Diseases of the small intestine Malabsorption Functions of

Diseases of the small intestine Malabsorption Functions of the GIT Digestion begins with: 1. Fragmentation by stomach 2. Secretion of pancreatic juice, bile , water 3. Brush border enzymes digestion 4. Enterocytes absorption 5. Site of absorption: whole or specific area. 6. Maldigestion or malabsorption

Classification of malabsorption 1. 2. - Inadequate digestion. Pancreatic dis Intraluminal bile salt deficiency Specific causes as disaccharidase deficiency Inadequate absorption surface Mucosal cell defect Diffuse disease of the small intestine

others 3. 4. 5. 6. Lymphatic obstruction Drug induced Multiple mechanisms Hyper absorptive state

Clinical picture of malabsorption 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Diarrhea , steatorrhea Picture of failure to thrive Wt loss &malnutrition Abdominal distention and edema Anemia Paresthesia Bone pain Bleeding tendency Nocturia milk intolerance Clubbing of fingers, pallor , fair hair &skin.

Investigations 1. 2. 3. 4. 5. 6. 7. 8. Fecal fat analysis Test of pancreatic exocrine function Bentiromide test Abdominal x-ray and CT scan Xylose absorption excretion test Radiological test Small intestinal biopsy Schilling test Breath test Specific malabsorption for B 12 , albumin , Vit. K, minerals

Celiac disease n 1. 2. 3. 4. 5. 6. 7. Pathogenesis: Gluten peptide is taken by epith. Cells Deamidation of gluten by tissue trasglutaminase give product which can fit the antigen binding site on APC. Present the combination to CD 4+ Triggering of TH 1 response to IL-1, IFN gamma , TNF alpha. Lymphocye infiltration Crypt hyperplasia Villous atrophy.

Clinical feature In infants n Older children n In adult : n Clinical features: Non specific as malaise , anorexia—iron, folate or Ca deficiency Diarrhea& steatorrhea—water, electrolyte , &fat malabsorption. Wt loss ---fat &CHO malabsorption. Abdominal pain &bloating—distended bowel loops. Aphthus ulcers –gluten sensitivity and Vit deficiency. Nausea & vomiting Itching spots +ve family history Oedema---hypoproteinemia n

n n n Pigmentation , tetany &bone pain—Vit D &Ca deficiency. Bleeding tendency---Vit K deficiency Night blindness ---Vit A deficiency Anemia ----iron and folate deficiency Myopathy ---osteomalacia.

investigations Duodenal biopsy. Total or subtotal villous atrophy. n Antibodies - Antigliadin Ab-Ig. A - Antiendomysial antibodies. - Tissue transglutaminase assay *blood test and biochemistry n

management n n n Gluten free diet Correct all deficit nutrients Rarely need steroid or immunosuppressive therapy

Failure to response to therapy n n n Dietary compliance Other dis accompany coeliac dis Accompanied by T cell lymphoma

Dermatitis herpetiformis n n n Picture of malabsorption +skin rash (intensive itching blisters) Treatment: Gluten free diet +depsone 100 -150 mgday

Tropical sprue Chronic progressive malabsorption In tropical areas Viruses or toxin forming bacteria, E. choli, klebsiela, enterobacter First acute then chronic Diarrhea , fever , glositis, ankle odaema, , abd distention , folate deficiency anemia, remision and relapse. Treated by tetracycline for 28 days , folic acid, leave tropics

Bacterial overgrowth small intestine n n n Increase number of coliform bact 10*8 -10*10ml in duodenum &jujenum. Due to decrease acidity of stomach or impaired intestinal motility. Jujenal diverticulosis, DM diarrhea, systemic sclerosis, hypogammaglobulenaemia. Clinical features watery diarrhea & steatorrhea, Vit B 12 deficiency and increase folate Consumption of the bile salt Tetracycline, metronidazole&ciprofloxacin

Whipple’s disease n n n n n Gram +ve bacilli-Tropheryma whipplei. Foam macrophage infiltration in lamina properia. Gastrointestinal manifestations Musculoskeletal Cardiac Neurology Pulmonary Hematology Fever, pigmentation Treatment-Co-trimoxazole, ceftriaxone 6 -12 m.

Ileal resection n n Vit B 12 and salt deficiency Bile salt malabsorbtion. Lithogenic bile gall stone. Normally oxalate bind calcium and bile salt absorbed. Treated Vit B 12, colestyramine&Al(OH)3.

Radiation enteritis n n Acute short, oedematous villi& crypt abscess –resolve or oblitrative endarteritis Chronic fibroblastic proliferation, adhesion , ulcers, strictures , fistula &obstruction. Treated by symptomatic, local steroid, antibiotics , nutritional supplement colistyramine, treat bleeding spots No surgery.

Chronic intestinal pseudo obstruction n n Defect of smooth muscles of small intestine. Alteration of diarrhea and constipation. Bacterial over growth. Treat underlying cause

NSAIDs small intestinal toxicity n n Erosion , ulceration , mucosal web, stricture &sub mucosal fibrosis Diagnosis by laparatomy

Meckel’s diverticulum n n n Occur with in 100 cm of ileum , 3% , 5 cm long , contain gastric, colonic , pancreatic or endometrial tissue. Complicated by melena , bleeding or intestinal obstruction. Diagnosis by Tc 99 -pertechnate which concentrate in gastric mucosa

Lactose intolerance n n Glucose & galactose fermentation

Food allergy n Types