Small Bowel Disorders

Question 1

What are the small bowel disorders?

Answer 1

Diarrhea
Malabsorption
Celiac Disease

Question 2

define diarrhea

Answer 2

1. Increased frequency or volume of stool

A. 3 or > liquid or semi-solid stools qd for at least 2-3 consecutive days

Question 3

What is acute diarrhea?

Answer 3

≤ 14 days duration

Question 4

What is persistent diarrhea?

Answer 4

> 14 days duration

Question 5

What is chronic diarrhea? >

Answer 5

> 30 days duration

Question 6

What is the etiology of diarrhea?

Answer 6

1. Infectious
A. Most cases of acute diarrhea due infections w/virus or bacteria → self-limited
2. Bacterial Toxins
3. Dietary
A. Laxative use
4. Other GI disease
A. HIV
5. Noninfectious etiology more common as diarrhea persists & becomes chronic

Question 7

What are the viral causes of acute infectious diarrhea?

Answer 7

1. Norovirus
2. Rotavirus
3. Adenoviruses
4. Astrovirus

Question 8

What are the bacterial causes of acute infectious diarrhea?

Answer 8

1. Salmonella
2. Campylobacter
3. Shigella
4. Enterotoxic E. coli
5. C. difficile

Question 9

What are the protozoa causes of acute infectious diarrhea?

Answer 9

1. Cryptosporidium
2. Giardia
3. Cyclospora
4. Entamoeba

Question 10

What is secretory diarrhea?

Answer 10

1. Large volumes w/out inflammation
2. Indicative of:
   A. Pancreatic insufficiency
   B. Ingestion of bacterial toxins
   C. Laxative use

Question 11

What is inflammatory diarrhea?

Answer 11

1. Bloody diarrhea w/out fever
2. Indicative of:
   A. Invasive organisms
   -Salmonella, Shigella, Campylobacter (3 most common US)
   B. Inflammatory bowel disease (IBD)
   -Crohn’s Dz
   -Ulcerative Colitis

Question 12

What is antibiotic asst. diarrhea?

Answer 12

1. Primary organism A. Clostridium difficile

Question 13

What are the dx studies for diarrhea?

Answer 13

1. Stool WBC’s
A. Inflammatory process
2. Stool C&S
A. Identifies bacterial pathogens
3. Stool O&P (ova and parasite)
A. Microscopy
B. Identifies parasites
C. Diarrhea > 10 days
D. Recent travel to endemic region
E. Community water borne outbreak
4. Toxin identification
A. Used to identify enterotoxic E. coli or C. difficile

Question 14

What are the indications for dx studies for diarrhea?

Answer 14

1. Diarrhea > 7 days
2. Fever > 38.5°C (101.3°F)
3. Bloody diarrhea
4. Abd pain
5. IBD
6. Profuse watery diarrhea w/dehydration
7. Frail or elderly
8. Immunocompromised
9. Hospital acquired diarrhea
10. Systemic illness w/diarrhea, especially pregnant women (R/O listeriosis)
11. Food handlers

Question 15

Where is listeria found?

Answer 15

1. Listeria monocytogenes
   A. Bacteria inwater & soil
   B. Found in uncooked meats & vegetables, unpasteurized milk, & processed foods* (hot dogs & deli meats)
   *Contamination may occur aftercooking & before packaging

Question 16

How long is the incubation period for listeria?

Answer 16

Incubation 2-30 days

Question 17

What are the sxs of listeria infection in pregnancy?

Answer 17

1. Mild flu-like symptoms, headaches, myalgias,fever, N/V
2. Can cause meningitis, endocarditis, bacteremia, brain abscess, osteomyelitis
3. Most common 3rd trimester

Question 18

What are the complications of listeriosis in pregnancy?

Answer 18

1. Miscarriage
2. Prematuredelivery
3. Infection to newborn
4. Death to newborn

Question 19

What are the non abx treatment options for diarrhea?

Answer 19

1. Supportive therapy
A. Hydration- (water, salt, sugar)
2. BRAT diet
A. Rest bowel
3. Antidiarrheal
A. Loperamide (Imodium)
B. Acute diarrhea w/o fever or hematochezia

Question 20

What are the abx treatment options for diarrhea?

Answer 20

1. Empiric Tx for moderate to severe travelers’ diarrhea
2. Elderly
3. (+) signs & sx’s of invasive bacterial diarrhea such as fever and bloody diarrhea
4. NO antibiotic Tx w/enterohemorrhagic E. coli (unless severe)

Question 21

What abx are indicated for shigella caused diarrhea?

Answer 21

Fluoroquinolone (Cipro 500 mg po bid x 7 days)

Question 22

What abx are indicated for campylobacter caused diarrhea?

Answer 22

Fluoroquinolone (Cipro 500 mg po bid x 7 days)

Question 23

What abx are indicated for C. difficle caused diarrhea?

Answer 23

Metronidazole 500 mg po tid x 10-14 days

Question 24

What abx are indicated for Giardia caused diarrhea?

Answer 24

Metronidazole 250 mg po tid x 10 days

Question 25

What abx are indicated for Listeria caused diarrhea?

Answer 25

1. 1st line: ampicillin ≥ 6 g/d IV 7–14 d; if fetus survives, longer Tx 2. 2nd line: erythromycin 4 g/d IV, 7–14 d; if fetus survives, longer Tx

Question 26

What may malabsorption involve?

Answer 26

May involve a single nutrient, enzyme deficiency, or global

Question 27

What are examples of malabsorption?

Answer 27

1. Pernicious anemia – Vit B12 def 2. Lactase deficiency – inability to digest lactose products 3. Celiac disease

Question 28

What is the etiology of malabsorption?

Answer 28

1. Digestion problem 2. Absorption problem 3. Impaired blood flow & lymph flow

Question 29

What are the more common sxs of malabsorption?

Answer 29

1. Diarrhea A. Usually 1° complaint 2. Bloating 3. Abd pain

Question 30

What are the less common sxs of malabsorption?

Answer 30

1. Weight loss 2. Steatorrhea A. Large, greasy, foul smelling stools 3. Specific deficiencies can cause: A. Bone demineralization B. Bleeding C. Anemia

Question 31

What are the dx studies for malabsorption?

Answer 31

1. Fecal fat test A. Measures fat content in stool B. If (+) fat in stool → not digested or absorbed 2. If 72 hr fecal fat test is normal A. R/O pancreatic insufficiency B. R/O abnormal bile salt metabolism 3. D-Xylose Absorption test (Monosaccharide) 25 g po

Question 32

What is D-Xylose Absorption test (Monosaccharide)?

Answer 32

1. Now redundant due to Ab tests 2. Does not require enzyme (amylase) for digestion prior to absorption 3. Result determined by absorptive function of small intestine A. Normal=Urine D-Xylose 4.5 g in 5 hr B. Abnormal < 4.5 g in 5 hr 4. Polymerase chain reaction (PCR) based assay 5. EGD w/duodenal Bx to detect bacteria 6. CBC & vitamin assays A. Vit B12 def 7. Hydrogen breath test

Question 33

What is the purpose of D-Xylose Absorption test?

Answer 33

1. Differentiates maldigestion vs malabsorption A. Maldigestion=pancreatic insufficiency or bile salt deficiency or bacterial* overgrowth -*Whipple’s Dz-responds to antibx B. Malabsorption=Celiac Dz

Question 34

What is the the PCR assay for malabsorption?

Answer 34

1. DNA sequencing test 2. PCR of saliva, gastric, intestinal fluid, stool are highly sensitive, but not specific (use like D-Dimer to R/O bacteria) 3. (-) PCR=healthy

Question 35

What is the hydrogen breath test for malabsorption?

Answer 35

1. Used to diagnose lactase deficiency A. After ingesting 50 g lactose, ↑ breath hydrogen B. > 20 ppm w/in 90 min = (+) test

Question 36

How is lactase deficiency treated?

Answer 36

Lactose free diet | Lactaid pills

Question 37

How is celiac dz treated?

Answer 37

Gluten free diet

Question 38

How is pancreatic insufficiency treated?

Answer 38

Pancreatic enzyme replacement

Question 39

How is pseudomembranous colitis?

Answer 39

Metronidazole 500 mg po bid x 10-14 days

Question 40

What are the general characteristics of celiac dz?

Answer 40

1. Permanent dietary disorder caused by immunologic response to gliadin (gluten protein) A. Storage protein found in certain grains B. Wheat, barley, rye, sometimes oats 2. Characterized by mucosal inflammation, villous atrophy & crypt hyperplasia 3. Results in diffuse damage to proximal small intestinal mucosa -> malabsorption of nutrients

Question 41

What is the epidemiology of celiac dz?

Answer 41

Most cases undiagnosed | More prevalent in Northern Europeans

Question 42

What is the etiology of celiac dz?

Answer 42

``` 1. May be genetic A. HLA-DQ2 or HLA-DQ8 2. Immunologic A. T-cell mediated response in intestinal mucosa B. B-cell response C. Ab to gluten ```

Question 43

What are the classic sxs of celiac dz?

Answer 43

1. Diarrhea 2. Steatorrhea 3. Weight loss 4. Abd pain 5. Distention 6. Weakness 7. Muscle wasting

Question 44

What are the atypical sxs of celaic dz?

Answer 44

1. Fatigue 2. Depression 3. Iron def anemia 4. Osteoporosis 5. Amenorrhea 6. Dermatitis herpetiformis A. Pruritic papules & vesicles occurring in groups B. Elbows, dorsal forearms, knees, scalp, back, & buttocks

Question 45

What are the dx studies for celiac dz?

Answer 45

``` 1. Serologic tests A. > 90% sensitivity & > 95% specificity -IgA endomysial Ab -IgA tTG Ab 2. (-) test excludes celiac disease 3. False (-) & (+) ``` 4. Ab undetectable after 6-12 mo gluten free diet 5. Mucosal tissue Bx of distal duodenum or proximal jejunum

Question 46

What is the gold standard for dx celiac dz?

Answer 46

1. Mucosal tissue Bx of distal duodenum or proximal jejunum 2. Done if A. (+) serology to confirm Dx B. (-) serology w/high suspicion

Question 47

What are the ddx for celaic dz?

Answer 47

1. IBS 2. Bacterial overgrowth A. Pseudomembranous colitis B. Whipple’s Dz 3. Lactose intolerance

Question 48

What is the tx for celaic dz?

Answer 48

1. Gluten free diet 2. Dietary guides 3. Support groups 4. Lactose free diet A. Many pts with celiac disease have co-existing lactose intolerance 5. Dietary supplements early in disease A. Iron, folate, Ca, Vit A, B12, D, E

Question 49

What is the prognosis for celaic dz?

Answer 49

1. Excellent prognosis with Dx & Tx 2. Most common cause recurrent sx’s is dietary noncompliance 3. Celiac disease refractory to dietary management may be result of intestinal T cell lymphoma