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Small Bowel Diseases

One hour review of diseases of the small intestine for residents and nurses 03/2013

Patricia Raymond

on 6 March 2013

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Transcript of Small Bowel Diseases

Summary Share this:
http://prezi.com/rse33mngff82/malabsorption/ And one more thing... No specific evaluation
No specific testing
No specific management History
Chronic pancreatitis
Intestinal resection
Cystic fibrosis
On Orlistat (Alli)
Family history Symptoms Diagnosis Management Malabsorption
& Maldigestion Malabsorption
-Impaired transport of nutrients across the small intestinal lining
-Congenital or aquired
- Impaired digestion of nutrients in intestinal lumen or in brush border Classic global malabsorption:
-diarrhea with pale, greasy, voluminous, foul-smelling stools & weight loss despite adequate food intake.
-most are NOT classic Most are mild & nonspecific
mimic IBS
anorexia, flatulance, abdominal distension, borborigmi
signs of specific micronutrient deficiency
iron deficiency or osteoporosis with celiac
B12 deficiency with pernicious anemia Look to fat to Dx global malabsorption
Most complex absorption & most sensitive to interference
Most likely to cause weight loss Qualitative fecal fat
72 hour quantitative fecal fat if normal
on 100 gram fat/day diet
Normal is < 6 grams per day up to 125 grams fat intake daily
If Increased fecal fat
TTG IgA & total IgA for celiac
Fecal elastase testing for pancreatic insufficiency 4.3 grams of fat in a slice of bacon
=23 1/4 slices of bacon
OR Butter 81 g fat in 100 g
Each stick is 113 grams, or 91 grams fat Imaging
US used elsewhere
SBFT, CT, MR enterography
Looking for bowel wall thickening (Crohns) or dilation jejeunal loops (Celiac) Endoscopy (at least 4 duodenal biopsies)
Colonoscopy with intubation of TI Testing for carbohydrate malabsorption
D-xylose test measures absorptive capacity proximal small intestine, passive
25 gram xylose when NPO from midnight
5 hour urine collection
Normal with pancreas insufficiency, abnormal with proximal mucosal disease
False results with renal disease, impaired gastric emptying, bacterial overgrowth Lactose Tolerance Test
50 grams lactose after NPO from MN
Blood glucose at 0, 60, 120 minutes
Increase glucose < 20 mg/dl diagnositic, >40 normal
False results with diabetes, bacterial overgrowth, abnormal gastric emptying Patricia Raymond MD FACG
Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School
Gastroenterology Associates
a division of Gastrointestinal & Liver Specialists of Tidewater pllc Correct underlying pathology if possible
Limit caffeine to 1 serving per day
Reduce highly sugared beverages (soft drinks, juices)
May dilute with water at 1:1 ratio
Consider oral rehydration solution
Bile salt depletion: oral bile salts
Dietician consult Nutient supplimentation: need5-10 x DV
Use polar versions of fat soluble vitamins if steatorrhea
Hectorol or calciediol instead of D2 or D3
TPGS (d-alpha-tocopheryl PEG 1000 succinate)instead of vitamin E Intentional: Surgical malabsorption: post gastric bypass
Annual panel should include:
Iron saturation, copper, zinc, vitamin A & D
CMP, CBC, B12, folate, magnesium Carbohydrate maldigestion:
Trials of lactulose, alpha galactosidase (Beano), Prelief
Trial of low FODMAP diet
Dietary diary
Consider fructose intolerance
50% cannot absorb 25 g, daily intake ranges 11-54 g daily; role of HFCS Not just beans:Breaks down polysaccharides and oligosaccharides
Legumes (beans and peanuts)
Cruciferous vegetables (cauliflower, broccoli, cabbage, brussels sprouts, among others) MCT oil or oral supplement
Oil alone may cause nausea or osmotic diarrhea
10 cc MCT + 8 oz nonfat milk + 1 pkt powdered instant breakfast
Major site of MCT absorption is the colon Pancreatic enzymes
Target: 30K IU lipase per meal
15K IU per snack
One IU= 2-3 USP
Add H2 or PPI if gastric acid breakdown (Go with your guts.) Celiac Disease Healthy Individuals 1:133
Symptomatic Subjects 1:40
1st Degree Relative with Celiac 1:22
2nd Degree Relative with Celiac 1:39

Projected number Celiacs in US 2,115,954
Known Celiacs in US 40,000
For each known Celiac, there are 53 undiagnosed patients Testing:
TTG IgA & Total IgA Additional tests
Schilling test for B12
1.radiolabelled B12, 2.Intrinsic factor, 3.antibiotics prior to IF
Check B12 and methylmalonic acid instead
SeHCAT test-bile acid malabsorption (selenium homocholic acid taurine)
Administer selenium 75 labelled bile acid PO, measure retention with gamma camera at seven days (abnormal < 5 %)
Bacterial Overgrowth
Gold standard is bacterial count from aspirated intestinal fluid (<100,000 )
Prefer hydrogen breath test with lactulose or other carbohydrate substrate MALoderous MALadaptive MALadies Celiac Disease Crohn's Disease Whipple's Disease Cancer Adenocarcinoma
Carcinoid Ischemia SIBO No Irritable Bowel Syndrome Small Bowel Anatomy
& Physiology Patricia L. Raymond MD FACG
Gastroenterology Consultants a division of Gastrointestinal and Liver Specialists of Tidewater pllc If you cannot do great things,
do small things in a great way.
~Napoleon Hill Nothing SMALL about it:
Diseases of the
less than large intestine Small bowel anatomy & physiology What we'll cover: Crohn's disease of the small intestine Celiac Disease Whipples Disease Ischemia Small Bowel Obstruction SIBO Malabsorbtion No giardia
No cryptosporidia
No amyloidosis
No intussusception
No Meckels We never worry about the big things,
just the small things.
~Travis Barker Small things amuse
small minds.
~Doris Lessing Mechanical digestion
Chemical digestion
Vitamin B12
Lipids and fat-soluble vitamins
Water and electrolytes
Carbohydrates and proteins
Minerals and micronutrients Duodenum, about 25 cm (10 inches) long
Jejunum, about 2.5 m (8 feet) long
Ileum, about 3.6 m (12 feet) long SBO Strangulation complicates
from 7 to 42 percent
of bowel obstructions plain films can be equivocal in 20 to 30 percent of patients and are "normal, nonspecific, or misleading" in 10 to 20 percent Careful surgical history The presence of water soluble contrast in the cecum within 24 hours predicts resolution of adhesive small bowel obstruction (sensitivity and specificity of 97 and 96 percent, respectively) computerized tomography (CT) has been replacing the small bowel series as the adjunctive study of choice since it can simultaneously provide information about the presence, level, severity, and cause of obstruction risk of developing an obstruction after surgery from postoperative adhesions is estimated to be
9 % within the first year after abdominal surgery
19 % by 4 years
35 % by 10 years open operations > laparoscopic surgery
7 % in open cholecystectomies versus 0.2 % in laparoscopic cholecystectomies Eight trials
Therapeutic role of WSCA
Significant reduction in the need for an operative intervention in patients randomly assigned to WSCA versus bowel rest, nasogastric aspiration, and intravenous fluid rehydration (20.8 versus 29.6 percent, odds ratio 0.62, 95% CI 0.44-0.88). The WSCA group also had a significantly shorter hospital stay by almost two days. Adenocarcinomas 25 to 40 % of small bowel cancers Age 50 to 70, slight male predominance
Younger age with predisposing conditions (Crohn's, Celiac) Location: most in duodenum
(except Crohns: ileum) Cumulative risk of a small bowel adenocarcinoma in patients with small bowel Crohn's disease was 0.2 percent at 10 years and 2.2 percent at 25 years Vague symptoms
Most advanced
(stage III or IV at dx) Gastroenteropancreatic neuroendocrine tumors
Morphologically unique appearance
Produce biologically active amines. Gastrinoma of the duodenum
Zollinger-Ellison syndrome
85 % localized to the pancreas
15 % will be found in the upper duodenum Carcinoid tumors
Well-differentiated neuroendocrine tumors
Indolent disease course
40 % of primary small intestinal malignancies
Ages 20 to 80 years old, with the highest incidence in the 60s Intermittent obstruction occurs in 25 percent Intraluminal tumor
Mesenteric kinking and distortion by tumor invasion and a secondary desmoplastic response For carcinoids <1 cm
Distant metastasis is 0 to 2 % for appendiceal
15 to 18 % for small bowel
For carcinoid tumors > 2 cm
47 % of small bowel primaries metastasized to liver lungs and bone adults, peaking in the seventh decade, and 60 percent of patients are male [60]. Some of the predisposing conditions include:

Autoimmune diseases
Immunodeficiency syndromes (eg, AIDS)
Long-standing immunosuppressive therapy (eg, posttransplantation)
Crohn's disease
Radiation therapy
Nodular lymphoid hyperplasia Sarcoma
Metastatic disease
Desmoid tumors (FAP)
Hamartomas (Peutz Jehgers) GH Whipple described a 36-year-old clinician in 1907 with "gradual loss of weight and strength, stools consisting chiefly of neutral fat and fatty acids, indefinite abdominal signs, and a peculiar multiple arthritis." 1991 Tropheryma whipplei
Greek "trophe"- nourishment
"eryma"- barrier In Europe healthy adult population 11 percent
Detected in sewage and is more prevalent in the fecal samples of sewage workers (12 to 26 percent) than the general population Annual incidence since 1980
~ 30 cases per year 86 percent were male
mean age at diagnosis of 49 years
Only 10 (1.5 percent) were of African descent, three Indian, one American Indian, and one Japanese
35% were farmers, and 66 percent had occupational exposure to soil or animals underlying host immune deficiency and possibly secondary immune downregulation induced by the bacterium
accumulation of massive numbers of organisms within the intestinal tract, and subsequent impaired nutrient absorption
patients with Whipple's disease do not appear to be prone to opportunistic infections or to malignancy. Arthralgias
Weight loss
Abdominal pain present with migratory arthralgias of the large joints or, less often, a chronic, migratory nondeforming oligoarthritis or polyarthritis which may precede other symptoms by many years pathognomonic for Whipple's disease: oculomasticatory myorhythmia (continuous rhythmic movements of eye convergence with concurrent contractions of the masticatory muscles), and oculo-facial-skeletal myorhythmia . These abnormalities are almost always accompanied by supranuclear vertical gaze palsy.
fever of unknown origin
chronic serositis
progressive central nervous system disease with myoclonus or ophthalmoplegia
migratory polyarthropathy
generalized lymphadenopathy Rx: parenteral ceftriaxone followed by oral trimethoprim-sulfamethoxazole (TMP-SMX, one double-strength tablet twice daily) maintenance therapy for one year. IgA endomysial antibodies – sensitivity 85 to 98 percent; specificity 97 to 100 percent
IgA tissue transglutaminase antibodies – sensitivity 90 to 98 percent; specificity 95 to 97 percent
IgA antigliadin antibodies – sensitivity 80 to 90 percent; specificity 85 to 95 percent
IgG antigliadin antibodies – sensitivity 75 to 85 percent; specificity 75 to 90 percent whites of northern European ancestry
1:100 to 1:250 IgA deficiency 2 to 5 percent
general population <0.5 percent Four to six biopsies in the duodenal bulb
and second and third portion of the duodenum 99 % with celiac disease have HLA DQ2 and/or DQ8
40 % general population 80 % small bowel involvement, usually in the distal ileum, with one-third of patients having ileitis exclusively.
Approximately 50 percent of patients have ileocolitis, which refers to involvement of both the ileum and colon.
Approximately 5 to 15 percent have predominant involvement of the mouth or gastroduodenal area, Fistula Obstruction Active disease Regional 5-ASA
Systemic immunosuppression
Immunomodulators prednisone is 40 to 60 mg/day
60-80% will respond within 10 to 14 days
gradual tapering by 5 mg/week CIR budesonide 9 mg/day for 8 to 16 weeks
tapered by 3 mg increments over two to four weeks
Less (not absent) steroid systemic effects Cholestyramine
non-stenosing ileitis
chronic watery diarrhea. B12: Check & replace Azathioprine and 6-mercaptopurine
Biologic therapies
- Anti-TNF therapies
Adalimumab and certolizumab pegol
- Natalizumab
- Ustekinumab infliximab, azathioprine, and 6-MP
steroids and sulfasalazine not successful
for inducing fistula closure Stricture
Stenosis with inflammation
Adhesion Post operative recurrence
Endoscopic precedes clinical clinical relapse rate was 24 percent and the severe endoscopic recurrence rate was 50 percent endoscopic findings were present in 73 percent of patients within one year and 85 percent within three years of resection Extended (often lifelong) prophylactic medical therapy for all patients with Crohn's disease after surgery (Grade 2B).

Demonstrated efficacy include mesalamine, imidazole antibiotics, azathioprine, and 6-MP.

Mesalamine for low risk

Imidazole antibiotics have more consistent clinical effects than mesalamine in the short-term, but their long-term use (beyond three months) is greatly limited by side effects.
Recommend three months of imidazole antibiotic maintenance therapy in all patients starting immunosuppressive therapy and patients unwilling to consider other long-term therapies or in those with contraindications to immunosuppressive therapy.

Long-term azathioprine (2.0 to 2.5 mg/kg daily) or 6-MP (1.5 mg/kg daily) with metronidazole (250 mg three times daily for the first three months) in patients who have high-risk predictive factors for recurrence or poor outcomes following recurrence. Factors that put patients at increased risk include:

Jejunal or extensive ileal-colonic disease
Initial presentation requiring surgery
Age less than 30 years
Fistulizing disease
Patients undergoing a second resection
Failure of medical management excessive colonization of the small intestine by bacteria (most commonly coliform bacteria
May be associated with mucosal inflammation (Crohns mimic) and nutrient malabsorption

Asymptomatic or bloating, abdominal discomfort, diarrhea, dyspepsia, and in severe cases weight loss Small Intestinal Bacterial Overgrowth Treatment options:
Reduce acid suppression
Low carbohydrate diet
Antibiotics 7-10 day course
Rifaximin (1650 mg/day), a nonabsorbable antibiotic, may be the antibiotic of choice
N= 142 patients with SIBO were randomized to seven days of rifaximin (1200 mg/day) or metronidazole (750 mg/day), glucose breath test normalization rates at one month were significantly higher in patients treated with rifaximin compared with metronidazole (63.4 versus 43.7 percent).
Amoxicillin-clavulanate (30 mg/kg/day) .
Metronidazole (20 mg/kg/day) combined with a cephalosporin (30 mg/kg/day), such as cephalexin or trimethoprim-sulfamethoxazole (10 to 12 mg/kg/day), or oral gentamicin (10 mg/kg/day). If gentamicin is used on a continuous basis, random drug levels should be obtained intermittently to assess for any toxicity ].
Norfloxacin (800 mg/day)
Empiric Abx
Jejeunal aspirate (>10x5)
[14C]-d-xylose breath test
Breath hydrogen analysis Diagnosis Celiac- through duodenum
SMA- through mid transverse colon Mesenteric arterial embolism — due to dislodged thrombus from the left atrium, left ventricle, or cardiac valves.The SMA is anatomically most susceptible to embolism due to its large caliber and narrow take-off angle from the aorta. The IMA is rarely affected due to its small caliber The middle segment of the jejunum is most often involved.

Mesenteric arterial thrombosis — Acute thrombosis of the mesenteric circulation usually occurs as a superimposed phenomenon in patients with a history of chronic intestinal ischemia from progressive atherosclerotic stenoses. There does not appear to be a significant association between inherited coagulation defects and mesenteric arterial thrombosis

Mesenteric venous thrombosis — Risk factors for the development of mesenteric venous thrombosis include hypercoagulable states, portal hypertension, abdominal infections, blunt abdominal trauma, pancreatitis, splenectomy, and malignancy in the portal region. rapid onset of severe periumbilical abdominal pain, which is often out of proportion to findings on physical examination. Nausea and vomiting are also common.
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