MalabsorptionMalabsorptionand and

DiarrheaDiarrheaMed 2Med 2

Feb 9, 2007Feb 9, 2007

GoalsGoals

Define the different presentations of Define the different presentations of diarrhea and establish a diagnostic diarrhea and establish a diagnostic approachapproachUnderstand the diagnostic approach to Understand the diagnostic approach to malabsorption in general and recognize malabsorption in general and recognize the most common malabsorption the most common malabsorption diseasesdiseasesKnow who to evaluate and when to Know who to evaluate and when to manage patients who presentmanage patients who present

Definition of diarrhoeaDefinition of diarrhoea

The abnormal passage of loose or liquid The abnormal passage of loose or liquid motions more than three times daily motions more than three times daily and/or a volume of stool >200g/dayand/or a volume of stool >200g/dayincontinence often misinterpreted as incontinence often misinterpreted as diarrheadiarrhea by patientsby patientschronic: >4 weeks of nonchronic: >4 weeks of non--infectious infectious origin (no consensus)origin (no consensus)

PrevalencePrevalence

Between 7 and 14% in elderly Between 7 and 14% in elderly population population in western population 4in western population 4--5% (excessive 5% (excessive stool frequency without the presence stool frequency without the presence of abdominal pain, of abdominal pain, ““excludesexcludes””functional diarrhoeafunctional diarrhoeaIBS 9IBS 9--12% of the population12% of the populationtherefore clinical definition will lead therefore clinical definition will lead to overlap with IBSto overlap with IBS

Everyone has had Everyone has had it at some timeit at some time

Most never seek Most never seek medical reviewmedical review

HistoryHistory1. 1. Duration of symptomsDuration of symptoms2. Incubation period2. Incubation period3. Description of stool:3. Description of stool:a. Volume/texturea. Volume/textureb. Presence of blood, mucus (bowel ulceration) and b. Presence of blood, mucus (bowel ulceration) and PMNPMN(inflammatory)(inflammatory)4. Associated symptoms or signs:4. Associated symptoms or signs:–– Systemic illness/fever Systemic illness/fever -- invasive pathogen.invasive pathogen.–– Vomiting as predominant symptoms: viral or foodVomiting as predominant symptoms: viral or foodpoisoningpoisoning–– Abdominal pain: inflammatory process (Abdominal pain: inflammatory process (ShigShig, Camp, , Camp, C.C.diff; particularly EHEC)diff; particularly EHEC)–– Persistent abdominal pain and fever: Persistent abdominal pain and fever: YersiniaYersinia

CluesClues

1212--72 h 72 h ++++VirusesViruses (Norwalk)(Norwalk)

Salmonella, Salmonella, ShigellaShigella,,Campylobacter,VibrioCampylobacter,Vibriosppspp., EIEC., EIEC1212--72 h 72 h +/+/--ToxinToxin--produced produced in vivoin vivo::

C. C. perfringensperfringens, B. cereus, B. cereus11--16 h16 h +/+/--

ToxinToxin--preformedpreformedS. S. aureusaureus, , B. cereusB. cereus

2. 2. Vomiting PathogensVomiting PathogensIncubationIncubationperiodperiod--ShigellaShigella, Salmonella,, Salmonella,CampylobacterCampylobacter--Viruses (Norwalk)Viruses (Norwalk)--Mucosal invasionMucosal invasion--Viral syndromeViral syndromeNosocomialNosocomial diarrheadiarrhea::–– C. C. difficiledifficile_ DRUGS_ DRUGS

More CluesMore CluesFever as predominant Fever as predominant SxSx

Viral agents or foodViral agents or foodPoisoningPoisoning

•• Presence of mucus:Presence of mucus:Small # mucus: irritable bowel syndromeSmall # mucus: irritable bowel syndrome

Large # mucus: invasive diarrheaLarge # mucus: invasive diarrhea•• Blood: inflammatory or ischemiaBlood: inflammatory or ischemia–– Infection with invasion of mucosaInfection with invasion of mucosa–– IschemiaIschemia–– DiverticulosisDiverticulosis, , diverticulitisdiverticulitis–– Inflammatory bowel disease (ulcerative colitis)Inflammatory bowel disease (ulcerative colitis)–– Radiation injuryRadiation injury•• PMN: colonic mucosal inflammationPMN: colonic mucosal inflammation–– InfectionInfection–– Inflammatory bowel diseaseInflammatory bowel disease

CausesCauses

Colonic carcinomaColonic carcinomacolonic inflammationcolonic inflammationsmall bowel inflammationsmall bowel inflammationsmall bowel malabsorptionsmall bowel malabsorptionmaldigestionmaldigestion due to pancreatic due to pancreatic insufficiencyinsufficiencymotility disordersmotility disorders(IBS)(IBS)

A change in absorption by 1-2% can cause diarrhea

SleisengerSleisenger and and FordtranFordtran’’ssGastrointestinal and Liver DiseaseGastrointestinal and Liver Disease. . 7th edition. 2002. p132.7th edition. 2002. p132.

NetterNetter’’s Gastroenterologys Gastroenterology. . ed. Martin ed. Martin FlochFloch 2005. 2005. p 367.p 367.

Acute DiarrheaAcute Diarrhea

<4 weeks duration<4 weeks durationUsually selfUsually self--limitedlimitedMost are infectiousMost are infectious

Majority (virus and bacterial) Majority (virus and bacterial) few (protozoa)few (protozoa)

Grossly underestimated prevalence due Grossly underestimated prevalence due to most patients donto most patients don’’t seek medical t seek medical assistanceassistance

Acute DiarrheaAcute DiarrheaNeed Medical evaluation when:Need Medical evaluation when:

Signs of Signs of hypovolemiahypovolemiaBloody stoolsBloody stoolsFever >38.5Fever >38.5Severe abdominal painSevere abdominal painHospitalized or recent antibioticsHospitalized or recent antibioticsElderly or Elderly or immunocompromisedimmunocompromised

Acute DiarrheaAcute Diarrhea

Diagnostic ApproachDiagnostic ApproachHistory of exposure and dietHistory of exposure and dietCBC (? anemia, ? CBC (? anemia, ? wbcwbc), BMP), BMPStool for WBC and Stool for WBC and hemeheme to evaluate for to evaluate for inflammatory diarrheainflammatory diarrheaStool Cultures for the following patients:Stool Cultures for the following patients:

ImmunocompromisedImmunocompromisedCoCo--morbiditiesmorbiditiesIBDIBD-- distinguish flare from infectiondistinguish flare from infectionInstitutionalized or hospitalizedInstitutionalized or hospitalizedAntibiotics in the last three monthsAntibiotics in the last three months

Acute DiarrheaAcute Diarrhea

Check O&P for the following patients:Check O&P for the following patients:Persistent diarrheaPersistent diarrheaPersistent diarrhea with:Persistent diarrhea with:

Travel historyTravel historyHomosexual malesHomosexual malesExposure to infants in daycareExposure to infants in daycare

Community outbreakCommunity outbreakBloody diarrhea without or few WBCBloody diarrhea without or few WBC

Acute DiarrheaAcute Diarrhea

EndoscopyEndoscopyRarely needed in acute diarrheaRarely needed in acute diarrheaIBD versus infectionIBD versus infectionC. DiffC. DiffImmunocompromisedImmunocompromised --?viral (CMV,HSV)?viral (CMV,HSV)Suspicion of Ischemic ColitisSuspicion of Ischemic Colitis

WorkWork--up and Management of up and Management of DiarrheaDiarrhea

NonNon--inflammatory diarrheainflammatory diarrhea::–– RehydrationRehydration–– AntiperistalticAntiperistaltic agentagent((loperamideloperamide))Inflammatory diarrheaInflammatory diarrhea::–– RehydrationRehydration–– AntiperistalticAntiperistaltic agentagent

avoid unless givenavoid unless givenAntimicrobial if indicatedAntimicrobial if indicated

usually a usually a quinolonequinolone

SleisengerSleisenger and and FordtranFordtran’’ssGastrointestinal and Gastrointestinal and Liver DiseaseLiver Disease. 7th . 7th edition. 2002. p140.edition. 2002. p140.

Chronic DiarrheaChronic DiarrheaCauses:Causes:

Inflammatory (IBD, microscopic colitis)Inflammatory (IBD, microscopic colitis)Osmotic (lactose intolerance)Osmotic (lactose intolerance)SecretorySecretory ((NeuroendocrineNeuroendocrine tumors)tumors)Iatrogenic (medication, postIatrogenic (medication, post--choleycholey, , vagalvagal injury)injury)Motility (rapid transit, secondary bacteria Motility (rapid transit, secondary bacteria overgrowth, DM, scleroderma)overgrowth, DM, scleroderma)Functional (IBS)Functional (IBS)IncontinenceIncontinence

Chronic DiarrheaChronic DiarrheaLoose stools +/Loose stools +/-- increased stool frequency for increased stool frequency for >4 weeks>4 weeksObtain historyObtain history

DurationDurationEpidemiologyEpidemiologyStool characteristicsStool characteristicsIncontinence?Incontinence?Abdominal painAbdominal painWeight lossWeight lossAggravating and alleviating factorsAggravating and alleviating factors

Chronic DiarrheaChronic DiarrheaExam:Exam:

Dehydration, systemic disease (rash, mouth ulcers, Dehydration, systemic disease (rash, mouth ulcers, thyroid nodules, etc.), rectal examthyroid nodules, etc.), rectal examCBC, CMPCBC, CMPStool: Stool:

Stool osmotic gap = (290Stool osmotic gap = (290-- 2(Na+K))2(Na+K))<50 <50 secretorysecretory, >50 osmotic), >50 osmotic)

HemeHeme testtestWBCWBCStool fatStool fatpHpH

Schiller, L. Schiller, L. ““Chronic DiarrheaChronic Diarrhea”” Gastroenterology 2004; p:289.Gastroenterology 2004; p:289.

Chronic Watery DiarrheaChronic Watery DiarrheaOsmotic DiarrheaOsmotic Diarrhea

Osmotic laxativesOsmotic laxativesCarbohydrate malabsorptionCarbohydrate malabsorption

SecretorySecretory DiarrheaDiarrheaCongenitalCongenitalBacterial toxinsBacterial toxinsIlealIleal bile acid malabsorptionbile acid malabsorptionInflammatory Bowel Disease (Inflammatory Bowel Disease (CrohnCrohn’’ss and UC)and UC)Microscopic colitisMicroscopic colitisDiverticulitisDiverticulitisVasculitisVasculitisDrugsDrugsLaxative abuseLaxative abuseDisordered motility (Disordered motility (vagotomyvagotomy, diabetic autonomic neuropathy, diabetic autonomic neuropathyEndocrine DiarrheaEndocrine Diarrhea

Hyperthyroid, AddisonHyperthyroid, Addison’’s, s, GastrinomaGastrinoma, , VIPomaVIPoma, , SomatostatinomaSomatostatinoma, , carcinoidcarcinoid, , pheopheoTumors (colon ca, lymphoma, villous Tumors (colon ca, lymphoma, villous adenoomaadenooma))IdiopathicIdiopathic

Chronic Watery DiarrheaChronic Watery Diarrhea

Determine if osmotic versus Determine if osmotic versus secretorysecretoryExclude infectiousExclude infectiousExclude structural diseaseExclude structural disease

Colonoscopy with biopsiesColonoscopy with biopsiesEndocrine causesEndocrine causes

Schiller, L. Schiller, L. ““Chronic DiarrheaChronic Diarrhea”” Gastroenterology 2004; p:290Gastroenterology 2004; p:290

Chronic Inflammatory DiarrheaChronic Inflammatory Diarrhea

Inflammatory Bowel DiseaseInflammatory Bowel DiseaseUCUCCrohnCrohn’’ssDiverticultisDiverticultisUlcerative Ulcerative jejunoileitisjejunoileitis

Infectious diseaseInfectious diseasePseudomembranousPseudomembranous colitis (C. Diff)colitis (C. Diff)Invasive bacterial infections (TB, Invasive bacterial infections (TB, yersiniayersinia))Ulcerating viral infections (CMV, HSV)Ulcerating viral infections (CMV, HSV)Invasive parasitic infections (Invasive parasitic infections (amebiasisamebiasis, , stronglyoidesstronglyoides))

Ischemic colitisIschemic colitisRadiation colitisRadiation colitisNeoplasmNeoplasm

Colon Colon cancarcancarLymphomaLymphoma

Chronic Inflammatory DiarrheaChronic Inflammatory Diarrhea

Evidence of mucosal disruption and Evidence of mucosal disruption and inflammation (WBC or blood in stools)inflammation (WBC or blood in stools)Evaluate structural diseaseEvaluate structural disease

Flex Flex sigmoidoscopysigmoidoscopy/colonoscopy/colonoscopySmall bowel biopsySmall bowel biopsySmall bowel XSmall bowel X--rays, CTrays, CT

Rule out infectious causesRule out infectious causes

SomebodySomebody

Else'sElse's

LectureLecture

Schiller, L. Schiller, L. ““Chronic DiarrheaChronic Diarrhea”” Gastroenterology 2004; p:290Gastroenterology 2004; p:290

Chronic Fatty DiarrheaChronic Fatty Diarrhea

Malabsorption SyndromesMalabsorption SyndromesMucosal diseases (celiac, WhippleMucosal diseases (celiac, Whipple’’s)s)Short bowel syndromeShort bowel syndromeSmall bowel bacterial overgrowthSmall bowel bacterial overgrowthMesenteric ischemiaMesenteric ischemia

MaldigestionMaldigestionPancreatic exocrine deficiencyPancreatic exocrine deficiencyInadequate luminal bile acid concentrationInadequate luminal bile acid concentration

Chronic Fatty DiarrheaChronic Fatty Diarrhea

Patient historyPatient historyFecal fat excretion and concentrationFecal fat excretion and concentration

In patients with diarrhea >14g/24 hours In patients with diarrhea >14g/24 hours strongly suggests fat absorption problemsstrongly suggests fat absorption problems

RadiologyRadiologyCT of Abdomen (liver, pancreas, lymphatic CT of Abdomen (liver, pancreas, lymphatic system)system)

EndoscopyEndoscopyAspirate and biopsiesAspirate and biopsies

Schiller, L. Schiller, L. ““Chronic DiarrheaChronic Diarrhea”” Gastroenterology 2004; p:290Gastroenterology 2004; p:290

MalabsorptionMalabsorption

IntroductionIntroductionNormal absorption requires:Normal absorption requires:

luminal processing luminal processing absorption into the intestinal mucosaabsorption into the intestinal mucosatransport to the circulationtransport to the circulation

MalabsorptionMalabsorptionLuminal DefectsLuminal Defects

Fat MalabsorptionFat MalabsorptionDecreased Lipase (pancreatic insufficiency)Decreased Lipase (pancreatic insufficiency)Decreased Duodenal pH (Decreased Duodenal pH (ZollingerZollinger--Ellison)Ellison)

Protein MalabsorptionProtein MalabsorptionDecreased proteases (pancreatic insufficiency)Decreased proteases (pancreatic insufficiency)

Impaired Impaired solubilizationsolubilizationDecreased micelle formation ( Liver disease, biliary tract Decreased micelle formation ( Liver disease, biliary tract obstruction)obstruction)DeconjugationDeconjugation of bile salts ( Bacterial overgrowth)of bile salts ( Bacterial overgrowth)

Mucosal (absorption) DefectsMucosal (absorption) DefectsDecreased surface area (Celiac Decreased surface area (Celiac spruesprue, tropical , tropical spruesprue, Whipple , Whipple disease, disease, CrohnCrohn disease, infections, disease, infections, amyloidamyloid, drug, GVHD or , drug, GVHD or AIDsAIDsenteropathyenteropathy))Decreased brush border enzymes ( Lactase, sucroseDecreased brush border enzymes ( Lactase, sucrose--isomaltaseisomaltase))Single enzyme defect (B12 malabsorption)Single enzyme defect (B12 malabsorption)

Delivery DefectsDelivery DefectsLymphatic obstruction (Lymphatic obstruction (neoplasticneoplastic, primary intestinal , primary intestinal lymphangiectasialymphangiectasia))

MalabsorptionMalabsorption

Clinical featuresClinical featuresSymptoms vary greatly on degree of malabsorptionSymptoms vary greatly on degree of malabsorptionIsolated malabsorptionIsolated malabsorption

Symptoms related to specific nutrient that is Symptoms related to specific nutrient that is malabsorbedmalabsorbed

Global malabsorptionGlobal malabsorptionDiarrheaDiarrhea-- pale greasy, high volume, foulpale greasy, high volume, foul--smelling stools smelling stools (rare)(rare)mild GI symptoms and mimic IBS (majority)mild GI symptoms and mimic IBS (majority)

AnorexiaAnorexiaFlatulenceFlatulenceAbdominal distentionAbdominal distentionborborygmiborborygmi

NetterNetter’’s Gastroenterologys Gastroenterology. . ed. Martin ed. Martin FlochFloch p 358. p 358. 2005.2005.

MalabsorptionMalabsorption

Laboratory featuresLaboratory featuresDecreased Decreased –– HgbHgb, serum , serum folatefolateIncreasedIncreased-- oxalate (urine), oxalate (urine), prothrombinprothrombin timetimeSerum screening testsSerum screening tests

IronIronFerritinFerritinVitamin B12Vitamin B12CalciumCalciumCholesterolCholesterolAlbuminAlbumin

Luminal Digestion ImpairmentLuminal Digestion Impairment

Normal Normal intraluminalintraluminal digestion requires digestion requires normal gastric normal gastric chymechyme release, mixing release, mixing with pancreatic enzymes and bile saltswith pancreatic enzymes and bile saltsAbnormal mixingAbnormal mixing-- leads to impaired leads to impaired lypolysislypolysis and micelle formation, nutrient and micelle formation, nutrient malabsorptionmalabsorption

Surgical changesSurgical changesAbsent pancreatic enzymesAbsent pancreatic enzymesDecreased bileDecreased bile

Fat malabsorptionFat malabsorption

Not digestedNot digestedOlestraOlestra

Decreased enzyme Decreased enzyme secretionsecretion

OctreotideOctreotideLipase inhibitorLipase inhibitorDrugs: Drugs: OrlistatOrlistat

Decreased CCK secretionDecreased CCK secretionCongenital CCK Congenital CCK deficiencydeficiency

Decreased CCK secretionDecreased CCK secretionMucosal DiseaseMucosal DiseaseAbsent pancreatic lipaseAbsent pancreatic lipaseCongenitalCongenitalDenature lipaseDenature lipaseZE syndromeZE syndrome

SomatistatinomaSomatistatinomaNeonatalNeonatal

Pancreatic cancerPancreatic cancer

SteatorrheaSteatorrheaRarely, Vitamin D, A, Rarely, Vitamin D, A, K, E deficiencyK, E deficiency

decreased enzyme decreased enzyme productionproduction

Chronic Chronic PancreatitisPancreatitisManifestationManifestationMechanismMechanismDiseaseDisease

Chronic Chronic PancreatitisPancreatitis

7070--80% from ETOH (#1 cause in US)80% from ETOH (#1 cause in US)Tropical (nutritional) most common worldwideTropical (nutritional) most common worldwide>90% of pancreas destroyed before malabsorption >90% of pancreas destroyed before malabsorption occursoccursPresentation with Presentation with steatorrheasteatorrhea, abdominal pain, , abdominal pain, DM, and wt loss (usually from food avoidance)DM, and wt loss (usually from food avoidance)2 features of pancreatic insufficiency from 2 features of pancreatic insufficiency from Chronic Chronic pancreatitispancreatitis--

>30g/day of fecal fat. Bulky, greasy, difficult to flush>30g/day of fecal fat. Bulky, greasy, difficult to flushFatFat--soluble vitamins are usually preservedsoluble vitamins are usually preserved

Impaired Impaired SolubilizationSolubilization

Normal micelle formation requires bile Normal micelle formation requires bile saltssalts

Bile salt binderBile salt binderCholestyramineCholestyramine

Bile salt Bile salt precipitationprecipitation

ZE syndromeZE syndrome

Bile salt Bile salt malabsorptionmalabsorption

IlealIlealdisease/resectiondisease/resection

Bile salt Bile salt deconjugationdeconjugation

Bacterial Bacterial overgrowthovergrowth

Watery diarrhea, Watery diarrhea, steatorrheasteatorrhea, fat, fat--soluble vitamin soluble vitamin deficiencydeficiency

Decreased Bile salt Decreased Bile salt delivery and delivery and synthesissynthesis

PBC, bile duct PBC, bile duct obstructionobstruction

ManifestationManifestationMechanismMechanismDiseaseDisease

Bacterial OvergrowthBacterial Overgrowth

Normally <10^4/ml of lactobacillus, Normally <10^4/ml of lactobacillus, enterococcusenterococcus, gram+ aerobes, , gram+ aerobes, facultative anaerobes in small bowelfacultative anaerobes in small bowelMotility is most important factor in Motility is most important factor in clearing the proximal small bowel clearing the proximal small bowel Bacteria overgrowth is secondary to Bacteria overgrowth is secondary to stasis or recirculation of colonic content stasis or recirculation of colonic content into the small bowelinto the small bowel

Conditions Associated withConditions Associated withBacterial OvergrowthBacterial Overgrowth

StructuralStructuralSurgicalSurgical

GastrojejunostomyGastrojejunostomyIC valve resectionIC valve resectionSurgical loopsSurgical loopsJejunoilialJejunoilial bypassbypass

AnatomicAnatomicDuodenal/Duodenal/jejunaljejunaldiverticuladiverticulaObstructionObstruction

IBD, adhesionsIBD, adhesionsMotorMotor

SclerodermaSclerodermaDMDMIdiopathic pseudoIdiopathic pseudo--obstructionobstruction

HypochlorhydriaHypochlorhydriaAIDSAIDSAtrophic GastritisAtrophic GastritisPPIsPPIsAcid reducing Acid reducing surgery for PUDsurgery for PUD

MiscellaneousMiscellaneousImmunodeficiencyImmunodeficiencyPancreatitisPancreatitisCirrhosisCirrhosis

Bacterial OvergrowthBacterial OvergrowthClinical manifestationsClinical manifestations::

Watery diarrhea, Watery diarrhea, steatorrheasteatorrhea, abdominal pain, , abdominal pain, bloating, wt lossbloating, wt lossVitamin B12 deficiencyVitamin B12 deficiencyElevated or normal Elevated or normal folatefolate

DiagnosisDiagnosisSmall bowel aspirate (>10^5 colonies/ml or strict Small bowel aspirate (>10^5 colonies/ml or strict anaerobes)anaerobes)

TreatmentTreatmentAntibioticsAntibiotics

Often need reOften need re--treatment and rotated monthlytreatment and rotated monthlyBroad spectrum antibioticsBroad spectrum antibiotics-- tetracycline, tetracycline, metronidazolemetronidazole, , quinalonesquinalones, etc., etc.

Impaired mucosal absorptionImpaired mucosal absorption

Villous bluntingVillous bluntingMethotrexateMethotrexateAltered membrane trafficAltered membrane trafficColchicineColchicine

Drug InducedDrug Induced??coliformcoliform bacteriabacteriaTropical Tropical spruesprueLack of plasma cellsLack of plasma cellsAgammaglobulinemiaAgammaglobulinemiaTropherymaTropheryma whippleiiwhippleiiWhippleWhipple’’ssCrypto,IsoCrypto,Iso, MAC, MACAIDSAIDS--relatedrelatedGiardiaGiardia lamblialambliaGiardiaGiardia

InfectionsInfectionsGlutenGlutenCeliac diseaseCeliac disease ? Pan ? Pan MalabsorptionMalabsorption

Load dependantLoad dependantDisease dependantDisease dependant

Celiac likeCeliac likeCeliac likeCeliac like

Flat MucosaFlat MucosaFatsFatsMutation MTPMutation MTPAbetalipoproteinemiaAbetalipoproteinemiaCHOCHODecreased/absent lactaseDecreased/absent lactaseLactase deficiencyLactase deficiency

Normal Appearing MucosaNormal Appearing MucosaMalabsorptionMalabsorptionMechanismMechanismDiseaseDisease

Carbohydrate MalabsorptionCarbohydrate Malabsorption

Most common is lactase deficiencyMost common is lactase deficiencyHighest prevalence in Asians, African Highest prevalence in Asians, African Americans, and Native AmericansAmericans, and Native AmericansSymptoms: increased gas, distention, Symptoms: increased gas, distention, diarrhea, typically without weight lossdiarrhea, typically without weight lossEvaluation: extensive dietary history, and Evaluation: extensive dietary history, and triggers, fecal fat pH< 6triggers, fecal fat pH< 6H2 Breath testH2 Breath test--

Ingest 1g/kg of lactose and measure peak H2 Ingest 1g/kg of lactose and measure peak H2 output from baselineoutput from baseline

Late peak (3Late peak (3--6 hrs) = lactose intolerance6 hrs) = lactose intoleranceEarly peak = Bacterial overgrowthEarly peak = Bacterial overgrowth

Celiac DiseaseCeliac DiseaseInflammatory disease of small intestine due Inflammatory disease of small intestine due to ingestion of gluten (wheat, barley, and to ingestion of gluten (wheat, barley, and rye)rye)Inflammation leads to blunting of small Inflammation leads to blunting of small bowel villousbowel villous

decreased surface areadecreased surface areafluid, electrolyte and nutrient malabsorptionfluid, electrolyte and nutrient malabsorption

1:4500 in the US1:4500 in the USIncreased risk first degree relative, Increased risk first degree relative, individuals with DM or autoimmune thyroid individuals with DM or autoimmune thyroid diseasedisease

Celiac DiseaseCeliac Disease

Clinical presentationClinical presentationExtensive diseaseExtensive disease

Diarrhea, wt loss, vitamin and mineral Diarrhea, wt loss, vitamin and mineral deficiencies, electrolyte abnormalitiesdeficiencies, electrolyte abnormalities

Mild/Moderate diseaseMild/Moderate disease-- selective diseaseselective diseaseAnemia (Iron/ Anemia (Iron/ folatefolate deficiency)deficiency)Bone Disease (Calcium/Vitamin D deficiency)Bone Disease (Calcium/Vitamin D deficiency)Neurological disease (Neurological disease (myopathymyopathy, epilepsy), epilepsy)Psychiatric (depression, schizophrenia)Psychiatric (depression, schizophrenia)

Celiac Disease DiagnosisCeliac Disease DiagnosisGold Standard is Small Bowel BiopsiesGold Standard is Small Bowel BiopsiesAntibody testingAntibody testing

AntiAnti--gliadingliadin –– highly sensitive, not very highly sensitive, not very specificspecificAntiAnti--endomysialendomysial-- 100% specific, lab 100% specific, lab dependent sensitivitydependent sensitivityAntiAnti--tissue tissue transglutaminasetransglutaminase-- sensitive and sensitive and specificspecific

ScreeningScreeningTest for mineral, vitamin deficienciesTest for mineral, vitamin deficiencies

CBC, CMP, Mg, CBC, CMP, Mg, PhosPhos., ., folatefolate, , VitVit B12, B12, VitVitA&E, ZincA&E, Zinc

Celiac DiseaseCeliac Disease

Normal Small Bowel Celiac disease

Atlas of Gastroenterology. 2nd Ed. Yamada.1999 p.285

Celiac DiseaseCeliac Disease

TreatmentTreatmentStrict diet Strict diet

Nutritionist and support groupsNutritionist and support groupsNo barley, wheat or ryeNo barley, wheat or rye

Relapse or not respondingRelapse or not respondingNonNon--adherence to dietadherence to dietMicroscopic colitisMicroscopic colitisLymphoma (TLymphoma (T--cell)cell)Incorrect diagnosisIncorrect diagnosis

Irritable Bowel SyndromeIrritable Bowel Syndrome

DefinitionDefinitionChronic continuous or remittent GI illness Chronic continuous or remittent GI illness characterized by frequent unexplained characterized by frequent unexplained symptoms of abdominal pain, bloating, symptoms of abdominal pain, bloating, fluctuations of diarrhea or constipation fluctuations of diarrhea or constipation or erratic bowel habit.or erratic bowel habit.No recognizable structural abnormality or No recognizable structural abnormality or specific causespecific cause

NetterNetter’’s Gastroenterologys Gastroenterology. . ed. Martin ed. Martin FlochFloch 20052005p 338.p 338.

IBS DiagnosisIBS DiagnosisDiagnostic (Rome) CriteriaDiagnostic (Rome) Criteria

At least 12 weeks or more, in the proceeding 12 months of At least 12 weeks or more, in the proceeding 12 months of abdominal discomfort or painabdominal discomfort or pain2 of 3 required2 of 3 required

relief with defecationrelief with defecationonset with change in stool formonset with change in stool formonset with change on frequency of stoolonset with change on frequency of stool

Supportive symptoms: Supportive symptoms: abnormal stool frequency, form, or passageabnormal stool frequency, form, or passagepassage of mucuspassage of mucusBloating and/or abdominal distention.Bloating and/or abdominal distention.

IBS BackgroundIBS BackgroundMore common in western countries (10More common in western countries (10--15% of 15% of population)population)Women 2Women 2--3 X more likely to have symptoms then men3 X more likely to have symptoms then menMost new cases prior to age 45Most new cases prior to age 45Psychiatric illness 3x more common than organic GI Psychiatric illness 3x more common than organic GI conditions (depression, phobias, anxiety, etc.)conditions (depression, phobias, anxiety, etc.)Most common reason for GI referralMost common reason for GI referral22ndnd highest reason for work absenteeism after the highest reason for work absenteeism after the common coldcommon cold

IBS EvaluationIBS EvaluationCareful history and physicalCareful history and physical

Recurrence of abdominal pain with altered bowel Recurrence of abdominal pain with altered bowel habitshabitsOnset of symptoms at times of stressOnset of symptoms at times of stressAbsence of systemic symptoms (fever, weight loss)Absence of systemic symptoms (fever, weight loss)SmallSmall--volume stool without bloodvolume stool without bloodNo nocturnal stoolsNo nocturnal stoolsWorse in the morning and better throughout the dayWorse in the morning and better throughout the day

Evaluate for Evaluate for ““red flagsred flags””Blood on stoolBlood on stoolWeight changeWeight changeNight time symptomsNight time symptomsFamily history of IBD or cancerFamily history of IBD or cancerLab or physical abnormalitiesLab or physical abnormalities

IBS IBS Diagnostic studiesDiagnostic studies

Based on patients age of onset, duration of Based on patients age of onset, duration of symptoms, family historysymptoms, family history

CBC and chemistry profileCBC and chemistry profileCeliac disease (diarrhea)Celiac disease (diarrhea)

Young with diarrheaYoung with diarrhea-- colonoscopy to colonoscopy to r/or/o IBDIBD>40>40-- colonoscopy to colonoscopy to r/or/o neoplasmneoplasmRule out lactase deficiency in patient with Rule out lactase deficiency in patient with excess diarrheaexcess diarrhea-- diet trialdiet trialIf abdominal pain is If abdominal pain is epigastricepigastric-- EGDEGDPostprandial RUQ painPostprandial RUQ pain-- U/SU/SAny abnormal test results exclude IBSAny abnormal test results exclude IBS

IBSIBS

SleisengerSleisenger and and FordtranFordtran’’ss Gastrointestinal and Liver DiseaseGastrointestinal and Liver Disease. 7th edition. 2002. p1802... 7th edition. 2002. p1802..

IBSIBS

TreatmentTreatmentCounseling and DietaryCounseling and DietaryStool bulking agentsStool bulking agentsAntispasmodicAntispasmodicAntidiarrhealAntidiarrhealAntidepressantsAntidepressants

Case #1Case #1

32 32 y/oy/o white female with a history of anxiety white female with a history of anxiety and depression presents with a 6 month history and depression presents with a 6 month history of urgency and gas/bloat symptoms. She has of urgency and gas/bloat symptoms. She has formed stool, small volume, 4formed stool, small volume, 4--6 times a day. No 6 times a day. No blood. Occasional mucus. Denies abdominal blood. Occasional mucus. Denies abdominal pain. Has tried Imodium. This impacts her life pain. Has tried Imodium. This impacts her life in that she is scared to fly or go on a date, and is in that she is scared to fly or go on a date, and is often late for work due to her bowel habits.often late for work due to her bowel habits.

Case #2Case #2

82 82 y/oy/o white female with 3 year history of white female with 3 year history of profuse watery diarrhea. No medical problems profuse watery diarrhea. No medical problems and takes a vitamin daily. She denies blood in and takes a vitamin daily. She denies blood in her stools, some urgency and occasional night her stools, some urgency and occasional night time stools. She has a history of a time stools. She has a history of a cholecystectomycholecystectomy and and ““bowel surgerybowel surgery”” due to a due to a complicated ulcer 3 years ago. She has tried complicated ulcer 3 years ago. She has tried cholestyraminecholestyramine without results.without results.

ReferencesReferences

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