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Physician Assistant Exam: Celiac Disease and Malabsorption

A malabsorption syndrome is an inability to absorb key nutrients in the small intestine. The Physician Assistant Exam (PANCE) will expect you to have a firm grasp on nutritional deficiencies and celiac disease.

Vitamin deficiencies

Your intestine is responsible for the absorption of many vitamins and nutrients. One main cause of vitamin deficiencies is the lack of absorption in the small intestine due to conditions such as Crohn’s disease and the malabsorption syndromes, such as celiac disease. Here’s a quick review of some basic aspects of vitamin and nutritional deficiencies:

  • Vitamin A is important for maintenance of vision and of the immune system. Symptoms of Vitamin A deficiency include night blindness and increased susceptibility to infections.

  • Vitamin C is important for collagen formation. A deficiency of vitamin C is called scurvy, which can present as spongy gums, bleeding from mucous membranes, spots on the skin, and lethargy.

  • You know there are different kinds of vitamin B. Vitamin B1 is thiamine, and a deficiency causes Wernicke’s encephalopathy — the triad of cerebellar ataxia, nystagmus, and confusion, commonly seen in alcoholics. Vitamin B3 is niacin, and a niacin deficiency causes pellagra, with the triad of dementia, diarrhea, and dermatitis. Vitamin B6 helps with nerve health. A deficiency of B6 or an excess of B6 can cause a neuropathy.

  • A deficiency of Vitamin D causes problems with bone, namely osteomalacia.

  • Vitamin E (alpha-tocopherol) is a lipid-soluble antioxidant. A Vitamin E deficiency messes you up, and it may show up as spinocerebellar ataxia and myopathy, various neurological signs, and anemia, to name but a few.

  • Vitamin K is important for clotting of the blood, and a deficiency of this vitamin causes excess bleeding problems.

Celiac disease

Celiac disease, which is also known as gluten-sensitive enteropathy or celiac sprue, is an autoimmune reaction in the small intestine caused by gluten. Gluten can be found in wheat, rye, and barley. Histologically, you can see flattening of the small intestinal villi. Celiac disease is the most common form of malabsorption syndrome, affecting approximately 1 in 100 people.

The affected person can present with bloating, abdominal distention, and altered bowel habits, such as constipation and/or diarrhea. Celiac disease can also cause weight loss. It’s an uncommon cause of elevated liver function tests (transaminitis), and it can cause cirrhosis.

Here are several key points concerning celiac disease:

  • You’d order antigliadin antibody and tissue transglutaminase antibody in anyone you suspected has celiac disease.

  • The gold standard test to confirm the diagnosis is an endoscopy with biopsy of the small intestine.

  • The treatment includes the elimination of anything with gluten, which means prescribing a gluten-free diet for your patient. Many grocery stores have special gluten-free aisles.

  • It’s important to correct any nutritional deficiencies that may have resulted from celiac disease. This can include iron deficiencies, B12 and/or folate deficiencies, other vitamin deficiencies, and low magnesium levels.

Celiac disease can be associated with other medical conditions. A common one you may see on the PANCE is dermatitis herpetiformis, a blistering/bumpy type of rash commonly seen on the extremities, including the knees and elbows. It can also appear on the back. The treatment includes adherence to a gluten-free diet. A medication called dapsone (Aczone) is also used for treating this condition.

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