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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
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 gluten free diet is curative
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
Weight loss, recurrent greasy stools (steatorrhea) mixed with diarrhea after certain foods Celiac Sprue
Anti-endomysial antibodies Celiac Sprue
Beriberi Thiamine (B1) deficiency; Alcoholics, Neuro Sx +/- cardiomyopathy, CHF
Pellagra (raw skin) Niacin (B3) (4D’s dermatitis, diarrhea, dementia, death), bright red tongue
Scurvy Vit C (easy bleeding, bruising, hair & tooth loss, joint pain and swelling)
Rickets; hsm, lg skull, genu varus/ valgus Vit D (Osteomalacia)
Night blindness; Xerosis, Hyperkeratinization, Loss of taste, Bitot spots (white spots on conjunctiva) Vit A deficiency; secondary causes antiseizure meds, low Ca
Magenta tongue Riboflavin deficiency (B2)
decreased proprioception and vibratory sense, gait disturbance, possibly 2/2 deficiency of: Vit E; secondary causes CF, biliary atresia, Cholestatic liver dz
Dermatitis, Neuropathy, Stomatitis, Cheilosis vit B complex def (most often 2/2 EtOH)
uncommon causes of B3 def INH use, Hartnup dz, carcinoid
B1 (thiamine)def sxs impaired jejunal/ileal absorption; beri beri; Wernicke-Korsakoff
HLA-DQ2, HLA-DQ8 association celiac dz
assoc w/celiac dz dermatitis herpetiformis; Type 1 DM; autoimmune thyroid dz; RA; Sjögren; Down syndrome; poss CHD, sarcoid, CF, IBD, autoimmune hep, MG
celiac dz physical exam check for loss of enamel; mx atrophy; kyphosis; bruises; +abdominal signs
villous atrophy, lymphocytic infiltration of lamina propria, crypt hyperplasia, inc intraepithelial lymphocytes = celiac dz
Intensely pruritic papulovesicular rash of trunk, scalp and extremities = Dermatitis herpetiformis (think celiac dz)
B12 and colesterol are absorbed only at the: terminal ileum
If no sx improvement for celiac dz with gluten free diet, consider: alternate dx (lymphoma, Giardia, pancreatic insufficiency, lactose intolerance). Most common reason for GFD tx failure is incomplete dietary gluten removal
malabsorption: impaired digestion = ___ phase intraluminal phase
malabsorption: impaired absorption = ___ phase mucosal phase
malabsorption: impaired transit = ___ phase absorptive (transport) phase
If quantitative fecal fat is abnormal, and D-xylose test is normal: disease is: pancreatic disease (or bile salt deficiency)
If quantitative fecal fat is abnormal, and D-xylose test is abnormal: disease is: mucosal disease
When urinary D-xylose is abnormal, test for bacterial overgrowth with this test breath hydrogen test (after a glucose challenge)
If breath hydrogen test does not reveal bacterial overgrowth, next step is: mucosal bx
Bacterial overgrowth (SBBO) is associated with impairment of (3): gastric acidity, peristalsis, or intestinal immunoglobulins (IgA)
Secretory diarrhea MOA Elevated cAMP, cGMP, and/or Ca inhibit NaCl absorption and induce Cl secretion; H2O follows and accumulates in gut lumen => dehydration
3 characteristics of secretory diarrhea 1) high volume, 2) persist during fasting, 3) low stool osmotic gap (diff btw stool osmolality and lytes osmo)
Created by: Abarnard
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