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Description : GIT presentation for small intestine disease

Tags : Intestine Diseases,Malabsorption Syndrome,Irritable Bowel Syndrome

Published on : Sep 09, 2022 | Views : 1362 | Downloads : 4

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GASTROENTEROLOGY Dr. mohamed abobkar sharif mbbs, m.med Abubashir hospital Horn of Africa university Faculty of medicine 1
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CHAPTER FOUR Small intestine Diarrhea Irritable bowel syndrome Malabsorption Miscellaneous intestinal diseases Tumors of the small intestine 2
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Test case A 35-year-old woman presents complaining of 5 days of diarrhea . She has had 5 bowel movements a day since returning from a vacation in Mexic o. She has mild abdominal cramping but no fever, blood in stool, or vomitin taken any recent antibiotics and takes no medications. On exam:Afebrile. HR 100/mi.n BP 112/65 mm Hg A. bdomen is soft and nontender. What is the most appropriate management? What is the your diagnosis 35-year-old Woman Complaining of 5 Days of Diarrhea g. She has not Review of systems is Acute diarrhea with a recent travel history unremarkable Mild hypovolemia
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Diarrhoea The word ‘diarrhoea’ comes from the Greek meaning ‘to flow through’. It is a very common manifestation of GI disease with many causes. There are many definitions but commonly it is accepted is:- Diarrheais the passage of watery or loose stools,at least 3 times in 24 hours. 4
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Acute diarrhea < 14 days in duration Persistent diarrhea Chronic diarrhea Invasive diarrhea Diarrheawith visibleblood or mucus Important Definitions According To Duration
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Pathophysiology Osmotic diarrhoea The gut mucosa acts as a semipermeable membrane and fluid enters the bowel if there are large quantities of non-absorbed hypertonic substances in the lumen. This occurs because the patient: Has ingested a non-absorbable substance (e.G. A purgative, such as magnesium sulphate or magnesium-containing antacid) Has generalized malabsorption, so that high concentrations of solute (e.G. Glucose) remain in the lumen Has a specific absorptive defect (e.G. Disaccharidase deficiency or glucose-galactose malabsorption). The volume of diarrhoea produced by these mechanisms is reduced by the absorption of fluid by the ileum and colon. The diarrhoea stops when the patient stops eating or the malabsorptive substance is discontinued. 6
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Cont.. Secretory diarrhoea In this disorder, there is both active intestinal secretion of fluid and electrolytes, and decreased absorption. The mechanism of intestinal secretion Common causes of secretory diarrhoea are: • Enterotoxins (e.G. Cholera, E. Coli, C. Difficile toxin) • Hormones (e.G. Vasoactive intestinal peptide in verner–morrison syndrome;) • Bile salts (in the colon) following ileal resection • Fatty acids (in the colon) following ileal resection • Some laxatives (e.G. Docusate sodium). 7
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Cont… Inflammatory diarrhoea (mucosal destruction) Diarrhoea occurs because of damage to the intestinal mucosal cell so that there is a loss of fluid and blood. In addition, there is defective absorption of fluid and electrolytes. Causes are usually infective (e.g. dysentery due to Shigella) or inflammatory (IBD). Abnormal motility Diabetic, post-vagotomy and hyperthyroid diarrhea are all due to abnormal motility of the upper gut. Symptoms may be exacerbated by small bowel bacterial overgrowth. 8
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Acute diarrhoea Acute diarrhoea is defined as lasting less than 14 days. The cause is usually infectious, most commonly viral in children but sometimes bacterial (usually more severe cases). Common infectious causes include: • Viral infection, e.g. norovirus or rotavirus • E. coli food poisoning (causes a secretory diarrhoea) • Food poisoning from Salmonella, Campylobacter or Staphylococcus Bacteria • Clostridium difficile infection (usually due to recent course of antibiotics) • Contaminated food or water (‘traveller’s diarrhoea’), often Giardia or Entamoeba histolytica. 9
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Acute Diarrhea Bacteria associated with bloody diarrhea: Shigella Salmonella E. coli (enterohemorrhagic) Yersinia Vibrio Entamoeba Campylobacter In developed countries, most common causes are viral gastroenteritis or foodborne illness. Organismsassociated with acute watery diarrhea: Viral: norovirus, rotavirus, adenovirus, etc. Bacterial: Salmonella,Shigella, enterotoxigenicE. coli, Campylobacter, Clostridium Protozoal: Cryptosporidia, Giardia, Cyclospora, Entamoeba
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Clinical features associated with acute diarrhoea include fever, abdominal pain and vomiting. Stools are usually loose and watery but can also be bloody. If the diarrhoea is severe then dehydration can occur, especially in very young or elderly patients. INVESTIGATION Stool sample to try to isolate an organism. Stool microscopy culture sensitivities (MCS) should be sent in all patients. Samples for C. difficile toxin should be sent in at risk patients (elderly, nursing home residents, recent antibiotic 11
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Cont… Stool for ova, cysts and parasites should be sent in the following cases: • Persistent diarrhoea (>14 days <30 days) • Men who have sex with men • Immunocompromised patients • Recent travel abroad • If suspecting giardiasis/amoebiasis/cryptosporidium. 12
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 Severe abdominal pain Fever Bloody stools    Recent hospitalization or antibiotic use (risk forClostridium difficileinfection) Special population: elderly, immunocompromised, patients with inflammatory bowel disease, pregnancy  What Are Alarm Features in Acute Diarrhea? Lab studies are not indicated in acute diarrhea unless one or more alarm featuresare present.
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Management Management of acute diarrhoea usually focuses on volume repletion, usually with oral rehydration solutions that contain water, salt and sugar. In severe cases of dehydration, patients may need to be admitted to hospital for intravenous fluid resuscitation. Antibiotics are not usually empirically given unless it is a particularly severe case or complications develop. Antimotility agents (e.g. loperamide) should be avoided if possible. 14
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Indications for antibiotic treatment include: • severe/prolonged symptoms (>5 days) • systemic signs of infection • extremes of age • immunocompromise • presence of complications • bloody or mucoid stools. 15
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Chronic diarrhoea This is defined as diarrhoea present for longer than 30 days(2-4weeks). A thorough history is important including the onset, timeframe and severity of symptoms. Important points to address are any associated features such as bloody stools, abdominal pain, weight loss, steatorrhoea, recent changes in medication, food/other triggers and a full past medical history. A full examination is needed. Initial investigations should include: • full blood count, serum creatinine and electrolytes, thyroid function • coeliac screen (tissue transglutaminase (TTG) or endomysial antibodies (EMA) antibodies) • stool MCS, C. difficile toxin. Management of chronic diarrhoea involves treating the underlying cause 17
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Chronic diarrhea Diagnostic Algorithm for Chronic Diarrhea Send initial testing:fecal calprotectin, occult blood, colonoscopy, smallbowel imaging If abnormal: work up for inflammatory bowel disease or cancer If normal: check stool osmotic gap, fecal fat Exclude:causes of acute diarrhea, lactose intolerance, IBS, prior gastric/ileal resection, parasitic infection, medications, systemic disease
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Diagnostic Algorithm for Chronic Diarrhea If normal: Increasedosmoticgap Normal osmoticgap Increased fecal fat Malabsorption syndromes Pancreatic insufficiency Bacterialovergrowth Normal fecal fat Lactose intolerance Sorbitol, lactulose Laxative abuse Normal stool weight Increasedstool weight Irritable bowel • syndrome (IBS) Factitious diarrhea Secretory laxativeabuse (> 1000 g/24h)
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20 Comparison of acute and chronic diarrhea
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TAensstwcearse A 35-year-old woman presents complaining of 5 days of diarrhea . She has had 5 bowel movements a day since returning from a vacation in Mexic o. She has mild abdominal cramping but no fever, blood in stool, or vomitin taken any recent antibiotics and takes no medications. On exam:Afebrile. HR 100/mi.nBP 112/65 mm HgA. bdomen is soft and nontender. What is the most appropriate managemen?t Answer:No alarm features present manage with supportive care (oral rehydration therapy) 35-year-old Woman Complaining of 5 Days of Diarrhea g. She has not Review of systems is Acute diarrhea with a recent travel history unremarkable no alarm symptoms forinvasive diarrhea Mild hypovolemia Diagnosis: acute diarrhea, likely foodborneillness due to recent travel
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TAensstwcearse A 32-year-old woman is seen fo r 6 months of intermitte nt diarrhea alternating with periods of constipatio n. She frequentlypasses mucuswithstraining, and complains of abdominal discomfort and bloating that is relieved aft er she has a bowel movement . She has no fever, bloody stool, or weight loss. On exam: Normalvitals. Abdomendiffuselytender to light palpation but without rebound tenderness or guarding. Rectal examnormal. Lab studies show normal electrolytes and a normal hemoglobin. Answer: irritable bowel syndrome (IBS) A 32-year-old Woman with 6 months of Intermittent Diarrhea Chronic intermittent diarrhea withoutalarm features Abdominal pain associated withbowel movements Normal exam and labs suggest functional disorder
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Functional bowel disorder Presents with change in bowel habits associated with abdominal pain or distension,mucus stools, and relief or worsening of pain with bowel movement Symptoms worsen with stress Diagnosis of exclusion Irritable Bowel Syndrome (IBS) Stress Anxiety Depression Diarrhea Constipation CNS ANS & Enteric nervous system Intestines Smooth muscle
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Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder IBS – a multisystem disorder IBS patients suffer from a number of non-intestinal symptoms, which may be more intrusive than the classical features. IBS coexists with chronic fatigue syndrome fibromyalgia and temporomandibular joint dysfunction. Symptoms of anxiety and depression are more common in IBS patients, and stress or adverse life events often precede the onset of chronic bowel symptoms 24
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Diagnosis Diagnostic criteria state that, there should be at least 1 day per week in the last 3 months of recurrent abdominal pain associated with two or more of the following: 1. Related to defecation. 2. Onset associated with a change in frequency of stool. 3. Onset associated with a change in form (appearance) of stool. Subgroups of IBS patients can be identified according to the criteria listed. The decision as to whether to investigate and the choice of investigations should be based on clinical judgement. Pointers to the need for thorough investigation are the presence of the above symptoms in association with rectal bleeding, nocturnal pain, fever and weight loss, and a clinical suspicion of organic diarrhoea. 26
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Irritable Bowel Syndrome (IBS) Management Reassurance Fiber supplements Antidiarrheals Laxatives depending on predominant symptom
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Malabsorption syndrome is theinability to absorb nutrients due to an underlying condition. It most commonly involves the small bowel. What Is a Malabsorption Syndrome?
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The major disorders of the small intestine that cause malabsorption 29
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How Does Malabsorption Occur?
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Immune-mediated reaction to gluten and gliadins Presents with weight loss, steatorrhea, nutritional deficiencies Diagnosis:test for ant-itissue transglutaminase (TTG) or an-ti endomysial(EMA) antibodies Endoscopy/colonoscopy:villous blunting, intraepithelial lymphocytes Treatment:gluten-free diet Celiac Disease
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Thank You Dr. mohamed abobkar sharif +252613829727 Shariifcubayd@gmail.com www.dr.mash.com 32