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Path: Small Bowel Disease (ii) (Bowel obstruction (presenting features…
Path: Small Bowel Disease (ii)
Malabsorption syndromes
symptoms
failure to thrive
weight loss
steatorrhoea
anaemia
Coeliac disease
aka coeliac sprue, gluten-sensitive enteropathy
non-infectious
atrophy of villi (partial/subtotal)
sensitivity to gliadin fraction of gluten
HLA DQ2 + DQ8 specific to CD
dx = small bowel biopsy + serum endomysial Ab + transglutaminase Ab (TTG)
symptoms/histology improve with gluten-free diet +/- return when off diet
can be sub-clinical
crypt hyperplasia (provide stem cells for renewal of the intestinal epithelium)
lymphoplasmacytic infiltrate in lamina propria
increased intraepithelial lymphocytes (epithelium studded with lymphocytes)
a/w dermatitis herpetiformis (pruritic skin rash with vesicles/small blisters, eco on extensor surfaces)
long term complications (if refractory)
lymphoma
adenocarc
ulceration
stricture formation
splenic atrophy
malnutrition
Crohn's
Lactose intolerance
Tropical sprue
aka post-infectious sprue
affects people living in/visiting the tropics, esp Caribbean (no Jamaica), Africa, India, SE Asia, Central/S America
may be due to E coli or haemophilus
tx = broad spectrum antibiotics (tetracyclines), folic acid, vit B12
no increased risk of intestinal lymphoma
histopathology
various villous atrophy (none/partial/total)
injury to entire small bowel (not proximal as in coeliac sprue)
inflamm infiltrate
crypt hyperplasia
Bowel obstruction
can affect any part of intestine, but small bowel most commonly affected due to its narrow lumen
presenting features
colicky abdo pain with distension
anorexia, nausea, vomiting with relief
constipation
hernia
weakness/defect in wall of peritoneal cavity which permits a pouch-like sac of peritoneum
segments of viscera can intrude + become trapped in them - mat become incarcerated (permanently trapped) + strangulated (blood supply compromised - become dark + dilated)
adhesions
healing peritonitis - fibrous bridges can create closed loops through which intestines may slide + become trapped
intussusception
telescoping of a proximal bowel segment into the immediately distal segment
in children often no anatomic basis, in adults often due to an intraluminal mass
vasc supply of segment may become compromised
volvulus
complete twisting of a loop of bowel about its mesenteric base of attachment, leading to intestinal obstruction + infarct
neoplasms
gallstones
meconium
Neoplasms
benign
adenomas
harmatomatous polyps
disorganised growth of tissue indigenous to site
e.g. Peutz-Jeghers syndrome (AD)
lipomas
leiomyomas
malignant
adenocarc
rare
most in duodenim
may occur as complication of Crohn's or coeliac
primary GI lymphoma
commonest malignancy of small bowel
1-4% of all GI malignancies
types
T cell
often complicates coeliac (EATL - enteropathy-associated T cell lymphoma = v rare type of non-Hodkin's lymphoma)
CD3 +ve
B cell
arising from B cells of MALT (MALToma)
CD20 +ve
neuroendocrine (carcinoid tumours)
arise from neuroendocrine cells throughout GIT (regulate GIT movement)
presents usually in 60s
variable malignant behaviour
tendency of aggressive behaviour correlates with tumour size, depth of local penetration, site
overriding predictor of aggressive behaviour = grade (mitotic count / prolif index using a Ki-67 stain)
frequently asymptomatic
carcinoid syndrome
due to tumours synthesising + secreting serotonin
only seen in GIT tumours if there's hep mets
facial flushing, intestinal hypermotility (diarrhoea + cramps), asthmatic broncho constriction, right heart abnormalities - not left as lung can breakdown serotonin