malabsorption in tropical sprue & coeliac disease
DESCRIPTION
Definition, pathophysiology, clinical features, investigations and managements are included.TRANSCRIPT
MALABSORPTIONTropical Sprue
&Coeliac Disease
MARYAM JAMILAH BINTI ABDUL HAMID082013100002
IMS BANGALORE
MARYAM JAMILAH BINTI ABDUL HAMID082013100002
IMS BANGALORE
LEARNING OUTCOME
• Define tropical sprue
• Understand the causes, clinical features, investigations and managements for tropical sprue
• Define coeliac disease
• Understand the causes, clinical features, investigations and managements for coeliac disease
MALABSORPTION
“Inadequate assimilation of dietary
substances due to defects in
digestion, absorption, or transport”Major factors causing malabsorption:• Defective digestion• Faulty absorption
TROPICAL SPRUE
Definition:
“A malabsorption disease commonly found in the tropical regions, marked with abnormal
flattening of the villi and inflammation of the small
intestine lining”
ETIOLOGYThe etiology and pathogenesis areuncertain.Why?1) Its occurrence is not evenly distributed in
all tropical areas.• It is found in specific locations, southern
India, the Philippines and several Caribbean islands.
• Rarely observed in Africa, Jamaica or Southeast Asia.
2) An occasional individual will not develop symptoms of tropical sprue until long after having left an endemic area.
3) Multiple microorganisms have been identified on jejunal aspirate with relatively little consistency among studies but other studies have favoured a role for a toxin produced by one or more of these bacteria; Klebsiella pneumoniae, Enterobacter cloacae, or E. coli.
CLINICAL FEATURES
• Diarrhea
• Fatigue
• Weight loss
• Abdominal cramps
• Flatulence
• Malnutrition
INVESTIGATION
• Small-intestinal biopsy
– Less villous architectural alteration &
more mononuclear cell infiltrate in the lamina propria
– However, this resembles coeliac disease
– The way to differentiate these two is by having
gluten-free diet and it will not give clinical or histologic
improvement
• Endoscopy
– Abnormal flattening of villi and inflammation of
the lining of the small intestine can be observed
• Blood test
– Low levels of vitamins A, B12, E, D, and K, as
well as serum albumin, calcium, and folate
• Examination of stool
– Steatorrhoea
• Barium swallow– Thickened small bowel folds can be observed
MANAGEMENT
• Prescribe antibiotic – tetracycline or Sulfamethoxazole-
Trimethoprim (Co-trimoxazole) for 3 to 6 months
• Supplementation– vitamins B12
– folic acid
BEFORE TREATMENT
AFTER TREATMENT
with doxycycline and folic
acid therapy
Definition:
“An autoimmune disease where the immune system reacts
abnormally to gluten causing inflamed and flattened villi”
Coeliac Disease
Healthy villi Damaged villi
ETIOLOGY
• It is not known but environmental,
immunologic and genetic factors appear
to contribute to the disease.
1) Environmental
- Coeliac disease is associated with
gliadin (a component of gluten)
2) Immunologic
- Serum antibodies; IgA antigliadin,
IgA antiendomysial and IgA anti-tTG are
present.
- However, it is not known whether these
antibodies are primary or secondary to
the tissue damage.
3) Genetic factor
- Patients with coeliac disease express the
HLA-DQ2 allele (majority) and DQ2 allele
(minority) but 5% patients do not express any
of these alleles.
- Coeliac diseas varies widely in different
population groups (high in Caucasians, low in
blacks and Asians)
PATHOPHYSIOLOGY
• Partial villous atrophy in a mild lesion of small
intestinal lining
• Subtotal/total villous atrophy in a severe lesion of
small intestinal lining
– Forming flat mucosa due to more advanced
villous fusion (particularly of the upper jejunum)
• Surface epithelial cells are cuboidal or
low columnar type
• Lamina propria shows increased
number of plasma cells and
lymphocytes
NORMALPARTIAL VILLOUS
ATROPHYSUBTOTAL / TOTAL VILLOUS ATROPHY
Diagram shows histology of duodenal villi
CLINICAL FEATURES• Mild abdominal pain• Bloating• Steatorrhoea• Anaemia• Episodes of mild diarrhea or constipation• Loss of appetite• Weight loss• Tingling and numbness in your hands and feet • Vomiting (usually only affects children)• Alopecia (usually only affects adults)• Malnutrition
INVESTIGATION
• Blood test
– Positive tTG serology
– Low levels of vitamins A, B12, E, D, and K
• Small-intestinal biopsy
• Examination of stool
– Steatorrhoea
• Endoscopy– Usually duodenum appear normal but some
patients showing:-• scalloping of the small bowel folds• paucity in the folds• a "cracked-mud" appearance of mucosa• prominence of the submucosa blood vessels and a
nodular pattern to the mucosa
MANAGEMENT
• Diet
– Lifelong gluten-free diet
• Steroids or immunosuppressants
– Such as azathioprine
– This is only for refractory disease where
they do not improve on a gluten-free diet.
REFERENCES
• Longo, D. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Jameson, J. L., & Loscalzo, J. (2012). Harrison's principles of internal medicine. (18th ed., Vol. 2, pp. 2151-2160). McGraw-Hill Companies Inc.
• https://www.mja.com.au/journal/2005/182/10/tropical-sprue-far-north-queensland
• http://www.celiac.com/articles/8/1/What-is-gluten-What-is-gliadin/Page1.html
• http://www.solunetti.fi/en/patologia/ohutsuolen_villusatropia_40x/• http://www.nhs.uk/Conditions/Coeliac-disease/Pages/
Symptoms.aspx