Celiac Disease, IBS, Lactose Intolerance, Colon Polyps (Clin Med) – Flashcards
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Celiac disease is aka as what?
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-Non-tropical Sprue -Celiac Sprue -Gluten Enteropathy
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What is celiac disease?
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-Malabsorption disorder caused by an immunologic response to gluten
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What is gluten?
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-Storage protein found in wheat, barley, and rye -The problem is with gliadin, a component of gluten
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What is the epidemiology of Celiac disease? Is the incidence increasing? What is the largest affected population?
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-Incidence has increased in the last 50 years -Largest affected population is whites of Northern European ancestry, but it is present in worldwide populations
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What is the etiology of celiac disease?
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-Cause unknown -Environmental-Gluten -Genetics-Incidence in 1st degree relatives is 10%
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What are the clinical features of celiac disease?
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-Delayed diagnosis, s/s present for 10 years before Dx -S/S can occur at any age, infancy through 8th decade -Some patients are asymptomatic, incidental findings -Sx depend on how much of the SI is affected and age at time of Dx
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What are the classic Sx of celiac disease?
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-Diarrhea -Steatorrhea -Weight loss -Weakness -Abdominal distension -Growth retardation
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What are the atypical Sx of celiac disease?
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-Fatigue -Depression -Delayed puberty -Amenorrhea -Infertility
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In celiac disease, Sx can be related to what?
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A specific nutrient deficiency -Iron deficiency anemia -> fatigue, pallor -Vitamin K deficiency -> easy bruising -Vitamin A deficiency -> hyperkeratosis -Vitamin B12 deficiency -> peripheral neuropathy
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patients with celiac disease may have coinciding?
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-lactose intolerance
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What is found on physical exam for a patient with celiac disease?
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-Usually normal unless there is a finding related to nutrient deficiency
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What is the cutaneous variant of celiac disease? What is the Tx?
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Dermatitis Herpetiformis -Pruritic papulovesicles over the extensors of the extremities, trunk, scalp & neck -Little to no GI Sx -SI Bx will show histology c/w celiac -Few pt's w/celiac have DH -Tx w/dapsone
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What is the diagnostic evaluation for celiac disease? What is the gold standard?
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-SI BX: gold standard -Celiac serology -Laboratory Test
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Where is the SI Bx taken from in celiac disease?
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-Proximal & distal duodenum
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What does celiac serology consist of when testing for celiac disease?
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Blood test to check for antibodies -IgA endomysial antibody & IgA tissue transglutaminase antibody -Both have >90% sensitivity and >95% specificity -If serology is negative the result reliably r/o celiac disease
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What laboratory testing is done for celiac disease?
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-May have abnormal values related to specific nutrient deficiency -Anemias -low vitamin levels -low calcium
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What is the Tx for celiac disease?
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-Strict elimination of gluten from the diet -Correct nutritional deficiencies -Support groups
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When eliminating gluten from the diet in celiac disease, when should you expect symptom improvement? When are antibody levels undetectable? what other considerations should you make?
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-Sx improvement within a few weeks -Antibody levels will become undetectable s/p 3-12 months -Think about cross contamination, especially in processed food
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What are some associations & complications w/celiac disease?
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-Increased incidence of GI & non-GI cancer & intestinal lymphoma -Development of intestinal ulceration -Associations w/T1DM, Down Syndrome, Turner's Syndrome & other autoimmune dz
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What is the prognosis for celiac disease?
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-Excellent w/proper Dx, Tx, strict diet adherence
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What is IBS?
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-Chronic functional disorder -Characterized by abdominal pain & altered bowel habits
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To Dx IBS, what must the patient have?
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Abdominal Pain + 2 of 3 of the following -Relief w/defecation -Onset associated w/a change in frequency of BM -Onset associated w/change in GM appearance
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What gender is IBS MC in? When does it usually present?
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-2/3 of IBS patients are women -Usually presents late teens/early 20's -10% of population have IBS S/S
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What is the etiology/pathophysiology for IBS?
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-Exact cause is unknown -Dx of exclusion -Abnormal motility: primary motility d/o or secondary reaction to stress -Visceral hypersensitivity -Enteric infection -psychosocial
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How do enteric infections relate to IBS?
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-IBS s/s develop w/in 1 year after episode of bacterial gastroenteritis -Women & those w/increased stress at time of gastroenteritis at risk for post-infectious IBS
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How do psychosocial problems correlate to IBS?
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>50% who present w/IBS s/s have underlying depression, anxiety, or somatization
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Sx must be present for at least _____ before Dx of IBS can be made?
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-3 months
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What are the clinical features of IBS?
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-Abdominal pain: intermittent, crampy & in lower abdomen -pain relieved by defecation -Sx are r/t the type of IBS: w/diarrhea, w/constipation, or mixed -pt may c/o multitude of other Sx: heart burn, fatigue, HA, uro & gyn Sx, anxiety & depression
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What are alarm Sx for IBS?
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-Acute onset s/p 40-50 y/o -Nocturnal Diarrhea -Hematochezia -Weight loss & fever -FHx of colon cancer, IBD, or celiac disease
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What is found on physical exam for a patient with IBS?
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-Usually normal
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What is the Diagnostic work-up for IBS?
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-ROME criteria -Avoid a battery of unnecessary tests -Stool for O&P if pt has traveled -Colonoscopy if >50y/o, FHx of colon cancer, alarm Sx -If diarrhea predominant IBS, evaluate for celiac
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What is the conservative Tx for IBS?
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-Educate & support pt -Reinforce chronic nature of IBS -Move away from trying to find a cause -Make a plan for pt to cope w/symptoms -Diet therapy
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What is the diet therapy for IBS?
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-Fatty foods & caffeine poorly tolerated -Exclude lactose intolerance -Carbs, certain fruits & veggies can worsen gas & bloating
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What is the pharmacotherapy for IBS?
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-Anti-spasmodics- anticholinergics: Dicyclomine -Anti-diarrheal agents: immodium -Anti-constipation agents: Osmotic Laxatives (MOM), Linaclotide (linzess) -Psychotropic agents: TCA -probiotics
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What pt's is pharmacotherapy reserved for in IBS?
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-Patients w/severe symptoms -no standard drug for Tx, meds aim to Tx Sx
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What are the psychological therapies for IBS?
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-Relaxation techniques -Hypnotherapy -Cognitive behavioral therapy -Psych eval
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What is lactose intolerance?
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-Inability to digest lactose d/t a shortage of lactase
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What is lactose?
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-Sugar primarily found in milk & dairy products
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What is lactase?
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-Enzyme found in the SI that is necessary for lactose digestion -High levels of lactase present at birth but steadily declines during childhood & adolescence
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Lactose intolerance has a higher prevalence in what races?
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-Asian Americans -African Americans -Native Americans -Mexican Americans -Jewish Americans
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Lactose intolerance affects mostly those of ____ ancestry
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-Non-european
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What percentage of white americans are affected by lactose intolerance?
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<25%
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What is the etiology of lactose intolerance?
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-Genetics -Secondary to GI dz or surgery affecting the proximal SI mucosa: Crohn's, Celiac, Trauma
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What is the pathophysiology of lactose intolerance?
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-Malabsorbed lactose is fermented by intestinal bacteria, producing CO2 & organic acids -The non-metabolized lactose and organic acids increase stool osmotic load, resulting in diarrhea
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What are the clinical features of Lactose intolerance?
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-Sx can vary & can depend on severity of lactase deficiency & amount of lactose intake -Bloating, gas, diarrhea, cramping -Red flag if pt is losing weight! Needs more extensive work-up
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What are the diagnostic evaluations for lactose intolerance?
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-Trial of lactose free diet -hydrogen breath test
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What is the hydrogen breath test?
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-Pt ingests 50gm of lactose -A positive test is a rise in breath hydrogen of >20ppm within 90 minutes: The result indicates bacterial carbohydrate metabolism
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What is the goal of Tx in lactose intolerance?
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-Achieve patient comfort
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Can patients with lactose intolerance tolerate a small intake of lactose?
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-Complete intolerance is rare, so many patients can tolerate a small intake of lactose -8oz of milk per day spread out over the day is usually well tolerated w/no Sx or need for lactase supplements
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What is the Tx for lactose intolerance?
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-lactose free diet -Milk pretreated w/lactase -Lactase enzyme replacement: Lactaid -Consider calcium supplementation for patients w/a very lactose restrictive diet
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What is a colon polyp?
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-Small clump of cells that form in the lining of the colon -may be stalk like
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Are colon polyps common? What gender are they more common in?
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-30% of adults 50y/o and up have them, common -Men at slightly greater risk
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Where do you see an increased incidence of colon polyps?
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-Industrialized nations -Also a genetic influence
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What are the risk factors for colon polyps?
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-High fat diet -Diet high in red meat -Low fiber diet -Cigarette smoking -Obesity
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What are hyper plastic polyps?
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-Small, located in rectum or sigmoid colon -No malignancy potential
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What are adenomatous polyps?
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2/3 of polyps are this type -Some cancerous potential -The larger the lesion the higher the risk for cancer (>1cm)
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How do you distinguish between hyper plastic and adenomatous polyps
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-Biopsy
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What are the Sx of polyps?
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-Completely asymptomatic -Large Polyps may ulcerate -> hematochezia -Found on routine colonoscopy or eval for positive FOBT
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What is the best way to visualize and remove any suspicious lesions?
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-Colonoscopy
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What is a polypectomy?
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-Removal of polyp via colonoscopy -Risks of perforation & bleeding
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What does surveillance of colon polyps depend on?
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-Number, size, location, Bx result of polyps found on initial colonoscopy
