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Dia, Mal, Celiac Dz
CM Chronic Diarrhea, Malabsorption, Celiac disease
| Question | Answer |
|---|---|
| 85% of acute diarrhea is | infectious. Not so for chronic diarrhea |
| Chronic Diarrhea is diarrhea > than | 4 or 6 weeks |
| Causes of chronic diarrhea | Abnormal transport (Na,Cl) across intestinal epithelium (decreased absorption, increased secretion), Non-absorbable molecules, inflammation, abnormal intestinal motility |
| If a patient doesn't eat and it gets better | it is likely osmotic. Not so with secretory |
| Small volume stools, fecal leukocytes, some blood | inflammatory process |
| Bacterial overgrowth can be caused by | stasis/decreased motility |
| Never see blood with | secretory or osmotic diarrhea. Must be something invading mucosa, be concerned about inflammatory causes |
| History to get for chronic diarrhea | stool size, blood, diet, medications, travel history, sexual history, family history (IBD, Celiac dz) |
| Physical exam for chronic diarrhea | weight, thyroid, skin & eye findings, lymphadenopathy |
| Lab evaluation for chronic diarrhea | CBC, ESR (or CRP), Chem panel, stool cultures, fecal fat, fecal leukocytes |
| If you are looking for an inflammatory cause of chronic diarrhea, make sure to get | ESR, fecal leukocytes |
| Classic infection that can cause malabsorption and diarrhea | Giardia. Steatorrhea |
| Chronic diarrhea + weight loss +/- nutritional deficiencies suggests | malabsorption |
| Chronic bloody diarrhea suggests | ulcerative colitis |
| Chronic diarrhea without nutritional deficiencies | lactose or other intolerance, IBS, Laxative overuse |
| Always consider ______ in pts >40 years who present with chronic diarrhea | colon cancer |
| ________ should be included in the differential diagnosis of all patients presenting with chronic diarrhea | malabsorption |
| These three characteristics increase absorption ability of the small bowel | microvilli, protein brush border, capillary network |
| Patients who have edema and muscle atrophy may have malabsorption of | protein |
| If Giardia goes on for more than 6 weeks it becomes | a small bowel malabsorption problem |
| Complication of untreated Celiac Dz | lymphoma |
| Classic test for malabsorption | Fecal Fat. Can do a Quantitative Fecal Fat (Gold Standard: high fat diet for 2 days before collection), Qualitative (sudan stain), D-xylose test, Hydrogen breath test |
| Most useful test for diagnosing lactase deficiency | Hydrogen Breath test. However, this is expensive, and it is cheaper and easier to first try removing offending agents |
| Lactase over a lifespan | highest in childhood, usually decreases as people age |
| Classic malasorption disease | Celiac Disease |
| Inflammatory response of proximal small bowel to ingestion to gluten proteins found in wheat, rye and barley | Celiac Disease. Patients also advised to avoid oats simply because of cross contamination in manufacturing process |
| Celiac Disease is what kind of disorder? | Autoimmune. HLA-DQ2, HLA-DQ8 association (only people with these HLA types can get Celiacs). first degree relatives of affected persons have 10-15-fold risk of CD |
| Classic presentation of Celiac disease | diarrhea with steatorrhea, weight loss, nutritional deficiencies (in children, add FTF),constitutional symptoms (may mimic IBS)Some patients have persistent diarrhea resembling traveler’s diarrhea, Other GI Sx:distention,flatulence, borborygmi |
| Extraintestinal Manifestations of Celiac disease | Short stature, fatigue, amenorrhea, decreased fertility, arthropathy, iron deficiency anemia, folate and Vit k Def, osteopenia, osteoporosis, muscle atrophy, neuro def, dental enamel hypoplasia |
| Classic malabsorption signs in Celiac disease is usually seen when what is involved? | the distal bowel and mucosa |
| Conditions definitely associated with Celiac dz | Dermatitis herpetiformis, Type I DM, Autoimmune thyroid dz, RA, Sjogren's syndrome, Down's syndrome |
| Conditions likely associated with Celiac Dz | Congenital heart disease, sarcoidosis, cystic fibrosis, IBD, autoimmune hepatitis, myasthenia gravis |
| intensely pruritic papulovesicular rash of trunk, scalp and extremities | dermatitis herpetiformis. Responds to gluten free diets. only 10% of patients with CD have DH but nearly all patients with DH have CD on duodenal biopsy though they may not have clinically apparent disease |
| Vitamin K deficiency manifests in | multiple bruising |
| Physical exam of Celiac | check teeth for loss of enamel; muscle atrophy kyphosis; bruises; ↑abdominal signs, pallor due to anemia, hyperkeratosis due to Vit. A deficiency, bone pain due to osteomalacia, or neuro signs due to B12 or vit. E deficiency |
| Lab Evaluation of Celiac | CBC, PT (vit K deficiency), iron, B12, folate level, chemistries: calcium, alk phos, albumin, B-carotene. ESR. Serologic test should be performed in ALL patients suspected of having Celiacs |
| Stool Exam for Celiac | Giardia, C. Diff, qualitative or quantitative fecal fat |
| Most specific serology test in Celiac | Anti-tTGA is the test of choice. Total IgA may catch people who get a false negative on Anti-endomysial IgA (because 3% of pts have an IgA deficiency). DQ2/DQ8 is the genetic screen |
| Gluten free diet relationship to antibody levels in Celiac | Gluten free diet will cause antibody levels to decrease. Antibodies undectable after 6-12 months and thus can be used to monitor adherence to gluten free diet |
| ___ is the gold standard to confirm Celiac's (even in the presence of positive serology) | Endoscopic mucosal biopsy of the distal duodenum or proximal jejunum. Recommended to biopsy at least 6 sites |
| Histological findings in Celiac endoscopy with biopsy | scalloping (borders of durodenum will have lacey effect), blunting or loss of intestinal villi, hypertrophy of teh intestinal crypts, and extensive infiltration of the lamina propria with lymphocytes and plasma cells |
| Tx for Celiac Dz | Gluten-free diet. 90% of patients have symptomatic improvement after 2 weeks |
| Most common reason for tx failure in Celiac Dz | Incomplete removal of gluten from diet |
| Inflammatory dz of small bowel secondary to overgrowth of coliforms | Tropical Sprue. Most common in India, SE Asia, affects both residents and travelers |
| Megaloblastic anemia is a presentation of | Tropical Sprue. |
| Tx of Tropical Sprue | Extended abx therapy, folate, B12 supplementation |
| Malabsorption caused by Tropheryma whippeli | Whipple's disease (rare multisystemic illness caused by infection). Most common in white males 40-60 |
| Treatment for Whipple's Dz | Prolonged therapy (1 year) with antiobiotics |
| Most common problem with bacterial overgrowth | deconjugation of bile salts |
| Causes of bacterial overgrowth | gastric achlorhydria, impaired motility of small bowel, anatomic abnormalities |
| Whipple's Dz presentation | arthralgias, or a migratory nondeforming arthritis, GI sx, weight loss (most common presenting sx seen in almost all patients), low-grade fever, lymphadenopathy |
| Diagnosis of Whipple's Dz | In most cases, the diagnosis is established by endoscopic biopsy of the duodenum with histologic eval which shows infiltration of the lamina propria with PAS-positive macrophages that contain gram-positive bacilli |
| Which test is the most reliable to diagnose bacterial overgrowth? | the [C]Xylose breath test is the most reliable. Bacterial uptake and degradation of this isotope leads to the release of CO2, which can be measured in the exhaled breath. |
| Tx of bacterial overgrowth | 1-2 weeks of broad-spectrum abx effective against enteric aerobes and anaerobes |
Created by:
ltm12