Flashcards in Small Bowel and Appendix Deck (43):
1
Tumors of the appendix
About 1/2= carcinoid (neuroendocrine tumor), mets to liver can produce serotonin syndrome (episodic flushing, diarrhea, wheezing and right sided valvular heart disease)
-Mets rare if tumor pseudomyxoma peritonei charac by diffuse collections of gelatinous material thru the abdomen
2
Appendicitis
-mid abdominal pain that migrates to the RLQ
-Nausea and vomiting -High fever, WBC count and severe pain suggest perforation.
-IV fluids, IV antibiotics and surgical resection are the treatment.
3
Plicae circulares
more in prox jejunum, absent terminal ileum
(ileum empties into cecum of LI)
4
absorption and transport of fluids
9L secreted/ingested
8.9 L absorbed
100 ml excreted
5
Malabsorption/maldigestion
-inadequate absorp of nutrients
-Clinical signs: weight loss, diarrhea, steatorrhea, vitamin deficiencies
-Pale, bulky, malodorous stool: float, hard to flush, oily residue
6
Causes of malabsorption
Surgery:
-gastric bypass
-small bowel resection
Bacterial overgrowth
Meds:
cholestyramine-ADEK
phenytoin, folate
Pancreatic insufficiency
Liver disease
Intestinal inflammation/villous flattening (celiac sprue, Whipple's disease, tropical sprue)
Ulceration
Ischemia
Infiltration (amyloidosis)
7
What test might you use to dx fat malabsorption?
Sudan fat stain
8
Pancreatic insufficiency
90% burned out
Lipid (first) then protein then rarely carb malabsorption
-chronic pancreatitis
-CF
9
Liver disease
bile needed for absorption of lipids
-Cirrhosis (decreased func of hepatocytes, decreased bile formation)
-Biliary obstruction
10
Gastric Bypass
B-II, Roux-en Y
inadequate mixing of food with biliary and pancreatic secretions
11
Gastric Bypass Vitamin Deficiencies
B12, Fe, Ca, Vit D deficiencies are the most common
-Vit C, Cu rare
Prevention: multivitamin
Monitoring recommended
12
Small Bowel Bacterial Overgrowth
Normal:
13
Vitamin levels with bacterial overgrowth and
Dx
fat soluble vitamins and B12 deficiency (bacteria deconjugate bile salts, bacteria consume B12)
Folate: normal to high (bacterial production)
Dx:
-Aspiration of duodenum w/ culture
-Glucose-hydrogen breath test
-empiric treatment with antibiotics
Treatment: antibiotics (eg Ciprofloxacin)
14
Sx of Vit A def
night blindness
xerophthalmia
15
Sx of Vit D def
Osteomalacia
-bone mineralization defects
16
Sx of Vit E def
rare in adults
hemolytic anemia
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sx of vit K def
clotting dysfunction
-PT
18
Celiac Sprue
-gluten sensitive enteropathy (wheat, barley, rye)
-inflammatory disease of small intestine
-loss of villi, crypt hyperplasia, lymphocytes
-80% asx (0.5-1% of US pop)
-incidence increases with age
19
Signs/sx of celiac sprue
Abdominal distension
Abdominal pain
Anorexia
Bulky, sticky, pale stools
-Steatorrhea
Diarrhea
Flatulence
Failure to thrive
-Weight loss
-Fatigue
Vomiting
20
Atypical signs/sx of celiac sprue
Iron deficiency Anemia
Dermatitis Herpetiformis
Liver function tests
-AST, ALT elevations
Cerebellar ataxia
Osteoporosis
Oral apthous ulcers
21
Celiac pathogenesis
-assoc w/ autoimmune diseases: thyroiditis, Type-I DM
-HLA-DQ2, HLA-DQ8 (40% US)
APC MHC II present gluten peptides
CD4+ Tcell response
All have ab to tissue transglutaminase (TTG)
22
Dx of Celiac sprue
Dx:
-finding on SI biopsy
-Serologic tests: anti-TTG, anti-endomysial antibodies, anti-gliadin IgA and IgG
Tx: gluten free diet
23
Findings on endoscopy for celiac
scalloped duodenal folds
24
Tropical sprue
-residents/visitors of tropics
-Cause: bacterial toxins or colonization of aerobic coliform bacteria
Classic presentation: Megaloblastic anemia from B12 and folate deficiency
Diagnosis: intestinal biopsy with villous flattening and travel history
Treatment: Antibiotics, B12, and folate
25
Whipple's Disease
RARE (
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Mesenteric Ischemia
Atherosclerosis, Clot, Radiation
Chronic: 2 of 3 major vessels occluded
post-prandial abdominal pain, weight loss, sitophobia, malabsorption
Acute: embolus, severe abdominal pain
27
Malabsorption diagnostic tests
Focused testing-clinical scenario
Fecal Fat
Vitamin levels
CBC, albumin
CT-small bowel, liver, pancreas, bile ducts
Endoscopy
28
Small Intestinal Tumors
RARE primary tumors (
29
Two main causes of diarrhea
decreased fluid/elec absorption
increased secretion
-occurs when colonic water load exceeds absorptive capacity
30
Diarrhea classification
Fatty
-malabsorption
-maldigestion
Watery
-osmotic
-secretory
Inflammatory/exudative
Functional
31
Watery diarrhea-- osmotic
Carb malabsorption:
lactose
sorbitol (gum)
fructose (non-diet drinks and many commercial foods)
Osmotic laxatives:
-Magnesium containing
-Phosphate, sulfate (colonoscopy bowel preps)
Osmotic diarrhea: presence of OSMOLAR GAP
*ie presence of poorly absorbed luminal osmols
32
Osmotic vs secretory diarrhea
Osm gap= 290-2(stool sodium + potassium)
diff >50mOsm, diarrhea is osmotic
33
Lactose intolerance
>50% of world down-regulates lactase after weaning
-->diarrhea (osmotic), flatulence (colonic bacteria)
34
Secretory watery diarrhea
Bacterial toxins
-V. cholerae, E. coli enterotoxins
Neuroendocrine tumors
-gastrinoma, VIPoma, carcinoids, calcitonin
Ileal bile salt malabsorption
Stimulant laxatives
Disordered motility/regulation
-Diabetic neuropathy, postvagotomy, irritable bowel syndrome
35
Bile acid induced diarrhea
-from ileal dysfunction (only site of ACTIVE bile acid absorption
-increased bile acid into colon--> colonic secretion of fluid/elec--> diarrhea
36
Fatty diarrhea
Malabsorption syndromes
-Mucosal diseases (Celiac disease, Whipple’s disease)
-Short-bowel syndrome
-Small bowel bacterial overgrowth
Maldigestion/Malabsorption
-Pancreatic insufficiency
-Inadequate luminal bile salt concentration (chronic liver disease, biliary obstruction)
37
Inflammatory diarrhea
Infection
Inflammatory Bowel Disease
-Crohn’s Disease
-Ulcerative Colitis
Ischemia
38
Fecal leukocytes in intestinal infections
Present:
Shigella
Campylobacter
Enterohemorrhagic, enteroinvasis E. coli
Variable:
Salmonella
Yersinia
Clostridium difficile (pseudomembranous colitis)
Absent:
V. cholerae
Enterotoxigenic E. coli
Giardia lamblia
39
Inflammatory diarrhea dx
Infection:
Usually Stool Culture
Endoscopy
Ischemia:
CT scan
Endoscopy-colon
Inflammatory Bowel Disease:
Endoscopy
40
IBS
Abdominal Pain and altered bowel habits in the absence of an organic cause:
Pain improved with defecation
Pain onset with change in stool frequency
Pain onset with change in stool appearance
Constipation and/or Diarrhea
10-15% of the population North America
Possible mechanisms:
Visceral hypersensitivity
Carbohydrate malabsorption
-FODMAPS fermentable oligo-, di-, and monosaccharides and polyols (Fructose, fructans (wheat polymers e.g.inulin) sorbitol, lactose,)
Low grade inflammation
41
When to be concerned about IBS
Weight Loss
Rectal bleeding
Anemia
Nocturnal symptoms
Electrolyte abnormalities
Elevated inflammatory markers
42
What could be the result of longstanding Celiac?
T cell lymphoma
43