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GIT.Malabsorption Syndrom

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GIT.Malabsorption Syndrom Powered By Docstoc
					             In Capsule Series                                         G.I.T.

                                 Malabsorption Syndrome
             ** Def:
                - Failure of absorption of one or more of the nutrient (fat,
                       ptn, CHO, minerals, vit.),
                - Steatorrhea (fatty stool) remains the main mark of
                       malabsorption. (>6gm/d).


             ** Causes:
                I-       Gastric Causes:
                           1- Gastrectomy.
                           2- Atrophic gastritis.
                           3- Cancer stomach → achlorhydria (↓HCl)→ Bact.
                              Contamination of intestine.
                           4- Zollinger-Ellison's syndrome → hyperchlorhydria
                              → ↑ HCl → inhibits pancreatic lipase.
                II-      Hepato-biliary Causes:
                           1- Liver cirrhosis
                           2- Chronic hepatitis.
                           3- Biliary obstruction.
                           4- Biliary fistula.
                III-     Pancreatic Causes:
                           1- Chronic pancreatitis
                           2- Cystic fibrosis dis. Of pancreas.
                           3- Cancer head of pancreas.
                           4- Pancreatectomy.




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             In Capsule Series                                             G.I.T.
                IV-   Intestinal Causes:
                A) Primary steatorrhea:
                        1- Tropical sprue: unknown aetiology but may be:
                       → Bacterial infection.
                       → folic acid deficiency.
                        2- Non-tropical          sprue        (Gluten   sensitive
                           enteropathy) inborn sensitivity to gluten (a ptn
                           commonly found in wheat) → Ag. Ab reaction →
                           impairs absorption of all food elements d. to
                           damage of intestinal mucosa.
                B) Secondary to intestinal diseases:
                1- Short gut syndrome: extensive intestinal resection → ↓
                   absorptive surface.
                2- Stagnant (blind) loop syndrome: part of S.I. is
                   narrowed so, there is stagnation of intestinal content →
                   ↑↑ bacterial growth which compete the host for vit B12 &
                   other contents. e.g.: strictures of S.I, Diverticulosis.
                   Hypothyroidism, intestinal myoputhy.
                3- Systemic diseases: Diabetic neuropathy, amyloidosis,
                   collagenosis.
                4- Infection:
             • Bacterial over growth.
             • T.B enteritis, Giardia, Strongeloides.
               5- Inflammation:
             • Crohn's disease.
             • Irradiation.
               6- Iatrogenic:
                     * Dendivan (anticoagulant). * Neomycin.


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             In Capsule Series                                                G.I.T.
                7- Lymphatic obstruction:
             • Lymphoma
             • Whipple's dis. (mainly affects MAN) → Malabs. Syndrome,
                Anemia, Neuropathy, lymphadenopathy.


             ** Clinical picture:
                I-      General manifestations:
                     1- loss of weight.      2- fatigue.
                     3- fever                     4- clubbing of fingers.
                II- Intestinal manifestations:
                        1- Steatorrhea: Stool is Pale, bulky, offensive, floats
                           on water, greasy, glistening.
                        2- Diarrhea:      malabsorption       usually   results   in
                           diarrhea.
                        3- Audible intestinal sounds (borborygmi).
                        4- Distension, colics.
                III- Nutritional deficiency:
             • ptn → muscle wasting, oedema.
             • Fats → loss of weight.
             • CHO → hypoglycaemia.
             • Minerals: Iron → anaemia.
                                       Na → Muscle cramps, hypotension.
                                       K → arrhythmia.
                                       Ca, Mg → tetany.
                                       Iodine → Goitre.
             • Vitamins: A → night blindness, follicular hyperkeratosis.


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             In Capsule Series                                                 G.I.T.
                                     D → Rickets, osteomalacia.
                                     E → infertility.
                                     K → Bleeding tendensy.
                                     C → Scurvy
                                      B1 → Beri – Beri
                                      B2 → glossitis – gastritis
                                      B3 → Diarrhea, Dermatitis, Dementia.
                                      B6 → peripheral neuritis.
                                      B12 → Megaloblastic anaemia.
                 IV- C/P of the cause:
                 - History of surgical operation.
                 - T.B: toxaemia, chest infection.


             ** Investigation:
                 I- Biochemical investigation:
                        1- Estimation       of   foecal     fat:   n=   6   gm/d   in
                           steatorrhea → >6 gm/d.
                                 à if split fat → intestinal dis.
                                 à Non split fat → pancreatic dis.
                        2- Pancreatic function tests.
                        3- Sugar curve flat curve
                        4- D-xylose test:
             -   normally, 25 gm D-xylose orally → 5h urine should
                 contrain at least 5 gm (20%)
             - if < 5 gm in 5h urine → malabsorption.


                 II-   Haematological Investigations:

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             In Capsule Series                                                G.I.T.
                        1- Blood picture: Anaemia. (Microcytic anemia due to
                           iron deficiency or macrocytic anemia due to vit B12
                           or Folate malabsorption.
                        2- Plasma ptn: hypoproteinaemia.
                        3- Serum electrolytes.
                        4- Prothrombin       time:    may      prolonged   bec.   of
                           malabsorption of vit. K.
                III-    Radiological investigations:
                        - CT        - MRI             - U.S.
                        - Barium meals: - S.I. → Dilated >25mm
                                           - loss of feathery app.
                IV-     Aspiration of Jejunal content à then culture.
             ** Treatment:
               1-   ϖ   of the cause:
                - T.B entritis → anti tuberculous drugs.
                - Stricture → surgical
                - Tropical sprue → antibiotic & folic acid.
                - Gluten sensitive ent. → cortisone.
                                           → elimination of gluten from diet.
                2- Diet: Low fat, low fibers, non irritant diet.
                3- Parentral vitamins, minerals, fluid.
                4- Synptomatic     ϖ    : - Antidiarrheal drugs
                                              à Difenoxylate (Lomotial).
                                               à Loperamide (Loperazin).




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             In Capsule Series                                               G.I.T.

                                              Diarrhea

              Def:
                   It means ↑↑ liquidity of stool and / or ↑↑ quantity
                   (N=150-200g/d) or ↑ frequency (N: 4 motions/d).
             AE:
             I- AE of acute diarrhea:
                1- Infection:
                   * Bacterial: Salmonella                 Shigella
                                     E.coli                Cholera
                     * Viral:       Rota virus
                                      Norwalk virus
                     * Protozoa: E.histolytica
                                      Malaria
                                      Giaradia
                     * Helminthes: Ascaris, strongyloids stercoralis.
                2- Iatrogenic:
                             * Laxatives               * Antibiotic
                             * Chemotherapy            * Allopurinol
                         * Para $                      * Mg cont. antacid.
                3- Toxins:
                             * Bacterial: staph, E.coli
                             * Lead                   * arscenic
                4- Diet:
                             * Unripe fruit           * Alcohol
                             * Mashroom.

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             In Capsule Series                                                 G.I.T.
                    5- Nervous: psychological stress e.g: before
             examination.


             II. AE of chronic diarrhea:
               - The same as malabsorption syndrome.


             Mechanisms of Diarrhea:
             i. Osmotic diarrhea: Substance in intestineal lumen
             maintain fluid &           prevent absorption (e.g: lactulose,
             sorbitol, mg laxative).
             ii-     Secretory diarrhea:         ↑↑     secretion    of   water &
             electrolytes into the lumen (watery D) e.g: cholera.
             iii-     Abnormality      of     intestineal     motility:   ↑↑    e.g:
             Thyrotoxicosis, IBS, D neuropathy.
             iv-       Abnormality       of     intestineal        mucosa.      e.g:
             inflammation.


             N.B: - Osmotic diarrhea: Stops with fasting.
                       - Secretory diarrhea: Continues with fasting.

             - Complication:
                      ↓ H2O → dehyderation.
                      ↓ K → hypokalemia.
                      ↓ HCO3 → Acidosis.



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             In Capsule Series                                      G.I.T.

             - Diagnosis:
             1- History analaysis:
             - Frequency: >4/d → diarrhea
             - Consistency: - watery: infilammation
                                 - greasy: malabsorption.
             - Associated symptoms:
                * Abd pain: all causes except drug induced &
                Thyrotoxicosis.
                * Nausea & vomiting: Acute infections.
                * Fever: infection, inflammation.
                * Constipation: IBS.
             2- Examination:
                 * abdominal tenderness
                 * bowel sounds
                 * degree of general hydration
                 * examination per rectum: to exclude rectal mass or
             blood.
             3- Investigations: 4S
             not every patient who presents with diarrhea needs to be
             evaluated with these expensive tests, watchfull waiting &
             symptomatic therapy with oral fluid are very enough.
             * Stool examination: - for ova, cysts & parasite
                                         - stool osmolarity
                                         - fat assay.
             * Sigmoidoscopy: if large bowel cause suspected.


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             In Capsule Series                                                   G.I.T.
             * Small bowel radiology: if small bowel cause suspected.
             * Serological tests:
                    + other invest. Of malabsorption syndrome in case of
                    chronic diarrhea (see before).
             Treatment: 3 S
             - Specific                Symptomatic                        Supportive
             - Specific: ϖ of the cause.
             - Symptomatic: * Anti D: Difenoxylate (lomotil)
                                          Loperamide (loperazine)
                                 * Anti emetic: motilium
             - Supportive:
                  - Diet: ↓ fat, ↓↓ irritant, light diet
                  - ϖ of complication: Fuid. – K – HCO3

                                          Dysentery
             Def:
                    Diarrhea + Tenesmus + Blood + mucous in stool.
                    Tenesmus:         painful    defecation        with     sense      of
                    incomplete bowel evacuation.
             AE: A: Amoebic dysentery
                  B: Bacillary dysentery, B dysentery.
                  C: Cancer colon, rectum.
                  D: Diverticolosis.
                  M: Malaria
                  R: Renal failure
                  G: Giardia (v.v. rare).


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             In Capsule Series                                              G.I.T.
             Dysentery Scheme:
                - Causative organism
                - Mode of infection
                - C/P: * Asymptomatic
                         * Symptomatic
                         * Complication
                - Investigation:             4S
                - ϖ:                         3S

                                  Amoebic dysentery
             • Causative organism: E. histolytica (cyst)
             • Mode of infection: feaco-oral.
             • C/P: Asymptomatic symptomatic complication
                   1- Asymptomatic: cysts in lumen.

                   2- Symptomatic: Acute – chronic
                         Acute:
                          Symptoms: dysentery: - Diarrhea
                                                       - Tenesmus
                                                       - blood in stool
                                                       - mucous in stool.
             N.B: Diarrhea: mild (8/d)
             Signs: - Local: Tenderness in colon esp. ceacum &
             sigmoid.
                       - General: - No fever: (superficial lesion)
                                   - No dehyderation (mild diarrhea)

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             In Capsule Series                                      G.I.T.
                         Chronic:
                          - recurrent attacks of acute dysentery.
                          - sometimes the patient may present by pain
                          (caecum, appendix, T. colon).
                   3- Complication:
                         Local: Amoeboma
                         Systemic: Amoebic hepatitis (see liver).
             Investigations: 4S
                   - Stool examination: cyst, mucous, blood.
                   - Sigmoidoscopy: flask shaped ulcer with intervening
                   healthy mucosa.
                   - Small bowel radiology
                   - Serological tests.
             ttt : 3 S
                   - Specific (antiamoebic)
                   - Symptomatic
                                         Like diarrhea
                   - Supportive


             * Antiamoebic drugs:
             I- Luminal: used for ϖ of cysts (chronic amoeba)
                1- Halogenated quinoline e.g:
                    di-Iodo-hydroxy quinoline
                    SE: Neuropathy, goiter
                    Dose: 500 mg t.d.s for 2 w



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             In Capsule Series                                     G.I.T.
               2- Phenanthroline quinines (Entobex)
                                      500 mg t.d.s for 2 w
               3- Diloxanide:
               4- Furamide 500 mg t.d.s for 1 w
               5- Antibiotic: paromomycin & erythromycin are directly
                   amoebicidal.
             II- Systemic drugs: (Acute & extra intest. Manifestation):
             Have no effect on cyst in intestinal lumen
                1- Emetine: SE: Cardiotoxicity
                2- Dehydroemetine: less toxic
                3- Chloroquine: used in hepatic amoebiasis.
             III- Lumin & systemic (Mixed):
             - Metronidazole (Flagyl)
             - Dose: 500 mg t.d.s for 10 days.
             - SE: nausea, metallic taste.




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             In Capsule Series                                            G.I.T.

                                   Bacillary dysentery
             Causative organism: G-ve bacilli (shigella)
             Mode of infection: feaco-oral.
             C/P: Asymptomatic               symptomatic           complication
             Symptomatic:
               1st phase: 1-2 days (mild)
                            fever – colic – diarrhea
               2nd phase: 1-2 dysentery:
                   (diarrhea – tenesmus – mucous – blood in stool).
             Diarrhea: severe 15-20 /d
             Tenesmus: (colic)
             General signs: fever & dehydration.
             Complication:
             Bacteramia: (urethritis – arthritis – iridocyclitis)
             Investigation: 4S
             - Stool examination: Culture: shigella pus (WBCs)
             - Sigmoidoscopy: diffuse inflammation with dirty yellowish
               pseudomembrane.
             - Small bowel radiology.
             - Serological test.
             ttt : - Specific
                   - Symptomatic
                                         Like diarrhea
                   - Supportive
             Specific ttt:
             - Ampicillin: 500 mg / 6h
             - Tetracycline: 2.5 gm in single oral dose.
             - Septrin (Co. Trimexazole) 2 tab twice daily for 5 days.


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             In Capsule Series                                       G.I.T.

                                   Bilharzial dysentery
             - Causative organisms: S.mansoni
             - Mode of infection:
                    infection occurs when i parasite penetrates i skin
             duing swimming in infected water.
             C/P:
             Asymptomatic symptomatic                 complication
             Symptomatic:
             (1) Dysentery (severe)
                    à Diarrhea
                    à Tenesmus
                    à Mucous
                    à Blood in stool
             (2) Bleeding per rectum
             (3) Pericolic mass in left iliac fossa.
             (4) HSM, clubbing.
             Complications:
             - Liver B
             - B cor pulmonale
             - Investigations:               3S + 2 B
             - Stool analysis: ova
             - Sigmoidoscopy: ulcers or polyps mainly in recto-
                sigmoid area.
             - Serological test: by ELISA
             - Barium enema: polyps.
             - Blood picture: Anemia – esinophilia.



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             In Capsule Series                                         G.I.T.

             Treatment:
             - Specific
             - Symptomatic
             - Supportive                      Like diarrhea

             Specific ttt : (antibilharzial drugs):
                1- Praziquntel
                2- Niridazole
                3- Antimonial drugs.
                4- Metrifonate
                5- Mirazid.
             Praziquentel: is i most effective drug.
                  • mech. of action: ↑↑ cell membrane permeability to
                     ca à marked contraction. & spastic paralysis of
                     worm.
                  • Dose: 40mg/ kg single dose or 20mg/ kg 3 times /
                     w`.
                  • S/E: headache, nausea, vomiting, pruritis, fever,
                     elevation of liver enzymes.

                                           Vomiting
             Def.: forceful expulsion of gastric content into mouth.
             Mech.: (vomiting reflex) :
                                             à stimulus
                                             à centre
                                             à response (vomiting)
                  • stimulus:          - peripheral e.g.: GIT
                                       - Centeral e.g.: ↑ ICT
                                       - Metabolic e.g.: ureamia

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             In Capsule Series                                           G.I.T.

                   • centre : vomiting centre in medulla.
                   • Response: vomiting.
                                       à Pylorus is closed.
                                       à cardia is opened
                                       à contraction of diaphragm.
             AE:
             I- Peripheral causes: (GIT causes)
                    - Gastritis        - peptic ulcer – cancer stomach
                    - Hepatitis        - pancreatitis - Appendicitis
                    - Cholecystitis - peritonitis
                    - pyloric opstruction – intestinal opstruction.
             II- Central causes:
             - Psychic : bad smell, sight.
             - Hysterical.
             - ↑ ICT: Tumour , Hge.
             - Pain: migraine, MI, renal colic.
             III- Metabolic causes:
             - Renal failure.
             - Liver cell failure.
             - Acidosis (DKA).
             - Alkalosis.
             - Electrolyte: ↑ Ca, ↓ Na, ↓ or ↑K
             IV- Iatrogenic:                 MAD
                    M : morphine.
                    A : Alcohol.
                    D : Digitials.




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             In Capsule Series                                               G.I.T.

             V- Pregnancy:


             * Diagnosis of a case of vomiting:
                   à Clinical              à History analysis.
                                           à examination.
                   à Investigation.


             I- History analysis:
                   1- Time of vomiting:
                          * Early morning :            - Pregnancy
                                                       - ↑ ICT
                                                       - Alcohol
                          * During meal :              oesoph. Obstruction
                                                       oesoph. Regurge.
                          * After meal by:
                                 1
                                     2   h : Gu
                                 2-4 h : Du
                                 > 8h : Intestinal obstruction.
                   (2) Associated nausea:
                          upper GIT causes.
                                 - No nausea: ↑ ICT
                   (3) Associated Abd. Pain: (GIT causes)
                          * peritonitis                * intestinal obst.
                          * pancreatitis               * cholecystitis
                          - painless vomiting: Neurological causes:
             N.B.: Vomiting relief pain: Gu.




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             In Capsule Series                                                 G.I.T.

                    (4) Associated headache: ↑ ICT.
                    (5) History of drug intake : MAD
                    (6) Biliary symptoms:
                          ‫ﺻﻔﺮا – ھﺮش – أﻟﻢ ﺑﺎﻟﺠﻨﺐ اﻟﯿﻤﯿﻦ – ﺗﻐﯿﺮ ﻓﻰ ﻟﻮن اﻟﺒﻮل أو اﻟﺒﺮاز‬
             - Jaundice
             - Pruritise
             - Abd. Pain
             - Color of urine & stool.
                    (7) Frequency: Persistent in peritonitis.
             II- Examination of vomiting:
             i. Content : undigested food: pyloric obst.
                          bile: below ampulla of vater
                          blood: ulcer, cancer, Mallory weiss $
                          F.B.: gall stone.
             ii- Odour: offensive: Malignancy, int. obstruction.
             III- Investigations:
             inv. For the causes.
             ttt:         * Specific: for i cause
                          * Symptomatic:              à Antiemetic
                                                           * motilum
                                                           * primpran
                                                      à IV nutrition
                                                      à Antidiarrheal
                          * Supportive: correct dehyderation & electrolyte
                          imbalance




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             In Capsule Series                                     G.I.T.

                                     Acute Pancreatitis
             AE:
             - gall stone
             - Alcohol
             - Viral infection e.g.: mumps
             - Hyper lipidemia.
             N.B.: gall stone is the most common causes
                    à back regurge of trypsin enzyme (autodigestion)
             C/P:
             - Abd. Pain: epigastric pain radiating to back.
             - Nausea & vomiting.
             - Tenderness & rigidity.
             - Cullen sign: umbilical ecchymosis.
             - Grey turner's sign: ecchymosis in flanks.
             Complications:
             - Abscess.
             - Hypocalcemia.
             - DIC
             - HF, Renal failure, Respiratory failure.
             Investigation:
             - Serum amylase: ↑↑ (5 times)
             - X ray, US, CT: gall stones.
                                      - swollen pancreas
                                      - calcification.
             ttt:
             - Nasogastric suction.
             - IV nutrition.
             - Somatostatin infusion

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             In Capsule Series                                       G.I.T.

                                  Chronic Pancreatitis
             AE: chronic alcoholism
             C/P: Triad          i- Abd. Pain: radiate to i back.
                                 ii- DM
                                 iii- steatorhea (malabsorption $)
             Investigation:
             - Like acute pancreatitis.
             - Calcification
             ttt: stop alcohol + symptomatic
                                       à pain: Analgesics
                                       à ttt of DM
                                       à ttt of steatorhea

                                 Cancer Head of Pancreas
                   à painless obstructive jaundice
                   à loss of weight
                   à Anoroxia

                                 Cancer Body of Pancreas
                   à Pain: radiate to back
                   à Jaundice: rare.




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             In Capsule Series                                                  G.I.T.

                            Inflammatory Bowel Disease
             - Crohn's disease & ulcerative colitis are both chronic
                inflammatory diseases of the GIT.
             - Aetiology:
                  • is still questionable.
                  • Most probably autoimmuno. (The local Tcells are
                     angry with something in common food !!).
                  • Genetic factor: play a great role.
                  • Infections (T.B, measles): not confirmed.
                  • Psychological factor may play a role.
                                      Crohn's disease              Ulcerative colitis
             Pathology:               Affects any part of GIT      - Limited to colon &
              Site:                   from mouth to anus,          rectum.
                                      esp. terminal ileum          - Terminal ileum can be
                                      (70%).                       affected in 5% only

              Layers             All three (transmural)    - Mucosa only
              Granuloma          Yes in (30%)              No
                                 N.B:       finding     of
                                 granuloma = crohn's
                                 disease
              Crypt abscesses    No                        Yes (30%)
                                                           N.B: finding of crypt
                                                           abscesses = ulcerative
                                                           colitis
              Fibrosis           Server                    No
              Pattern of colonic Skip lesions              Continuous involvement
              involvement
             C/P:
              Sex                     Equal                      Slightly more in ♀
              Age                     No specific age            30-40 4`
              Smoking                 ↑↑    incidence         in ↓↓ incidence in smokers
                                      smokers                    (80% non smokers)
              Abd. Pain:              Prominent                  Less prominent
              Diarrhea                Yes                        Yes       (severe    &
                                                                 sometimes dysentery)


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             In Capsule Series                                                   G.I.T.

                                     Crohn's disease               Ulcerative colitis
             Bleeding            per Uncommon                      Common
             rectum
             Anal & oral lesions Yes                             No
             Bowel obstruction May be                            No
             Malabsorption           May be                      No
             syndrome
             Intestinal fistula      May by                      No
             B12 deficiency          May be                      No
             Carcinoma risk           Minor                      High
             Systemic        (extra The same
             intestinal)
             manifestations
                             • skeletal : Arthritis,
                             • skin: erythema nodosa pyoderma gangrenosa.
                             • Liver: fatty liver – sclerosing cholangitis
                             Eye: uveitis, iritis
                                     Crohn's disease             Ulcerative colitis
             Investigation
                Radiological         - deep ulcers (cobble - shortened               colon,
                                         stone),     area    of     absence of hustra
                                         narrowing       in   i     (lead pipe sign)
                                         ileum.                  - pseudo        polyposis
                                     - Skip lesion                  15%.
                                     - Fistula & strictures.
                Colonoscopy & - Show involvement - Limited to i mucosa
                biopsy                   of i entire bowel          & may have crypt
                                         wall é granuloma           abscesses.
                                         formation.




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             In Capsule Series                                                 G.I.T.

                                               Medical
             Treatment:
                                               Surgical
             Medical ttt:
                1- Sulfasalazine: reduce inflammation esp in ulcerative
                    colitis.
                2- Cortisone: (prednisolone): This                 is i main ttt for
                    active disease 40-60mg/d.
                3- Immuno suppressants: Azathioprine (Imuran).
                4- Antibiotics: Metronidazole & ciprofloxacin.

             Surgical ttt:

             Indications:        * Failure of medical ttt.
                                 * Complications




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