answer 32

1. Fatigue 2. Weight loss or failure to thrive in children 3. Pallor (secondary to anaemia) 4. Bruising (Vit K deficiency secondary to malabsoption)

Question 33

List 4 complications of coeliacs disease

Answer 33

1. Anaemia (Iron, B12, folate deficiency) and other Vitamin deficiencies 2. Osteoporosis 3. Increased risk lymphoma (NHL) and small bowel cancer 4. Increased risks of other autoimmune diseases 5. Infertility

Question 34

What is essential to do when undergoing testing for Coeliacs?

Answer 34

It is ESSENTIAL that patients eat a gluten containing diet while undergoing testing to avoid false negatives

Question 35

How is a diagnosis of Coeliacs disease made? Highlight the gold standard

Answer 35

1. Total IgA levels to exclude IgA deficiency 2. Check for coeliac disease-specific antibodies: Anti- TTG asnd EMA 3. OGD and duodenal/jejunal biopsy ☆ 'Marsh classification'

Question 36

List 3 antibodies raised in coeliacs disease? (serology)

Answer 36

1. Anti-tissue transglutaminase (anti-TTG) 2. Serum and total IgA 2. Anti-endomysial (anti-EMA)

Question 37

What 3 findings are seen on endoscopy and intestinal biopsy in coeliacs disease?

Answer 37

1. Sub-total Villous atrophy 2. Crypt Hyperplasia 3. Intra-epithelial Lymphocytes

Question 38

Management of Coeliacs disease

Answer 38

Lifelong gluten-free diet are curative

Question 39

How can we measure disease progression of Coeliacs

Answer 39

Checking coeliac antibodies

Question 40

What is recommended by the BSG for maintaining and monitoring bone health in adults with coeliac disease?

Answer 40

1. At least 1000mg calcium/day. 2. DEXA scan on diagnosis to assess BMD 3. Weight bearing activity, avoiding smoking and ensuring adequate vit D

Question 41

Why are patients with coeliacs at an increased risk of BMD

Answer 41

1. Late or delayed diagnosis 2. Chronic malabsorption of calcium prior to diagnosis 3. ↓ intake of calcium post diagnosis (bread and cereal foods) 4. Lapses in the gluten free diet 5. Persistent villus atrophy 6. Lactose intolerance 7. Low BMI

Question 42

What is Non-coeliac gluten sensitivity (NCGS)?

Answer 42

Represents a large patient group who get symptoms upon eating gluten despite negative serological tests and duodenal biopsy ## Footnote No specific diagnostic test available, do FODMAPs to check if other components are to blame or if it placebo effect