A Lot of Fuss

A Lot of Fuss

1. Anatomy and histology of the Duodenum

   • C shaped round the head of pancreas. Start at pylorus of stomach and end in jejunum L1, L2 and L3 Mostly peritoneal and fixed except at gastroduodenal junction and duodenojejunal junction
     • Third horizontal
     • First Superior
     • Second descending
     • Fourth ascending
   • Duodenum has Brunner’s glands (mucous glands)
   • Ileum has Peyer’s patches

2. Malabsorption syndromes

   • Intraluminal
     • Pancreatic insufficiency
     • Bile acid/salt deficiency
   • Brush border and transepithelial transport
     • Small bowel disease (celiac- crohn’s- GVHD)
       • Celiac disease
         • Signs and symptoms of celiac disease
           • , Vitamin K deficiency, and Excessive bruising
           • Diarrhea
           • Bloating, Gas (flatulence, farting),
           • Anemia, Fatigue,
           • bleeding. Abdominal discomfort
           • Failure to thrive in children
           • the symptoms are not related to the bowel function, but instead are due to the consequences of chronic malabsorption of vitamins and minerals.
         • Immune-mediated damage of small bowel villi due to gluten exposure; associated with HLA-DQ2 and DQ8
           • Screening of the Celiac Disease
             • a biopsy of the small intestine is the only way to diagnose celiac disease.
               • To confirm diagnosis
                 • CBC (anemia)
                   • ESR / CRP (inflammation)
                     • Comprehensive metabolic panel (determine electrolyte, protein, and calcium levels, and to verify the status of the kidney and liver )
                       • Vitamin D and B12 and folate to measure vitamin deficiencies.
                         • Iron, iron binding capacity or transferrin, and ferritin to detect iron deficiency
                           • Stool fat, to help evaluate malabsorption
                             • steatorrhea
               • physician should order a bone density test at time of diagnosis to test for osteopenia/osteoporosis (thin bones)
             • Tissue Transglutaminase Antibodies (tTG-IgA)
               • IgA Endomysial antibody (EMA)
                 • Total serum IgA
                   • Deaminated gliadin peptide (DGP IgA and IgG)
                     • Gluten Challenge
           • Gluten is present in wheat and grains; its most pathogenic component is gliadin. l. Once absorbed, gliadin is deamidated by tissue transglutaminase (tTG). 2. Deamidated gliadin is presented by antigen presenting cells via MHC class II. 3. Helper T cells mediate tissue damage.
           • Normal VS Celiac disease Histological Slide
         • Treatment
           • Lifelong Adherence to the Gluten-Free Diet
           • Vitamins and Dietary Supplements
             • , people with celiac disease are deficient in fiber, iron, calcium, magnesium, zinc, folate, niacin, riboflavin, vitamin B12, and vitamin D, as well as in calories and protein. Deficiencies in copper and vitamin B6 are also possible, but less common
           • Dermatitis herpetiformis -->Dapsone or sulfapyridine
         • Associated with
           • Type 1 diabetes mellitus
           • Autoimmune hepatitis
           • Sjögren’s syndrome
           • Multiple Sclerosis
           • Addison disease
           • Arthritis
           • Idiopathic dilated cardiomyopathy
           • Autoimmune thyroid disease
           • IgA nephropathy
         • Complications
           • Central and peripheral nervous system disorders
           • Osteoporosis
           • Lactose intolerance
           • Lymphoma and small bowel cancer
           • Iron deficiency anemia
           • gall bladder malfunction
           • Pancreatic insufficiency
     • Disaccharidase deficiency- abetalipoproteinemia
     • Infective enterocolitis
   • Lymphatic transport TB- Lymphoma –whipple’s disease
   • chronic diarrhea, wt loss, flatulence, abdominal distention& pain, anemia, muscle wasting

3. Follow up

   • Dietitian role
   • Role of the Physician
     • Assess symptoms
     • Recommend a mental health professional
     • routine tests
     • flu shot
     • Repeat bone densitometry
     • For adults, consider repeat small intestinal biopsy

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