Malabsorption

Abstract: Background Iron deficiency anaemia (IDA) occurs in 2–5% of adult men and postmenopausal women in the developed world and is a common cause of referral to gastroenterologists. Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought. Defining iron deficiency anaemia The lower limit of the normal range for the laboratory performing the test should be used to define anaemia (B). Any level of anaemia should be investigated in the presence of iron deficiency (B). The lower the haemoglobin the more likely there is to be serious underlying pathology and the more urgent is the need for investigation (B). Red cell indices provide a sensitive indication of iron deficiency in the absence of chronic disease or haemoglobinopathy (A). Haemoglobin electrophoresis is recommended when microcytosis and hypochromia are present in patients of appropriate ethnic background to prevent unnecessary GI investigation (C). Serum ferritin is the most powerful test for iron deficiency (A). Investigations Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss (A). All patients should be screened for coeliac disease (B). If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation (B). In patients aged >50 or with marked anaemia or a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found (B). Colonoscopy has advantages over CT colography for investigation of the lower GI tract in IDA, but either is acceptable (B). Either is preferable to barium enema, which is useful if they are not available. Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be restored or maintained with iron therapy (B). In patients with recurrent IDA and normal OGD and colonoscopy results, Helicobacter pylori should be eradicated if present. (C). Faecal occult blood testing is of no benefit in the investigation of IDA (B). All premenopausal women with IDA should be screened for coeliac disease, but other upper and lower GI investigation should be reserved for those aged 50 years or older, those with symptoms suggesting gastrointestinal disease, and those with a strong family history of colorectal cancer (B). Upper and lower GI investigation of IDA in post-gastrectomy patients is recommended in those over 50 years of age (B). In patients with iron deficiency without anaemia, endoscopic investigation rarely detects malignancy. Such investigation should be considered in patients aged >50 after discussing the risk and potential benefit with them (C). Only postmenopausal women and men aged >50 years should have GI investigation of iron deficiency without anaemia (C). Rectal examination is seldom contributory, and, in the absence of symptoms such as rectal bleeding and tenesmus, may be postponed until colonoscopy. Urine testing for blood is important in the examination of patients with IDA (B). Management All patients should have iron supplementation both to correct anaemia and replenish body stores (B). Parenteral iron can be used when oral preparations are not tolerated (C). Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia (C).

Abstract: PART ONE MECHANISMS OF DISEASE AND PRINCIPLES OF TREATMENT Chapter 1 The Equine Immune System 1.1 Equine Immunology 1.2 Hypersensitivity Autoimmunity 1.3 Immunodeficiency 1.4 Immunomodulators Chapter 2 Mechanisms of Infectious Disease 2.1 Mechanisms of Establishment and Spread of Bacterial and Fungal Infections 2.2 Mechanisms of Establishment and Spread of Viral Infections 2.3 Internal Parasite Infections 2.4 Rickettsial Diseases Chapter 3 Clinical Approach to Commonly Encountered Problems 3.1 Syncope and Weakness 3.2 Polyuria and Polydipsia 3.3 Edema 3.4 Changes in Body Weight 3.5 Abdominal Distention 3.6 Dysphagia 3.7 Respiratory Distress 3.8 Cough 3.9 Changes in Body Temperature 3.10 Diarrhea 3.11 Clinical Assessment of Poor Performance Chapter 4 Pharmacologic Principles 4.1 Introduction to Clinical Pharmacology 4.2 Antimicrobial Therapy 4.3 Nonsteroidal Antiinflammatory Drugs 4.4 Respiratory Pharmacology Chapter 5 Clinical Nutrition Chapter 6 Critical Care PART TWO DISORDERS OF SPECIFIC BODY SYSTEMS Chapter 7 Disorders of the Respiratory System Chapter 8 Disorders of the Cardiovascular System Chapter 9 Disorders of the Musculoskeletal System Chapter 10 Disorders of the Neurologic System Chapter 11 Disorders of the Skin Chapter 12 Disorders of the Hematopoietic System Chapter 13 Disorders of the Gastrointestinal System 13.1 Examination for Disorders of the Gastrointestinal Tract 13.2 Pathophysiology of Gastrointestinal Inflammation 13.3 Pathophysiology of Diarrhea 13.4 Malabsorption Syndromes and Maldigestion: Pathophysiology, Assessment, Management and Outcome 13.5 Pathophysiology of Mucosal Injury and Repair 13.6 Gastrointestinal Ileus 13.7 Endotoxemia 13.8 Oral Diseases 13.9 Esophageal Diseases 13.10 Diseases of the Stomach 13.11 Duodentitis/Proximal Jejunitis (Anterior Enteritis, Proximal Enteritis) 13.12 Proliferative and Inflammatory Intestinal Diseases Associated with Malabsorption and Maldigestion 13.13 Inflammatory Diseases of the Gastrointestinal Tract Causing Diarrhea 13.14 Ischemic Disorders of the Intestinal Tract 13.15 Obstructive Disorders of the Gastrointestinal Tract 13.16 Neoplasia of the Gastrointestinal Tract 13.17 Peritonitis Chapter 14 Disorders of the Liver Chapter 15 Equine Ophthalmology Chapter 16 Disorders of the Reproductive System Chapter 17 Disorders of the Urinary System Chapter 18 Disorders of the Endocrine System 18.1 Calcium Disorders 18.2 Pars Intermedia Dysfunction (Equine Cushing's Disease) 18.3 Thyroid Gland 18.4 The Adrenal Glands 18.5 Endocrine Pancreas 18.6 Magnesium Disorders Chapter 19 Disorders of Foals Chapter 20 Toxicologic Problems Chapter 21 Veterinary Epidemiology

Abstract: We have previously reported our efforts to minimize postgastrectomy symptoms in two patients with benign disease who underwent resection of the head of the pancreas and the duodenum. In these cases the pylorus and first portion of the duodenum were preserved during pancreaticoduodenectomy. Our experience has now been extended to encompass 18 patients, eight of whom were available for comprehensive evaluation an average of six months postoperation. These studies have attempted to differentiate malabsorption of pancreatic insufficiency from possible gastrointestinal dysfunction of the new alimentary connection. Pancreatic insufficiency was evaluated by a 72-hour stool collection and radioactive trioctanoate (RATO) test. Gastrointestinal absorption was evaluated by D-xylose excretion and the Schilling test, as well as serum vitamin. A, vitamin B-12, carotene, folate, iron, and total iron binding capacity. Gastrointestinal secretion and motility were assessed by using pyloric fluoroscopy, gastric barium emptying, the Hunt test, and gastric acid analysis. Finally, a questionnaire regarding clinical symptoms of postgastrectomy syndromes and malabsorption was answered. Although every patient exhibited marked pancreatic insufficiency by laboratory tests, 88% described normal formed bowel movements, and weight loss was claimed by only 25%. Other test findings were generally normal. While the follow-up period has been limited to three years, the current data demonstrate that gastrointestinal function subsequent to preservation of the pylorus has not thus far predisposed to postgastrectomy syndromes or marginal ulcers. All of the patients required intensive pancreatic enzyme replacement.