Small Intestine Flashcards by Cal Schiller

Celiac Dz

Whipple Dz

Tropical Sprue

Lactose Deficiency

Bacterial Overgrowth

Short bowel syndrome

Malabsorption syndorme

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IRON

Calcium

Copper

Magnesium

Phosphorus

Riboflavin

Thiamin

Absorbed in Duodenum

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Vitamins ADEK

Folate

Jejunum

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Vit B12

Bile salts/acids

Ileum

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What are the BIG THREE clinical manifestations of malabsorption?

Steatorrhea

Microcytic/macrocytic anemia

Dairy intolerance

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Bulky, greasy stools that typically float

Sign of increased fat

Steatorrhea (sign of malabsorption)

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Lab = low serum iron

Microcytic anemia (malabsorption sign)

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Lab = low B12, low folate

Macrocytic anemia (malabsorption sign)

Consider tropical sprue OR bacterial overgrowth

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Typical symptoms: weight loss, chronic diarrhea, abdominal distention, growth
retardation.

Atypical symptoms: dermatitis herpetiformis, iron deficiency anemia, osteoporosis.

Abnormal serologic test results. Abnormal small bowel biopsy.

Clinical improvement on gluten-free diet.

Celiac dz

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Diffuse damage to the proximal small intestine

Celiac dz

Immunological response to gluten

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Usually diagnosed in late childhood/early adulthood

Grossly underdiagnosed

Celiac disease

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Most important step is to consider the diagnosis

SSx are variable for Celiac (Depends on small intestine into element). What are the classic symptoms?

Dyspepsia

Diarrhea

Steatorrhea

Wt loss

Flatulence/abd distention/bloating

Borborygmi

(Weakness/muscle wasting if severe)

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Many adults may present asymptomatically/atypically w/ with what ssx?

“Extraintestinal manifestations”

Fatigue

Depression

Iron deficiency anemia

Osteoporosis

Transaminitis

Dermatitis herpetiforims

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Regarded as a cutaneous variant of celiac dz

Skin rash w/pruritic papulovesicles over the extensor surfaces

Dermatitis herpetiformis

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Most cases of Celiac dz are unremarkable on PE

However, nutrient deficiencies maybe present due to malabsorption , such as?

Loss of muscles mass, bruising (due to def. in. Vit K), hyperkeratosis (Vit A def.), bone pain, neuro deficit is (def. in Vit B)

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Labs (such as CBC/CMP/UA) may produce non specific results … What’s the test of choice for Celiiac?

IgA trans glutaminase (IgA tTG)

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If IgA tTG is negative for celiac, but still a strong clinical suspicion for celiac.. what’s your next move?

Obtain serum IgA levels

Then do an anti-DGP test

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If a patient has IgA deficiency what Follow up test could be performed to asses for celiac?

Deamidated gliadin peptides(anti-DGP)

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Confirmatory test in pts w/ a Celiac positive serological test?

Endoscopic mucosal biopsy of proximal/distal duodenum

Normal biopsy excludes Celiac

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Histology exam reveals blunting and/or atrophy of the intestinal villi

(Near absence of villi = flat mucosa)

Celiac

Biopsy after pos serology

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Diff Dx for celiac?

IBS

chronic diarrhea

Tropical sprue

Lactose intolerance

Gastroenteritis

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Diagnostic approach to Celiac…

Diagnostic suspicion… Serologic testing… trial of gluten free diet…

Mucosal biopsy

Celiac

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Tx of Celiac?

Removal of all gluten products including oats

Should see improvement in 2-3 weeks…

(REFER TO DIETICIAN)

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Most common reason for tx failure in celiac?

W/ celaic, Any risk for cnacer?

Most common reason for failure is dietary noncompliance

SLIGHT increase in risk for adenocarcinoma and lymphoma

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No need for retesting if dietary measures are effective... However...

If symptoms persist, refer

Multisystem dz Fever/lymphadenopathy/arthralgias Wt loss Duodenal biopsy w/ Periodic Acid Schiff (PAS) positive macrophages w/ bacillus

Whipple Dz

In whom is whipple dz most common? How’s it spreads?

Most common in white males, age 30-50 No human-human spread.. Contact w/ sewage/waste water Fatal if untreated ``` White males 30 -50 Waste Water With human to human (fecal) With migrating arthralgia *first sign if present* WEIGHT LOSS - MOST common* With fever With lymphadenopathy Whippelii trophoryme WILL KILL YA! Will DIAGNOSE with EGD and find "foamy macrophages" ```

Common/class presentation of Whipple?

****MIGRATORY arthralgias - first sign Diarrhea Abd pn Wt loss - MOST COMMON FEVER OF UNKNOWN ORIGIN

Less common signs... What diseas? Skin hyperpigmentation Generaliazed lymphadenopathy Ophthalmoplegia

Whipple dz

Diagnosis of Whipple dz is usually performed how?

Endoscopic biopsy w/ evidence of bacterium “Foamy macrophages”

TX for whipple dz?

IV ceftriaxone for 2 weeks THEN TMP-SMX 1 tab PO BID for ONE YEAR

Environmental enteropathy Occurs in narrow Tropical band Chronic diarrhea (often after acute diarrhea) Involves entire small intestine CHaracterized by malabsorption (esp folic acid//B12)

Tropical sprure Tropical malabsopriton

Chronic diarrhea Steatorrhea Wt loss Malaise B12/Folate deficiency (glossitis/cheilitis)

tropical sprue

CBC would show megaloblastic anemia Endoscopy w/ biopsy would show flattened duodenal folds

Tropical sprue | Microscopic findings of blunted villi and ELONGATED CRYPTS

Prevention of tropical sprue? Tx?

Prevention : boiled/bottled water; peel fruits Tx: TMP-SMX x 6 mos; folate/B12 supps

Diarrhea, bloating, flatulence, and abdominal pain after ingestion of milk- containing products. Diagnosis supported by symptomatic improvement on lactose-free diet. Diagnosis confirmed by hydrogen breath test.

LactAse deficiency

BRush border enzyme that hydrolysis lactose in glucose and galactose

Lactase deficiency

Malabsrobed lactose is fermented by intestinal bacteria producing gas and organic acids

Cool LactAse deficiency

Top three lactase deficient populations?

Asian (95-100%) American Indians (80-100%) Black people (60-80)

Ssx of lactose are variable and dose dependent... 1. Small intake? 2. Mod intake? 3. Large intake?

1. Maybe asymptomatic 2. Bloating, cramps, flatulence 3. OSMOTIC DIARRHEA

Other signs of malabsorption SHOULD NOT be present in lactase deficiency... so if wt loss is present then what?

LOOKK FOR ANOTHER ETIOLOGY

Tx for Lactase deficiency Presumptive diagnosis of lactase deficiency? Diagnostic test for lactase deficiency?

Presumptive -> 2-3 week of lactose free diet Diagnostic test = hydrogen test

Symptoms of distention, flatulence, diarrhea, and weight loss. Increased qualitative or quantitative fecal fat. Advanced cases associated with deficiencies of iron or vitamins A, D, and B12. Diagnosis suggested by breath tests using glucose, lactulose, or 14C-xylose as substrates. Diagnosis confirmed by jejunal aspiration with quantitative bacterial cultures.

Bacterial overgrwoth

Consider what dz in these following pts: Pts on chronic PPI Pts who have an anatomical abnormality Or motility disorder of small intestine Pts who have gastrocolic/coloenteric fistula (e.g., Crohn, malignancy, surgical resection)

Bacterial overgrwoth

Bacterial overgrwoth is an important cause of malabsorption in what pt population?

Olds

Bacterial overgrowth can often be a symptomatic... What would be the ssx?

Flatulence Wt loss Abd pn Diarrhea Steatorrhea Macrocytic anemia

Specific diagnosis for bacterial overgrowth can be establish by aspirate and culture (but this is expensive and difficult) So what do we use?

Can use a noninvasive breath test but many clinicians use an empiric approach w/ abx

Thx for bacterial overgrwoth?

Empiric tx w/ antibiotics... Cipro, Amoxicllin-clavulanate, Rifaximin

Short bowel syndrome Due to removal of significant segments of small intestine What does the degree of malabsorption depend on?

Length Site Degree of adaptation of remaining bowel

Precipitating factors: surgery, peritonitis, electrolyte abnormalities, medications, severe medical illness. Nausea, vomiting, obstipation, distention. Minimal abdominal tenderness; decreased bowel sounds. Plain abdominal radiography with gas and fluid distention in small and large bowel.

Acute paralytic ileus

Types of intestinal motility disorders?

Acute paralytic ileus Chronic intestinal pseudo-obstruction Small bowel obsutrcion

Ileus considered in hospitalized pts as results of?

1. Intrabdominal processes (surgery/peritoneal irritation) 2. Severe medical illness (pneumonia, respiratory failure, etc.) 3. Medications that affect motility (opioids, anticholinergics, phenothiazines)

Failure or loss of intestinal peristalsis WITHOUT mechanical obstruction

Acute paralytic ileus

Diffuse, CONSTANT abd pn Nausea and vomiting LACK OF ABDOMINAL TTP (no signs of peritoneal irritation) Abdominal distension Diminished/absent bowel sounds

Acute paralytic ileus

Though lab findings in acute paralytic ileus are non-specific, they should be obtained why?

To exclude abnormalities as contributing factors

What would you see on a X-ray of acute paralytic ileus?

Gas-filled loops of the small/large intestine (air fluid levels may be present)

Ilues must be distinguished from mechanical obstruction. How might you tell

Pain from obstruction is typically intermittent w/ cramping and profuse vomiting. Ileus is CONSTANT

Treatment for acute paralytic ileus?

Tx underlying dz Pn mgmt/fluid maintenance/electrolyte replacement Nasogastric decompression for severe distension

Severe abdominal distention. Arises in postoperative state or with severe medical illness. May be precipitated by electrolyte imbalances, medications. Absent to mild abdominal pain; minimal tenderness. Massive dilation of cecum or right colon.

Acute Colonic pseudo-obstruction (Ogilvie syndrome)

Similar to gastroparesis Intermittent signs of obstruction in the absence of a physical obstruction

Chronic intestinal pseudo obstruction

Involvement of the small bowel results in.... Abd distension Vomiting Diarrhea Varying degrees of malutrition

Chronic intestinal pseudo obstruciton

In a work up of chronic intestinal pseudo obstruciton, what must you exclude? With what type of imaging?

Exclude mechanical obstruction with CT or endoscopy

Tx for chronic intestinal pseudo obstruciton?

Acute exacerbation require NG decompression and IV fluid/electrolyte replacement Refer to GI

What are most small bowel obstructions attributed to?

Postop adhesions or hernias (Other causes include neoplasm, strictures, foreign body , intussusception, gallstones

Prior abd/ pelvic surgery Abd/groin hernia Intestinal inflmmation Hx of neoplasm Prior radiation Hx of foreign body ingestion

RISK factors for SBO

How would a SBO clinically present?

ABRUPT onset of: COLICKY pn Nausea Profuse vomiting Obstipation

PE findings for SBO?

Abd distension (tympany) HYPERactive bowel sounds early, then progress to HYPOactive later Signs of dehyration

Labs for SBO include CBC, CMP, Urinalysis, and what? | If surgery is indicated?

Type and cross match for surgery

What type of radiographs for SBO? What do you expect to see?

Plain abdominal films... Upright and supine... DILATED LOOPS OF SMALL BOWEL W/ AIR FLUID LEVELS

When should you perform a CT scan for a suspected SBO/?

If pat has fever, tachy, localized abd pn, or leukocytosis | To dx a strangulated obstruciton

Thx for SBO?

Early surgical consultation ADMISSION Flui resuscitation Bowel decompression w/ NG Pain control Antiemetic meds

Complications of SBO?

Dilation -> comprised intramural vessels -> ischemia -> necrosis

Rare Due to impaction of gallstone in the ileum after passing through fistula Common in whom?

Gallstone ileus, more common in females/older patients Female/Fat/Forty/Fertile

Segment of intestine invaginates into adjoining intestinal lumen... Common in whom and what’s the stool look like?

Intussusception more common in kids and causes currant jelly stool

Though rare, primary malignancy of the small bowel can cause what?

Intussusception (obstruciton)

If small intestinal, Adenocarcinoma are most commonly in the Duodenum or proximal jejunum. How would it present?

Obstruciton, chronic GI bleed, wt loss

What populations have increased incidents of small intestinal lymphomas?

AIDS/immunosuppressed, Crohn dz Side Note: Small intestinal Neoplasms - mainly adenocarcinoma and lymphomas*

Intestinal carcinoid, Sarcoma

Small intestinal neoplasm possibilites

Usually a result of an already established GI order Causes excess loss of serum protein into GI tract (hypoalbuminemia)

Protein losing enteropathy

Thx of protein losing enteropathy?

treat underlying condition Dietary therapy and if severe, albumin replacemtn

Interruption of blood to the bowel Acute arterial occlusion (emboli or thrombotic) Non-occlusive -> vasospasm, low cardiac output Ischemia -> necrosis (emergency)

Mesenteric ischemia

Classically... pain out of proportion w/ PE DIagnose w/ CT angiography

Mesenteric ischemia

Tx for mesenteric ischemia?

Admit! Papaverine (smooth muscle relaxant) Thrombolytics Surgical referral

Most common CONGENITAL abnormality of the GI tract? Rule of twos....

Meckel’s diverticlum 2% of population. 2:1 male to female 2 feet of ileocecal valve 2 types of mucosa SSx before age 2 ``` Males 2:1 Manifests 2/yo (although under 10 y/o and adults less than 40 must suspect for different reasons) Maybe 2% of pop Most 2' w/i ileocecal valve 2 types of mucosa ```

Variable presentation... but can see GI bleeding Abd Pain (similar to appendicitis)

Meckel’s diverticula

Suspect Meckel’s in whom?

Children under 10 who present w painless GI bleeding w/o ssx of gastroenteritis or IBD Adult pts less than 40 w GI bleeding but ID’ed source on endoscopy

How to diagnose Meckel’s?

Capsule endoscopy Meckel’s scan (nuke medciine w/ 99m technetium)

Tx for Meckel’s?

Referral for surgical eval if ASYMPTOMATIC Symptomatic? Stabilize bleed and removal diverticula

pruritic papulovesicles or rash that appears as: Extremely itchy bumps or blisters appear on both sides of the body, most often on the forearms near the elbows, as well as on knees and buttocks, and along the hairline.

Dermatitis herpetiformis

Small Intestine Flashcards

(89 cards)