Chronic diarrhea - a case based approach

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Published on July 5, 2008

Author: kishanvuddanda

Source: authorstream.com

Malabsorption syndromes – A case based approach : Malabsorption syndromes – A case based approach Slide 2: a case based approach Malabsorption syndromes - Case –c/o : Case –c/o On 15-12-2007 a patient named Chinna Reddappa 22 Y old Weaver from Madanapalle came with C/O Loose Motions x 3 M Is it diarrhea? If so what’s ur ddx? Analysis : Analysis Do u know that ur going to get motion? Yes No diarrhea fecal incontinence frequency / consistency Stool output 200g/day Acute {3weeks} chronic Analysis : Analysis chronic diarrhea with fasting& with food Osmotic yes no secretory osmotic gap >50 stool OG =290-[2x(na+k)] osmotic gap<50 Lactose intolerance infection(parasite) Laxatives &antacids IBD(crohns) Malabsorptions Secretory syndromes Motility Analysis : Analysis malabsorption Steatorrhea: grayishyellow bulky greasy foul smelling stools screened by sudan 3 staining of fecal fat & confirmed by quantitativ 72 hr stool for fat(>7g/d) weight loss Case –present illness : Case –present illness Loose motions x 3m x non progressive 4/day food 8/day > osmotic Yellowish gray Loose ;bulky;oily : non bloodstained steatorrhea 2 to Foul smelling malabsorption c/undigested food particles > maldigestion Asso with weight loss& weakness confirms malabsorption Analysis : Analysis Causes? maldigestion Pancreatic insufficiency mucosal Bilesalt insufficiency celiac sprue tropical sprue whipples disease intestinal lymphangiectasis abnomalities Celiac disease{autoimmune } : Celiac disease{autoimmune } Gluten (gliadin)enteropathy Vesicular skin disease celiac sprue diagnosis : celiac sprue diagnosis Histopathology : Atrophic villi (jejunum) Compensatory crypt hyperplasia Lamina propria filled c plasmacells& lymphocytes histo Nondiagnostic B’cos tropical sprue has similar histopath Serology: (diagnostic Antitransglutaminase <most sensitive> Antiendomysial <most specific> Celiac sprue treatment : Celiac sprue treatment Gluten free diet In india mainly Avoid wheat barley, rye take more Rice/corn Tropical sprue : Tropical sprue Seen in tropics INDIA Idiopathic; But suspecting Infectious/nutritional def? B’cos it subsides by rx with Abx: tetracyclins& Vitamins B12 folate Histopath celiac sprue Whipples rarest of all {tropheryma whippelli} : Whipples rarest of all {tropheryma whippelli} Multisystem disorder involving Git : malabsorption Joints :assymmetric migratory polyarthralgia Cns: personality change & short term amnesia Skin ; gray-brown pigmentation DIAGNOSIS: histopath proximal jejunal biopsy TREATMENT: Abx; cefalosporins (3rd gen) Slide 16: Villi architecture is normal Laminapropria show Foamy macrophages Which block lymphatic uptake of fat In AIDS patients MAIcomplex&histoplasmosis is also considered Slide 17: PAS (+)VE Rod shaped bacilli in Macrophages INTESTINAL LYMPHANGIECTASIA Diarrhea &pitting edema Hypoalbuminemia Histopath:dialated & blocked lymphatics Treat edema &malabsorption symptomatically One best test to r/o small bowel mucosal abnormalities : One best test to r/o small bowel mucosal abnormalities D-XYLOSE TEST: NPV(High) LESS PPV analysis : analysis d xylose test r/o smallbowel endoscopy guided mucosal abnormalities jejunal biopsy atrophic villi normal villi Plama cells & lymphocytes foamy macrophage Celiac sprue tropical sprue whipples anti endomysial ab PAS +VE rods in macrophages Case – present illness : Case – present illness Loose motions x 3m x non progressive 4/day food 8/day > osmotic Yellowish gray Watery; bulky;oily ;non bloodstained steatorrhea 2 to Foul smelling malabsorption c/undigested food particles > maldigestion Asso with weight loss& weakness confirms malabsorption analysis : analysis Causes? maldigestion Pancreatic insufficiency mucosal Bilesalt insufficiency celiac sprue tropical sprue whipples disease intestinal lymphangiectasis abnomalities Case - presnt illness : Case - presnt illness Associated git c/o history: Intermittent episodes of watery brash Vomiting &abdominal pain x 3months x static 1severe episode of vomiting x 2weeks back 3-4/d;coffee coloured mucoid non foul smelling c undigested food associated c abdominal pain Abd pain episodic x above&around umbilicus dull aching non radiating Occurs after vomiting relived by taking sugar &rest Burning sense at angles of mouth oral cavity throat x 3 days no h/o of fever / micturition is normal diagnosis : diagnosis Malabsorpption syndrome 2 to pancreatic/ bile salt insufficiency with vit – B 2 deficiency? Common cause of pancreatic insufficiency - chronic pancreatitis bile salt insufficiency - post surgical -blind loop -short bowel non surgical -diverticulosis Chronic pancreatitis : Chronic pancreatitis DEF: chronic inflammation c parenchymal destruction fibrosis fat necrosis &dystrophic calcification Mc presentation – abd pain pain constant/ intermittent ;dull ;epigastric radiates to back assoc c vomiting Steatorrhea ;weight loss & diabetes(retino&neuro> nephro DKA) indicate advanced disease Causes ? : Causes ? Mcc –alcohol abuse (90%) if not present Other causes (Mc in india) Idiopathic (juvenile>senile) tropical/nutritional Other less common causes: obstructive(stenosis,stricture,stone,pseudoyst) auto immune : metabolic ( ca/TG): genetic Diagnosis Pancreatic function assessment testleast sensitive & specific : Diagnosis Pancreatic function assessment testleast sensitive & specific Exocrine fnx:- Direct: secretin stimulationtest (HCO3<50meq) Indirect: bentiromide test (6hr urine>50%PABA False +ve : DM , bilroth 2 gastrectomy Endocrine fnx: GTT Radio Diagnosis? : Radio Diagnosis? X-ray = calcifications (advanced disease) Helpful in a case of Steatorrhea / DM so NOT SENSITIVE NOT SPECIFIC b’cos Vascular calcification Mimics it So CT/ERCP -best CT – noninvasive 90%sensitive : 80-90% specific : CT – noninvasive 90%sensitive : 80-90% specific CT – scan shows Duct dialation filling defects& cystic/ cavitary lesions( pseudo cyst ) Endoscopic retrogrde pancreatogram {ERCP} 100% specific : Endoscopic retrogrde pancreatogram {ERCP} 100% specific Detects moderate to advanced disease CHAIN OF LAKE beading : normal of main pancreatic duct Based on this CP is graded by cambridge grading complications : complications Mc – PSEUDOCYST Mc presentation – severe abd/back pain Treatment – wait 6 weeks surgical/endoscopic internal drainage Less common : obstruction of bile duct , duodenum slenic vein thrombosis pancreatic ascites hyperoxaluric renal stone treatment : treatment Medical : alcohol cessation if present pain : non narcotic analgesics persistent/severe: enzyme( protease) somatostatin/amitryptilline steatorrhea: low fat high carbohydrate diet enzyme( lipase) Case – diagnosisBased on present H/o? : Case – diagnosisBased on present H/o? Malabsorpption syndrome 2 to pancreatic/ bile salt insufficiency with vit – B 2 deficiency? Common cause of pancreatic insufficiency - chronic pancreatitis bile salt insufficiency - post surgical -blind loop -short bowel non surgical -diverticulosis Case - past history : Case - past history Mdical H/o : not significant Surgical H/o: 2 surgeries at an age of 9yr both for c/o epigastric pain 11yr after food relived by vomiting with in ½ hr 0n 6/12/07 an upper GI endoscopy report shows N fnx post GJ segment c no stromal ulcer no acid reflux analysis : analysis Surgery :? PV RING (Post. vertical retrocolic isoperistalitic no tension gastro jejunostomy ) OR Billroth 2 Short bowel syndrome+ Blind loop syndrome + Gastroperesis 2 to truncal vagotomy Case –diagnosis? Based on present &past H/o : Case –diagnosis? Based on present &past H/o 1. post G J Malabsorption 2 to short bowel syndrome + blind loop bacterial over growth 2. chronic pancreatitis ? Remaining h/o : Remaining h/o He is uneducated unmarried with poor financial status & is under stress b’cos of his disease & some family problems non veg 3yrs veg non smoker non alcoholic no illicit drug use (Operated for similar c/o of gas trouble) suicide 62 (operated for fibroid) 22 27 ( in good health) Vital data : Vital data Pulse 62/min :sinus rhythm,low volume with NO radio radial/ radio femoral delay BP:90/60 mm Hg X supine X ( Rt arm ) Temp: 98.5’F Resp : 18/min regular O2 sat: not recorded Genaral examination : Genaral examination Built & Nourishment: wt: 37 kg ht : 1.7 mt BMI:12.5 & significant Wt loss( >4kg/month) General examination : General examination General appearance: Patient has sick look & dull facies Hair lack lusture & is easily pluckable Skin is dry shiny scaly & exfoliated Face show temporal & buccal hollowing Eyes show gross pallor & no jaundice Asx C – shaped DNS is present Mouth shows angular stomatitis glossitis pharyngits c good dental hygine Neck show NO swellings/engorged veins & JVP is not elevated CVP is normal Chest wall has emaciated look Extremities are cool with NO cyanosis / edema No lymphadenopathy Analysis : Analysis Protein & calorie malnutrition Vit B 2/ B 12/A & fe deficiency ? Systemic examination : Systemic examination CNS :conscious&coherent no focal neuro defict CVS :S1&s2 are heard no murmur/gallops RS: N vesicular breathe sounds ABDOMEN (supine) Inspection: abd asymmetrical flat except for a local bulging umbilicus midline NO visible pulsations/ peristalisis/engorged veins Inspection : Inspection swelling:4x4 cm subside on head/leg raising test non pulsatile no visible peristalisis Scars: s1 6cm paramedian s2 7cm midline Remaining examination : Remaining examination Auscultation :24/min x borborygmi succution splash over gastric region No bruit/ venous hum On palpation abdomen is soft & tender in left lumbar region on deep palpation only . NO of temp /No organomegaly On percussion liver span is 7cm traube space is tympanic no E/o free fluid stomach appear to be dialated Analysis : Analysis Local bulge : blind loop from weak linea alba / small pseudo cyst 2 to chronic pancreatits Lft lumbar tenderness on deep palpation suggest chronic pncreatitis Succution splash & dialated stomach Suggest:- gastroparesis ( diabeticneuropathy 2to CP/ truncal vagotomy in G J procedure) partial outlet obstr ( stricture) external compression ( pseudo cyst) Clinical diagnosis : Clinical diagnosis 1. postm GJ malabsorption syndrome 2 to short bowel syndrome+/- blindloop syndrome 2.Chronic pancreatitis c pseudo cyst formation Over view : Over view chronic diarrhea with fasting& with food Osmotic yes no secretory osmotic gap >50 stool OG =290-[2x(na+k)] osmotic gap<50 Lactose intolerance infection(parasite) Laxatives &antacids IBD(chrons) Malabsorptions Secretory syndromes Motility Over view : Over view Causes? maldigestion Pancreatic insufficiency mucosal Bilesalt insufficiency celiac sprue tropical sprue whipples disease intestinal lymphangiectasis abnomalities over view : over view d xylose test r/o smallbowel endoscopy guided mucosal abnormalities jejunal biopsy atrophic villi normal villi Plama cells&lymphocytes foamymacrophage Celiac sprue tropical sprue whipples anti endomysial ab PAS +VE rods in macrophages Specfic investigations : Specfic investigations To r/o secretory causes: - stool osmotic gap To confirm malabsoption of fat :- 72hr quantitative fecal fat protein: serum proteins&albumin To r/o small bowel mucosa disorders:- D xylose test To r/o CP:- abd X-ray , U/S , CT To confirm short bowel syndrome:- barium meal & upper GI endoscopy To confirm bacterial over growth in blind loop (>105 CFU/ml in duodenal aspirate) {GOLD STD} Lactulose H+ breathe test(>12PPM) Routine investigations : Routine investigations Complete haemogram BT, CT LFT , RENAL fx test & Urinanalysis RBS , HIV , HBs -Ag how 2 plan treatment? : how 2 plan treatment? Immediate correction of glucose protein & Electrolytes (ca,mg) Low fat high carbohydrate & protein diet Symptomatic relief: diarrhea :anti motility (loperamide) +/- Prokinetics(metaclopramide) severe pain :anti spasmodic (cyclopam) +/- amitryptilline To provide lost vit / min /protein: TPN of protein & vit & minerals If recovering oral multivit (Beneficiare)/miner(ca) Treatment : Treatment Disease oriented: Abx(3rd gen cef+ metroyl) bacterial growth H2 blockers/PPI acid secretion Suppl of pancreatic enzymes (before meals) & bile salts (with meals) Books & articles : Books & articles Clinical examination : bates & das manual Problem solving In clinical medicine (cutler) Lange case files of internal medicine CMDT 2007 Merck manual NEJM ( CASES & Clinical problem solving) GIT & LIVER SECRETS POCKET MEDICINE by sabatine Slide 54: Thank you

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