Diseases of small intestine in detail

1. Diseases of Small
Intestine.
Prepared Dr. Tarup Gokia
Gastroenterology
international school of medicine

2. • Amyloidosis
• What is amyloidosis?
• Amyloidosis is a rare disease of the blood. It is so rare
that the condition is difficult to research. Perhaps as
few as one in one million people contract this disease.
• Is amyloidosis cancer?
• No, amyloidosis is not a form of cancer; however, the
presence of this disease may indicate the presence of
certain cancers of the blood, among them, multiple
myeloma.

3. • What does amyloidosis do?
• Amyloidosis causes a buildup of a protein in the tissues
and organs. This is not normal, and this buildup
impedes the function of the organs involved.
• Amyloidosis may be primary when it occurs for
unknown reasons and secondary in response to chronic
inflammatory diseases such as multiple myeloma, or
Crohn's disease.

4. • How does amyloidosis affect my intestines?
• When amyloidosis affects the small intestines it renders
it functionless from two perspectives.
• Firstly, by causing diffuse infiltration it prevents normal
muscular contractions and the intestine cannot propel
its contents adequately. This will predispose it to
bacterial overgrowth as well as poor mixing of luminal
contents for digestion and absorption.
• Secondly, amyloidosis will also infiltrate the lining of
the intestine to such an extent that it will interfere with
normal cell function and impedes digestion and
absorption.

5. • Amyloidosis can assume many forms:
• AL amyloidosis — the most common in the United
States, and is usually not associated with an underlying
disease like Crohn's disease.
• AA amyloidosis — usually associated with some form
of underlying chronic disease
• Hereditary amyloidosis — inherited
• What are the risk factors for amyloidosis?
• more common in men
• more common over the age of forty
• can be inherited

6. • Diagnosing amyloidosis
• Amyloidosis can be difficult to diagnose by virtue of the
few people who get this disease. It is believed that
many people go undiagnosed because the disease is so
rare. Some tests may be given, including:
• blood work to look for proteins
• urine evaluation to look at kidney function
• ultrasound to examine organs, especially size

7. • Symptoms of amyloidosis
• weight loss and fatigue
• anemia
• joint pain
• kidney problems
• abnormal liver function
• Treatment for amyloidosis
• Methods of treating a person with amyloidosis may include:
• diet
• medications, including steroids
• chemotherapy to attack abnormal cells that are infected
• Amyloidosis is a difficult disease to treat. Organ and bone
marrow transplantation have been performed in people with
advanced cases of this disease.

8. • Is there a cure for amyloidosis?
• Currently, there is no effective therapy for amyloidosis;
however, the pace of research in digestive diseases is
increasing, and that makes amyloidosis a disease that
should be followed by those who suffer from this
condition.

9. Celiac Disease (Celiac Sprue)
• Celiac disease (sometimes referred to as celiac sprue,
non-tropical sprue, or gluten-induced enteropathy) is
essentially a sensitivity to gluten which is a component of
wheat. Patients with celiac disease who ingest any wheat
products develop abnormalities in the lining of the small
intestine, particularly the upper part (jejunum). The
incidence of celiac disease is unknown as there are many
individuals who have "silent" disease and have not been
diagnosed. Individuals at high risk are those with
ancestors from north western Europe and individuals
with insulin dependent diabetes (the latter association
being genetically related).

10. •Wheat, rye, barley and oats contain the proteins that
make up gluten and will all affect patients with celiac
disease. It is believed that there is an immunological
response to components of gluten which result in
inflammation of the lining of the small intestine which is
characterized by flattening of the finger-like projections
(villi). The mucosa can become so damaged that it can
become "leaky"; water and salts can leak out of the cells
into the small intestine and be lost with diarrhea.

11. • Patients classically have symptoms and signs of
malabsorption (i.e. diarrhea, nutrient deficiencies,
iron deficiency, folic acid deficiency, anemia). They
may experience weight loss, gastric distension,
features of other associated disorders such as
diabetes, dermatitis herpetiformis (a particular type
of skin disorder), and bone pain from
osteoporosis/osteomalacia. However, some patients
may not have any symptoms. Celiac disease may be
suspected by family history and routine blood tests.

12. Diagnosis
• Anemia is probably one of the most common
findings. Blood tests are available (antigliadin and
antiendomysial antibodies). The antiendomysial
antibody test is the most specific. The ideal way to
confirm celiac disease is to perform an upper
endoscopy and to inspect and take samples from
(biopsy) the small intestine. On inspection the lining
of the small intestine appears atrophic and has a
"cracked earth" appearance. The degree of
microscopic damage varies from mild inflammation
to complete blunting or atrophy of the villi.

13. Treatment
The treatment of celiac disease is to remove all gluten from the
diet. Even small amounts of gluten can prevent a clinical
response. It is important for the patient to become very familiar
with gluten free products. Information is available in celiac
disease support groups as well as on the Internet. Some patients
may not respond to a gluten free diet and need other treatment,
such as steroids. Failure to respond to a gluten free diet and/or
steroids should always raise the suspicion of another diagnosis.
Patients on gluten free diets should have supplements of
vitamins, particularly vitamin D, folic acid, and iron. These may
need to be given by injection if they cannot be absorbed in the
oral form.

14. Non-nutritional complications of
celiac disease
• Rarely, patients with celiac disease have developed
tumors of the esophagus and small intestine.
Patients may also develop multiple ulcers in the
small intestine with stricturing and intestinal
obstruction. Celiac disease is also sometimes
associated with a microscopic inflammation of the
colon (microscopic colitis) which can also
contribute to diarrhea.

15. 3.Dysmotility
• Dysmotility is a condition in which muscles of the
digestive system become impaired and changes in
the speed, strength or coordination in the digestive
organs occurs. In the normal small intestine,
liquefied food and secretions including digestive
enzymes are pushed onwards by waves of muscular
contraction. When these contractions are impaired,
the contents are trapped, and cause distention with
symptoms such as bloating, nausea, vomiting and
even malnutrition.

16. • There are many causes of abnormal intestinal
motility that can be separated into two different
groups:
• abnormalities of the muscle of the intestine
(myopathy)
• abnormalities in the neural (nerve) control of the
muscle (neuropathy)
• Nerve and muscle abnormalities may be genetically
inherited. In this situation, it is common to find many
patients' family members with contraction problems,
not only of the intestinal muscle, but also of the
bladder.

17. • There are secondary causes of intestinal dysmotility.
Examples of this include systemic Lupus
erythematosus, amyloidosis, neurofibromatosis,
Parkinson's disease, diabetes, scleroderma, thyroid
disorders, and muscular dystrophies. Certain
medications can also cause intestinal dysmotility.
Additionally, any disorders that cause inflammation
to the intestine can cause significant dysmotility (i.e.
radiation therapy, celiac disease).

18. Symptoms
• Symptoms may be absent or trivial. Some patients may
have severe ongoing attacks due to a blockage known
as an intestinal pseudo-obstruction. Patients who
develop bacterial overgrowth because of poor motility
may develop diarrhea, while others may be constipated.
Associated disorders of motility in other organs such as
the esophagus, stomach and colon will produce other
symptoms. Patients with severe dysmotility will
develop malnutrition because they are unable to eat
adequately.

19. Diagnosis
• Blood Tests – Blood tests help to assess the degree of
malnutrition, anemia and any salt imbalance. They may
also make a specific diagnosis such as diabetes, thyroid
problems and systemic disorders such as Lupus.
• X-ray Studies – barium X-ray studies help to delineate
the extent of bowel involvement by demonstrating
areas of distended intestines, and by excluding
mechanical obstruction. This must be done because
treatment of pseudo-obstruction and true obstruction
are very different.

20. • Motility/Transit Studies – Motility/transit
investigations help to define the degree of contractile
abnormality as well as propulsive abnormality of the
intestines.
• Biopsies – Biopsy samples of the intestine are
obtained at endoscopy or surgery, and may detect the
cause of the dysmotility.

21. Treatment• Mechanical obstruction (i.e. blockage) must be excluded
before a patient is diagnosed as having pseudo-
obstruction or intestinal dysmotility as a cause of their
symptoms. Specific treatments are available for some
causes of dysmotility, including abnormalities in salt
balance and endocrine problems such as thyroid disease.
• Unfortunately, many causes of dysmotility cannot be
cured, and symptomatic treatment is offered. Medicines
can stimulate intestinal motility and help with propulsion
of intestinal contents. Dietary modifications are advised.
It is important that adequate calories are taken, usually in
the form of meal supplements.

22. • Patients should avoid gas forming foods, carbonated
beverages, and foods that are difficult to digest.
Patients may need to be admitted to hospital for
intravenous fluids, and decompression of the
intestine with a tube placed in the stomach.
Occasionally, nutrition will have to be supplied
through a vein.
• When only a short segment of the small intestine is
involved, surgical resection may be appropriate.
However, patients must be carefully selected as
surgery can lead to scarring (adhesions) within the
abdominal cavity, with further disturbance of
intestinal motility.

23. 4.Infections of the Small
Intestine(Bacteriosis)
• The major function of the small intestine is to
digest, absorb and propel food along its length.
Most clinically important infections of the small
intestine will interfere with these functions.
Diarrhea is common; other symptoms include
bleeding, bloating, nausea, vomiting, abdominal
pain, and even features of complete abdominal
obstruction. Some infections have characteristic
features.

24. Salmonella Infections
• Salmonella appears in many forms. The so called non-
typhoidal Salmonella species is the most common cause
of food poisoning outbreaks in the United States. These
organisms are extremely common in meat products, but
have also been traced to pet turtles and iguanas.
Chickens and eggs are probably the most common
cause of infection.
• Patients will develop symptoms 10 to 48 hours after
eating contaminated food. They may have a wide range
of symptoms ranging from mild gastroenteritis to a
severe diarrheal illness with dehydration and profound
infection.

25. • . Patients with malignancies, sickle-cell anemia,
aortic aneurysms, and heart valve disease appear to
be more predisposed to getting a disseminated type
of infection (i.e. spread to the blood).
• Patients may get better without the use antibiotics.
Antibiotics are recommended for very ill patients. A
small percentage of individuals may develop a
chronic carrier state; they are asymptomatic, but
excrete salmonella in the stool for a year or longer

26. Typhoid Fever
• An infection from a particular species of Salmonella
(usually Salmonella typhi), typhoid fever is
characterized by prolonged fever, bacteria in the
blood and multiple organ dysfunctions, including
inflammation of the kidney and brain. Typhoid fever
is becoming rare in the United States. Immunization
is useful. Treatment requires powerful antibiotics
and specific treatments for other organ
involvements.

27. Staphylococcus Aureus
• Staphylococcus aureus is probably the second most
common cause of bacterial food poisoning in the
United States. The bacteria multiply in the food and
produce the toxin. The toxin that is produced by
the food is not inactivated by heating. Symptoms
develop within six to eight hours and are
dominated by vomiting and abdominal cramping.
Usually patients make a full recovery within 24 to
48 hours.

28. Bacillus Cereus
• Bacillus cereus is an organism that produces an
intestinal toxin. This infection is associated with the
consumption of fried rice. Vomiting usually occurs
within six hours of ingesting the food. Some
patients may develop diarrhea, but most improve
spontaneously without specific treatment.

29. Other Infections
• There are many other bacterial infections that can
cause acute symptoms. These include the various
E-coli, Clostridium, Campylobacter, Yersinia, and
Vibrio (cholera). There are also viral infections of
the intestine that can cause acute diarrheal
illnesses which usually resolve spontaneously.
Dehydration is the biggest problem.

30. Protozoal Infections-
Giardia Lamblia
• Giardia lamblia is a common parasitic pathogen which can
contaminate water supplies, and often occurs in travelers to
underdeveloped countries. Children in day care centers (and
adults working in them) have a higher incidence of contracting
Giardiasis.
• Symptoms vary but can include bowel disturbance, gas,
bloating and features of malabsorption. Patients may have
significant weight loss and some steatorrhea. Diagnosis can be
made by doing a specific stool analysis, or by examining a
duodenal biopsy specimen which is obtained during upper
endoscopy.
• Giardia is usually easily treated with a short course of
antibiotics. Infections can recur, and the intestine may remain
"irritable" for some weeks or months after the infection is
eradicated.

31. Intestinal Worms
• While true that many intestinal worms can be found in
the United States, they are, in fact, a global problem
with most instances occurring outside the USA.
• Hookworm – Hookworms attach themselves to
the lining of the small intestine. They are the most
common cause of iron deficiency anemia worldwide,
and can also result in abdominal pain and diarrhea.
Occasionally severe protein loss can occur from the
intestines. The diagnosis is made by stool examination.
Medication is effective

32. • Tapeworm – There are numerous types of
tapeworms that can be found in various meats, such
as pork, beef or fish. Infection occurs when poorly
cooked meats are ingested. The most common type
of tapeworm in the United States is thought to be
transmitted through contact with human feces.
• Tapeworms can cause obstruction to the intestine,
but usually cause few symptoms apart from non-
specific abdominal pains and occasional diarrhea.
The fish tapeworm can cause vitamin B12 deficiency.
Diagnosis is made by stool examination, and
effective medication is available.

33. • Pin Worm – Quite often seen in young children,
the most common symptom of pin worms is itching
in the anal area, though many infected individuals
are asymptomatic. The diagnosis is made by finding
the eggs or the actual worms around the peri-anal
area by placing a transparent sticky tape to the anal
area early in the morning. The sticky tape is then
examined under a microscope slide.
• Although specialized therapy is both available and
effective, testing and treatments may still need to
be conducted on other members of the household
to prevent reinfection.

34. Strongyloides Stercoralis –
• Strongyloides Stercoralis is most common in Africa, Asia and Latin
America but is found also in the southern part of the United States.
This worm enters the body by penetrating through the skin and
migrating through the venous system to the lungs and finally
reaches the small intestine.
• Patients may develop symptoms from lung involvement such as
cough, shortness of breath and wheezing. Chronic infection can
cause intermittent abdominal pain, vomiting, malabsorption and
weight loss.
• Patients with organ transplant or underlying malignancies such as
leukemia, lymphoma or those who are taking corticosteroid
therapy can develop a life threatening infection manifested by
severe gastrointestinal and pulmonary symptoms. The diagnosis is
made by careful stool examination and specific medication is
prescribed

35. Echinococcosis
• Echinococcus worm is found in the intestine of dogs and
sheep. Humans become infected with the cystic form. This
infection is found in areas where dogs, sheep and humans
live in close proximity, particularly under conditions of poor
hygiene. Humans become infected when they ingest the
eggs in fecally contaminated food such as vegetables, wild
fruits and water.
• Once the eggs enter the human intestine the larvae invade
the bowel wall and circulate to various organs such as the
liver and lung where they form cysts.
• Diagnosis is made by X-ray studies. A special blood test can
detect specific antibodies. Although some patients will also
require surgery, all will be treated with medications.

36. Inflammatory Bowel Disease (IBD)
• What is IBD?
• Inflammatory Bowel Disease is a set of conditions that affects
the colon and small intestine. There are two primary forms of
inflammatory bowel disease (IBD), Crohn's disease and
ulcerative colitis. Both are classified as autoimmune disorders.
An autoimmune disorder is a condition that takes place when
the body's immune system errantly attacks its own healthy
tissue.
• Together these disorders, which may run in families, affect
more than 500,000 Americans with men and women being
equally affected. Although a compromised immune response is
implicated in the typical inflammatory reactions in the
intestinal wall, the triggering event, possibly a bacterial or viral
infection, is as yet unknown.

37. • What are the symptoms of IBD?
• Symptoms may include:
• persistent abdominal pain
• bowel sores
• diarrhea
• intestinal bleeding
• weight loss
• In some cases, the inflammatory processes associated
with Crohn's disease and ulcerative colitis trigger skin
lesions, joint pain, inflammation of the eyes, and liver
disorders.

38. • Diagnosing IBD
• Inflammatory bowel diseases are diagnosed through:
• physical examination
• tests for anemia resulting from blood loss in the stool
• increased white blood cells indicative of an inflammatory
condition
• flexible sigmoidoscopy, whereby the intestinal lining is
viewed directly through a flexible tube inserted through the
anus
• X-rays (small bowel follow-through and/or barium enema),
which can indicate abnormal inflammation, thickening or
constriction of the small intestine and colon
• Samples of inflamed intestinal tissue may also be taken for
microscopic examination.

39. • What are the treatments for IBD?
• Treatment for both disorders includes:
• dietary adjustments
• medication
• surgery
• No specific dietary regimens have proved fully effective,
although avoidance of foods which exacerbate inflammation
is recommended.
• Both Crohn's disease and ulcerative colitis are initially
treated with sulfasalazine and mesalamine. More serious
cases of Crohn's disease are treated with prednisolone,
metronidazole or azathioprine. With ulcerative colitis,
surgery becomes necessary in one in four patients, for
whom the prognosis is usually good.
• While medication, diet, and surgery may lead to temporary
remission, both disorders persist throughout the patient's
lifetime.

40. Intestinal Lymphangiectasia
• What is Intestinal Lymphangiectasia?
• Intestinal lymphangiectasia affects children and young
adults. It is an abnormality of lymphatic channels (the
tubular system of channels that transports fats from the
small intestine to the liver and other organs). When the
lymphatic channels become blocked they become very
dilated and rupture and discharge their contents into the
colon.
• What are the causes of Intestinal Lymphangiectasia?
• Intestinal lymphangiectasia can be congenital or acquired.
The acquired forms are usually due to some form of
infiltrative or mechanical process such as amyloidosis or
malignancy.

41. • Symptoms of Intestinal Lymphangiectasia
• swelling of the lower limbs, also known as edema
• mild diarrhea or steatorrhea
• weight loss, fatigue, and abdominal pain
• Diagnosis of Intestinal Lymphangiectasia
• Endoscopic examination
• Blood tests indicate a significant protein loss.
• Leakage of lymphatic juices into the small bowel
• The diagnosis is confirmed by taking a biopsy from the
lining of the small intestine, which shows typical gross
dilatation of the lymphatic vessels.
• Treatment of Intestinal Lymphangiectasia
• Patients are treated with a low fat diet; normal fat is
replaced with medium chain triglycerides.

42. Intestinal Lymphoma
• What is Intestinal Lymphoma?
• A lymphoma is a cancer that occurs in our body's lymph nodes.
Lymph nodes are small organs found throughout the body,
including deep inside the abdominal cavity, that aid our immune
system. This lymphatic system, which bears some resemblance to
our vascular system, has vessels that circulates lymph (a fluid)
throughout the body. However, this passage of lymph occurs as a
result of muscle movement; unlike the heart in the vascular
system, there is no pump to regulate the flow.
• What causes intestinal lymphoma?
• Intestinal lymphoma of the small intestine is a recognized
complication of celiac sprue, and can occur in immunodeficiency
syndromes. Patients with the human immunodeficiency virus
(HIV) infection have a higher risk of developing intestinal
lymphoma. These lymphocytic tumors are also more common in
men, occurring in middle age or later years.

43. • What are the symptoms of intestinal lymphoma?
• Symptoms can include:
• crampy-like abdominal pain
• weight loss
• features of malabsorption
• rectal bleeding
• severe constipation and/or bowel obstruction

44. Lactose Intolerance
• What is lactose intolerance?
• Lactose is a special type of sugar which occurs in dairy products
(ex. milk, butter, yoghurt, cheese, etc.). To be absorbed by the
body, the lactose needs to be split into its two component sugars,
glucose and galactose. This digestion is brought about by lactase
enzymes which lie in the microvilli—microscopic, finger-like
projections—of the lining of the small intestine. An enzyme is a
substance produced by a living organism that acts as a catalyst to
bring about a specific biochemical reaction.
• Photo of a bottle of milk next to a roll of toilet paper.
• When there is a deficiency of this lactase enzyme, lactose cannot
be broken down. Resulting diarrhea is caused by fluid entering
into the small intestine, but also due to lactose passing to the
colon where it is broken down by bacteria to organic acids and
fermented.

45. • A significant amount of water can be lost into the
intestine following the ingestion of a large lactose load.
• Some individuals can develop secondary lactose
intolerance. This occurs when the intestinal mucosa is
injured such as in celiac disease, Crohn's disease or
even infections. The inflammation damages the cells
that produce lactase.
• Lactose intolerance is probably one of the most
common genetic deficiencies occurring in 5–10% of
Caucasians of northwestern European ancestry, but in
greater than 90% of people of African, Chinese or
Mediterranean background. However, it is not always
clinically significant as this depends on the amount of
lactose that is ingested.

46. • What are the symptoms of lactose intolerance?
• The classic clinical features of lactase deficiency are:
• diarrhea
• bloating and gas
• Many patients are labeled with the diagnosis of
irritable bowel syndrome (IBS) before lactase
deficiency is considered. Occasionally, patients may
develop osteoporosis as they avoid all milk
products and become calcium and vitamin D
deficient.

47. • Diagnosing lactose intolerance
• An informal diagnosis of lactose intolerance can be made
by asking the patient to avoid all milk products.
Alleviation of symptoms can occur in a few days on a
modified dairy free diet.
• A more formal way of diagnosing lactose intolerance is to
perform a specialized breath test. During this test the
patient ingests radioactively labeled lactose and is then
asked to breathe into a bag which measures labeled
hydrogen and methane (produced by the breakdown of
lactose by colonic bacteria). If the patient is truly lactose
intolerant they may develop significant symptoms during
this test.
• Another way for assessing for lactase deficiency is to
perform a blood test after lactose ingestion to measure
blood sugar levels, which should rise if it is being
digested and absorbed normally.

48. • Treating lactose intolerance
• Treatment includes restriction of dietary lactose,
prevention of dietary deficiencies (particularly
calcium and vitamin D), and use of lactase
preparations which can be taken whenever a small
amount of dairy product is eaten.

49. Small Bowel Obstruction
• What is Small Bowel Obstruction?
• From the moment you swallow food until you release
the remains of your meal in a bowel movement, the
entire digestive tract performs an amazing feat of
moving the food through the organs by way of a special
set of muscles that contract and expand. In fact, the
sound you hear when your stomach growls is a result of
the contractions that are going on as you digest food.
• Small bowel obstruction is a potentially dangerous
condition. There are a number of conditions in which
the contractions of the bowel muscles make the
process of moving the food very slow. These can be
annoying and impact the quality of life.

50. • There are two types of small bowel obstruction:
• functional — there is no physical blockage, however,
the bowels are not moving food through the digestive
tract
• mechanical — there is a blockage preventing the
movement of food.
• Funtional causes may include:
• Muscle or nerve damage that may be the result of
abdominal surgery, or disorders such as Parkinson's
disease
• Infections
• Certain medications that paralyze the contractions.
Strong narcotics have this effect.

51. • There are also serious conditions which may require
immediate intervention:
• Hernias — probably the most common condition in
children and adults, in which a small part of the
intestine protrudes through another part of the body.
Adhesions may also be a cause. Scar tissue can form
that blocks the intestinal canal.
• Inflammatory Bowel Disease — a condition in which
the walls of the intestine become inflamed
• Tumors in the intestine that impede the flow
• A volvulus, or a twisting of the intestine
• Intussusception, a condition in which a segment of the
intestine collapses into itself

52. • Symptoms of Small Bowel Obstruction
• intermittent pain due to perstalsis
• distension of the stomach depending on where the
obstruction is located
• vomiting
• constipation
• fever and a racing heart

53. • Why you need to see a physician if you suspect you have a
small bowel obstruction?
• If a part of the intestine becomes twisted, blood flow to
that portion may be reduced, and the blocked part may
die. This is a very serious condition. Another serious
condition can occur in which the intestine ruptures,
leaking contents into the bowel cavity. This causes an
infection known as peritonitis.
• Your doctor may ask you these questions about your
condition:
• How long have you been experiencing this problem
• Have you had this condition before? Did it clear up?
• Did the pain arise quickly?
• Is the pain constant?
• Have you ever had surgery in the abdominal area?

54. • Diagnosis of Small Bowel Obstruction
• Usually all that is required to diagnos an obstruction of
the small bowel is an x-ray of the abdomen.
• Luminal contrast studies
• computed tomography (CT scan)
• ultrasonography (US)
• Once the diagnosis of bowel obstruction is entertained,
location, severity and etiology are to be determined.
Most importantly is the differentiation between simple
and complicated obstruction

55. • Treatment of Small Bowel Obstruction
• Antiemetics are medications that keep you from
throwing up
• Analgesics are mild pain relievers
• Antibiotics will attack any infection you may have
• Bowel decompression is a procedure in which a
tube is guided into the impacted area in an attempt
to reduce the pressure and address adhesions.
• Surgery

56. • Complications of Small Bowel Obstruction
• Abdominal abscesses are pockets of infected pus in
the abdominal cavity
• Sepsis, a condition in which the blood becomes
infected
• Short Bowel Syndrome is a condition that results in
malabsorption of nutrients
• Quick intervention is the best medicine for small
bowel obstructions. Complications arise quickly, and
require complex surgery. Early intervention results
in favorable outcomes with few complications. See
your doctor if you think you may be having a
problem.

57. Tropical Sprue
• Tropical sprue is a malabsorptive disorder (like celiac sprue)
characterized by abnormalities in the lining of the small
intestine, resulting in poor absorption of folic acid, salts
and increased water loss. It is believed to be infectious in
origin, and typically occurs after travel to third world
countries. Patients will complain of diarrhea, weight loss,
dyspepsia, bloating, and eventually develop nutritional
deficiencies.
• Tropical sprue is clinically suspected from the clinical
symptoms and history of recent foreign travel. There are
no specific blood tests to diagnose tropical sprue. Upper
endoscopy is often performed to obtain a small intestine
biopsy sample of the intestinal lining. The biopsy will show
variable degrees of atrophy of the small intestine with
villous blunting and inflammation.

58. • To treat tropical sprue, patients are prescribed high
doses of folic acid, and antibiotics are often
required. Once treated, tropical sprue does not
recur unless the patient is re-exposed by returning
to tropical areas.

59. Tumors of the Small Intestine
• Tumors of the small intestine are rare. They are
usually single, but may be multiple particularly in
certain syndromes (i.e. intestinal polyposis
syndrome). Tumors can be benign or malignant.
Some benign tumors can progress and become
malignant (i.e. adenomas, leiomyomas).

60. • Most small intestine tumors are clinically silent
for long periods. Nearly half of all benign small
intestine tumors are found only incidentally
either during an operation or an investigation to
visualize the intestine for other reasons.
Symptoms can be chronic and/or intermittent
and include abdominal pain, nausea, weight loss
and bleeding. The larger the tumor, the more
likely the patient will experience symptoms of
bowel obstruction. Tumors can also become
ulcerated and bleed.

61. Malignant Tumors
• Adenocarcinoma – Adenocarcinoma of the small intestine probably
develops mainly from adenomas. Most tumors occur at the ampulla in
the duodenum. Other risk factors for adenocarcinoma include Crohn's
disease, celiac sprue, different types of previous surgery (i.e. surgery
joining the urinary system with the intestines), and neurofibromatosis.
Patients can present with obstruction or bleeding. The tumor may be
diagnosed by radiologic techniques (barium studies), endoscopy or
surgery, and confirmed by biopsy sampling. Treatment depends on the
location, size and shape of the tumor, and whether it has spread. Options
include endoscopic removal and surgery. Chemotherapy and radiation
may be helpful.
• An endoscopic image of a healthy small intestine.
• An endoscopic image showing multiple tumors in part of the small
intestine.
• Images showing the inside of a healthy small
• intestine (top) and another showing multiple
• tumors inside the small intestine (bottom).

62. • Intestinal Lymphoma – Intestinal lymphoma of the
small intestine is a recognized complication of celiac
sprue, and can occur in immunodeficiency
syndromes. Symptoms include crampy-like
abdominal pain, weight loss, features of
malabsorption, bleeding, or even bowel
obstruction.

63. • Leiomyosarcoma – This is a malignant tumor
arising from the muscle wall of the intestine and
can also arise from a benign leiomyoma.
Whenever possible, complete surgical resection is
recommended. Chemotherapy and radiation are
also used.
• Metastic Malignancy from Other Organs – (i.e.
lung, breast or melanoma

64. • Benign Tumors
• Leiomyoma – Leiomyomas are tumors of one of the muscle
layers of the intestinal wall. Some can grow into the lumen
of the bowel and become ulcerated and cause bleeding or
anemia, which is the most common symptom and finding.
They can be very difficult to diagnose, especially when they
occur in the small intestine. Endoscopic ultrasound is a
useful way to determine the site of the tumor within the
bowel wall. Some leiomyomas do have malignant potential.
Biopsy sampling and surgical resection is the normal course
of action.
• Adenomas – Adenomas are benign tumors that do have
malignant potential. They cause symptoms due to blockage.
When they arise in the region of the papilla or the area of
the duodenum where the bile duct and pancreas drain they
can cause jaundice. Because of the risk of malignant
degeneration, adenomas are usually removed (by surgery or
endoscopy)

65. • Lipomas – Lipomas are collections of fatty tissue within the
wall of the intestine that, when viewed endoscopically, have
a mild yellowish appearance. These are completely benign
tumors with no malignant potential. Lipomas do not need to
be removed unless they become very large and cause
obstructive symptoms (or bleeding due to ulceration).
• Hemangiomas – Hemangiomas are collections of blood
vessels that form a benign vascular tumor in the wall of the
stomach or intestine. They are benign and sometimes found
in conjunction with other syndromes. Hemangiomas can
cause gastrointestinal bleeding and anemia. They are
detected by endoscopy. They can be treated endoscopically
with application of a heater probe to burn the vessels.
Patients may need resection of areas of intestine heavily
involved with hemangiomas if they cause significant
bleeding. Various medicinal therapies (i.e. estrogens) have
been tried to reduce the amount of bleeding from
hemangiomas. Reports of success have been variable.

66. • Neurogenic Tumors – Neurogenic tumors are
benign growths arising from neural (nerve)
tissue. The most common variety is
neurofibroma. These usually solitary tumors
can be confirmed by their microscopic
appearance after biopsy sampling.

67. Polyposis Syndromes Involving the
Small Bowel
• There are four important polyposis syndromes that
involve the small intestine: Familial Adenomatous
Polyposis; Peutz-Jeghers Syndrome; Generalized
Juvenile Polyposis; and, Cronkhite-Canada
Syndrome. These are a group of disorders
characterized by the presence of multiple polyps
affecting all or parts of the gastrointestinal tract.
They are distinguished by the way they can be
inherited but also by the microscopic appearance
of the polyps.

68. • Familial Adenomatous Polyposis – Familial Adenomatous
Polyposis are very strongly inherited (autosomal dominant).
They are characterized by the presence of multiple
adenomatous polyps in the colon and thus place the patient in
a high risk of developing colon cancer. Over 80% of patients
with these syndromes can also have adenomas involving the
small intestine, which are also pre-malignant. They tend to be
most common in the upper part of the small intestine
(duodenum). In patients who have had their colon removed to
avoid death from colon cancer, the most common cause of
death from cancer is the development of cancer in the
duodenum (the periampullary region). Unfortunately, it is not
possible to remove all of the adenomas in the small intestine.
Therefore, surgical or endoscopic removal is used only for
large polyps. Certain medications related to aspirin appear to
halt or at least reduce the growth of some of these adenomas
in the small intestine. Patients are usually advised to have
examinations of the small intestine every few years.

69. • Peutz-Jeghers Syndrome – This is a syndrome
essentially characterized by excessive growth of normal
intestinal tissue that occurs mainly in the jejunum and
ileum, and most often present problems with bleeding
and obstruction of the bowel. There is a small risk of
cancer, but far less than familial adenomatous
polyposis. There is also a slightly increased incidence of
malignancy in the gynecological organs, as well as
pigmentation (dark spots) in the region of the lips and
mouth. Although it tends to fade after puberty, this
pigmentaton can also sometimes affect the genital
areas and limbs.

70. • Generalized Juvenile Polyposis – Generalized juvenile
polyposis can be inherited or sporadic. The polyps may
be found anywhere in the intestinal tract and are
characterized by their microscopic appearance. Large
polyps may present with symptoms of obstruction or
bleeding and there is a small increased risk of
developing gastrointestinal cancer.
• Cronkhite-Canada Syndrome – This is a syndrome
characterized by many intestinal polyps, pigmentation,
diarrhea, protein loss from the intestine and alopecia
(local hair loss). The polyps are most commonly found in
the small intestine and usually do not become
malignant. The patient's main problem is usually
malnutrition. Aggressive nutritional support is usually
necessary.

71. Whipple's Disease
• What is Whipple's disease?
• Whipple's disease is a rare, infectious condition that
prevents the small intestine from properly absorbing
nutrients. Inflammatory cells infiltrate the intestine to such
an extent that the villi —small, finger-like projections that
protrude from the intestinal wall— become distended and
very abnormally prominent preventing transport of
nutrients to the body.
• What are the symptoms of Whipple's disease?
• An illustration showing healthy villi of the small intestine.
• The most common symptoms of Whipple's disease are:
• diarrhea
• abdominal pain
• weight loss
• malabsorption
• edema

72. • Neurological symptoms may include:
• headaches, and vision problems
• memory problems and dementia
• muscle weakness or twitching
• Although not covered in detail on this page,
Whipple's disease can also affect other parts of
the body such as the skin, joints, nervous system,
brain, lungs, and heart. Patients can present
with a long history of joint problems, fever,
diarrhea, weight loss, enlarged lymph nodes,
skin pigmentation and intermittent
exacerbations of abdominal pain.

73. • How do you diagnose Whipple's disease?
• A biopsy is performed during endoscopic
examination of the small intestine.
• biopsy with tissue staining
• electron microscopes can examine biopsy tissue
• DNA testing, but this is a recent diagnostic tool
• How do you treat Whipple's Disease?
• Antibiotics are prescribed for a long period:
• tetracycline
• penicillin
• ampicillin
• Patients with Whipple's disease are treated with
antibiotics for several months, and usually go into
remission; some may have relapses.