Malabsorption PDF

Malabsorption  Secretory insuffiency Impaired motility with bacterial overgrowth & bile salt inactivation Impaired mucosal function Major disorders of the small intestine that cause malabsorption: Celiac disease Intestinal resecti...

Malabsorption  Secretory insuffiency Impaired motility with bacterial overgrowth & bile salt inactivation Impaired mucosal function Major disorders of the small intestine that cause malabsorption: Celiac disease Intestinal resection Dermatitis Whipple’s disease herpetiformis Radiation enteritis Tropical sprue Parasite infestation: Bacterial – Giardia intestinalis overgrowth – Cryptosporidiosis  Coeliac disease (gluten-sensitive enteropathy) Inflammation  Pepsin Immune response 2 age peaks Symptoms & Signs Symptoms: Non specific: Diarrhoea \ steatorrhoea Abdominal discomfort, bloating and pain signs : few, non-specific: anaemia & malnutrition. Mouth ulcers & angular stomatitis: frequent, intermittent. Infertility Anxiety and depression Tongue  Features Of Complications Tetany Osteomalacia Gross malnutrition with peripheral oedema.  Features Of Complications Neurological: – Ataxia (due to cerebellar calcification) – Muscle weakness, paraesthesia – Polyneuropathy ↑ malignancy Variable prognosis Ulcerative jejunitis  Features of Associated Diseases Autoimmune Primary biliary cirrhosis, Down ,Turner Chronic liver disease, Inflammatory bowel Interstitial lung disease disease IgA deficiency Epilepsy  Investigations Serology – IgA transglutaminase antibodies: very high sensitivity & specificity – Ig A endomysial antibodies: less sensitive Indications: symptomatic patients If positive: intestinal biopsy  Subtotal villous atrophy Distal duodenal biopsy: – Definitive diagnosis – four to six forceps biopsies should be taken: patchy Important Differential Diagnoses Of Subtotal Villous Atrophy Coeliac disease Giardiasis Tropical sprue Hypogammaglobulinaemia Dermatitis Radiation herpetiformis Whipple's disease Lymphoma Zollinger-Ellison syndrome AIDS enteropathy  Blood count: – Mild anemia: Iron deficiency: common Folate deficiency: almost always B12 deficiency: rare. Small bowel radiology or capsule endoscope: suspected complications  HLA typing: useful for ruling out the disease e.g., patients already on a gluten free diet. Bone densitometry: ↑risk of osteoporosis  Management Life long gluten free diet Correction of any vitamin deficiency Pneumococcal vaccinations (because of splenic atrophy) once every 5 years  Monitoring: – Response & compliance with diet – By: Symptoms & serology Re-biopsy: no response, diagnostic uncertainty Dermatitis herpetiformis  Uncommon Pruritic blistering subepidermal eruption of the skin A gluten-sensitive like enteropathy  Most patients with celiac sprue do not develop it. The skin condition responds to dapsone but a gluten-free diet improves both the enteropathy and the skin lesion. Tropical sprue  Tropical sprue Progressive small intestinal disorder Chronic diarrhoea , malabsorption & megaloblastic anemia Tropical areas. Unknown etiology, ??? infective  Diagnosis: – Evidence of malabsorption + mucosal biopsy (+\- like celiac) – Exclude infective causes of diarrhea ttt: folic acid+ tetracycline 3-6 m+ nutritional definciency Bacterial overgrowth  Bacterial overgrowth Occurs when there is stasis of intestinal contents: abnormal motility or structure  Clinical features Diarrhoea & Bacteria overgrowth steatorrhoea. Mild B12 deficiency Symptoms due to the underlying small bowel pathology B12 Diagnosis: Therapeutic trial of antibiotics Hydrogen breath test : in exhaled air after oral lactulose  Management: – ttt of the cause – Rotating courses of antibiotic: tetracycline & metronidazole Intestinal resection According to the extent & level  Short-bowel syndrome: – ttt: Parenteral nutrition – Intestinal trasplantation : few centers  The ability to cope without supplemental IV nutrition depends on: – Amount of resected bowel – Location of resection – Colon intact or not – Health of residual intestine Whipple disease  Whipple disease Rare infectious bacterial disease caused by Tropheryma whipplei.  weight loss Diarrhoea W H A D P P E S E S I I hyperpigmentation of skin Interstitial nephritis intestinal pain Skin rash pleuritis Eye disease Pneumonitis Arthropathy lymphadenopathy Subcutaneous Encephalopathy nodules Endocarditis Steatorrhea  Arthritis & arthralgia, Weight loss ,diarrhoea , abdominal pain, systemic symptoms of fever and weight loss.  Peripheral lymphadenopathy 15% : atypical symptoms.  Blood tests: Normal chronic inflammation & malabsorption. Endoscopy: pale, shaggy duodenal mucosa with eroded, red, friable patches.  Diagnosis by small bowel biopsy: Periodic acid– Schiff (PAS)-positive macrophages , nonspecific.  On electron microscopy, the characteristic trilaminar cell wall of T. whipplei in macrophages. T. whipplei antibodies & PCR-based assay.  Whipple's disease : fatal if untreated Treatment: antibiotics : 160 mg trimethoprim and 800 mg sulphamethoxazole (co-trimoxazole) daily for 1 year. radiation enteritis  Radiation enteritis Acute effects: nausea, vomiting, diarrhoea & abdominal pain, usually improving within 6 weeks. The chronic effects : muscle fibre atrophy, ulcerative changes & fibrotic strictures. – Symptoms persist for 3 months or more.  Treatment – Symptomatic: often unsuccessful in chronic radiation enteritis. – Surgery : Avoid if possible Reserved for obstruction or perforation. 0_84ba1_3786d586_orig THANK YOU