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Celiac Disease


In pts≥ 40 years with chronic diarrhea: always consider colon cancer
Causes of chronic diarrhea abnormal ion transport: dec absorption, inc secretion (meds, bowel resection); non-absorbable molecules (osmotic laxatives, lactose intolerance, Mg, sorbitol); inflammation (UC); abnormal intestinal motility
chronic diarrhea & weight loss +/- nutritional deficiencies = malabsorption
chronic bloody diarrhea = UC (wt loss, other systemic sx)
chronic diarrhea without nutritional deficiencies = lactose intolerance, IBS, laxative overuse
malabsorption: impaired digestion intraluminal phase
malabsorption: impaired absorption mucosal phase
malabsorption: impaired transit absorptive phase
TOC for malabsorption Sudan stain for fecal fat (25% false neg)
D-xylose: identifies mucosal malabsorption in small bowel
Hydrogen breath test: most useful for: diagnosing lactase deficiency
Celiac dz: classic presentation: sx can be protean; classic = diarrhea with steatorrhea, weight loss, nutritional deficiencies (in children, add FTF); may mimic IBS/travelers; other GI sx: distention, flatulence, borborygmi
Celiac EIMs Short; fatigue, amenorrhea, dec fertility; osteopenia, osteoporosis; arthropathy; Fe def anemia; folate, vitamin K deficiency
Celiac dx S/S depend on: length of sm bowel involved & age at which disease presents
Pts w/ mild proximal Celiac dz may have: only anemia and osteoporosis without any GI symptoms
Pts w/ sig distal Celiac dz & mucosal involvement: usually have persistent diarrhea
Intensely pruritic papulovesicular rash of trunk, scalp and extremities = Dermatitis herpetiformis
PE for celiac dz: check teeth for loss of enamel; mx atrophy; kyphosis; bruises; inc abd sx (bloating, abd pain, chronic diarrhea, IBS-like sx); EIM (wt loss, fatigue, arthralgias, skin lesions)
Celiac dz labs CBC, PT; iron, B12 and folate; Ca alk phos, alb; beta-carotene; ESR; Stool exam: Giardia, C. diff; quantitative or qualitative fecal fat (in patients with chronic diarrhea)
Most specific serologic test for celiac: anti-endomysial Ab
TOC (cheaper, less tech difficult) for celiac: anti-tGA (total IgA & genetic tests may also be indicated)
Gold std for celiac testing mucosal bx (even if pos serologies)
Mucosal bx: pathognomonic findings: villous atrophy; lymphocytic infiltration of lamina propria; crypt hyperplasia; inc intraepithelial lymphocytes
Celiac dz Tx GFD curative; most common reason for tx fail = incomplete diet gluten removal; if no improvement, consider alt dx (lymphoma, Giardia, panc insuff, lactose intol)
Celiac dz: complications Malig (lymphoma); also esoph (SC) ca; colon & hepatocell ca; other autoimmune; nutrition def; Musculoskel injuries
Most common malig assoc w/celiac: lymphoma
Inflam dz sm bowel 2/2 overgrowth of coliforms = Tropical sprue
Tropical sprue: dx & tx: diarrhea, megaloblastic anemia; tx = extended Abx tx; folate, B12 supplementation (B12/megalo anemia usu not part of celiac dz)
Whipple dz: 2 stages: prodromal & steady-state
Whipple: Dx arthralgias; GI sx; wt loss, chronic cough, low-grade fever, neuro sx (steady-state: wt loss & diarrhea); bx is confirmatory (villous atrophy, macrophage infiltration of lamina propria); tx = prolonged antibiotic therapy
Whipple: in DDx of: inflammatory arthropathies; any conn tissue dz; malabsorption with small bowel involvement; neurologic disease
Overgrowth of bacteria in small bowel can cause: malabsorption
Overgrowth of bacteria: poss causes gastric achlorhydria (PPIs); impaired motility of small bowel; anatomic abnormalities
Created by: Adam Barnard Adam Barnard