Tropical sprue pathophysiology: Difference between revisions

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Latest revision as of 00:30, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S [2]

Overview

The exact pathophysiology of tropical sprue is unclear but is thought to be related to intestinal inflammation following an episode of diarrhea. The inflammation damages the intestinal villi and also result in lymphocytosis in the intestinal wall. Deficiency of lactase enzyme in results in malabsorption of carbohydrates and the dysfunctional enterocytes cause steatorrhea.

Pathophysiology

Pathogenesis

Tropical sprue leads to villous atrophy which primarily affects the proximal and the distal gastrointestinal tract including the terminal ileum causing vitamin B12 and folate deficiencies. The pathogenesis of tropical sprue is unclear and multiple theories have been proposed. The pathogenesis of tropical sprue includes:^[1]

Post infectious diarrhea theory is the most supported due to:
- The occurrence of the disease following an episode of acute gastroenteritis.
- Occurrence of the disease in epidemics in rural areas with poor sanitation.
- Susceptibility of visitors from developed countries to endemic regions in developing countries.
- The frequency of small bowel bacterial overgrowth in patients with tropical sprue.
  - The small intestinal bacterial overgrowth affects the enterocyte brush border activity, duodenal morphology causing villous atrophy and lymphocytosis in the intestinal cells.
Other factors that can result in tropical sprue include the following:^[2]
- Impaired host immune response results in prolonged inflammation of the small bowel affecting the enterocyte function.
- Reduced gut defense mechanisms results in increased bacterial overgrowth which damages the enterocytes and crypt cells leading to intestinal villous atrophy and eventually chronic diarrhea.
- Bile acid deconjugation affects the enterohepatic circulation and causes steatorrhea.
- Vitamin B12 deficiency can occur if the ileum is involved and the megaloblastic change in the intestinal musocal epithelium results in the formation of dysfunctional epithelial cells.
- Slow mouth to cecum transit due to intestinal stasis promotes small intestinal bacterial over growth and patients with tropical sprue have higher levels of enteroglucagon, peptide YY, and neurotensin which decrease the motility of intestine all these can predispose to the development of tropical sprue.^[3]
- Mucosal disaccharidase deficiency is also a potential cause as patients with tropical sprue have higher levels of urinary lactuose excretion suggesting a deficiency of lactase enzyme.
The bacteria after an episode of diarrhea damages the enterocytes resulting in small bowel stasis, bacterial over-growth, reduced gut motility, malabsorption and loss of folate with further damage to the enterocyte. All these factors contribute to the vicious cycle of events resulting in tropical sprue.
Treatment with tetracyclines eliminates the bacterial overgrowth and supplementation of folate helps in regeneration of the intestinal epithelium. The diagnosis of tropical sprue is confirmed only if the patient responds to treatment with tetracyclines and folate supplementation.

Genetics

People with Aw-19 HLA haplotype are at higher risk of developing tropical sprue.

Associated Conditons

There are no associated conditions with tropical sprue.

Microscopic Pathology

Small bowel biopsy reveals similar changes as gluten sensitive enteropathy.
The features demonstrated on a duodenal biopsy include:^[4]
- Incomplete villous blunting
- Intra epithelial lymphocytosis
- Eosinophilic infilteration of the mucosa

References

↑ Ghoshal UC, Kumar S, Misra A, Choudhuri G (2013). "Pathogenesis of tropical sprue: a pilot study of antroduodenal manometry, duodenocaecal transit time & fat-induced ileal brake". Indian J Med Res. 137 (1): 63–72. PMC 3657900. PMID 23481053.
↑ Brown, Ian S.; Bettington, Andrew; Bettington, Mark; Rosty, Christophe (2014). "Tropical Sprue". The American Journal of Surgical Pathology. 38 (5): 666–672. doi:10.1097/PAS.0000000000000153. ISSN 0147-5185.
↑ Ghoshal UC, Ghoshal U, Ayyagari A, Ranjan P, Krishnani N, Misra A; et al. (2003). "Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time". J Gastroenterol Hepatol. 18 (5): 540–7. PMID 12702046.
↑ SWANSON VL, THOMASSEN RW (1965). "PATHOLOGY OF THE JEJUNAL MUCOSA IN TROPICAL SPRUE". Am J Pathol. 46: 511–51. PMC 1920377. PMID 14278662.

Template:WS Template:WH

[pmid23481053-1] Ghoshal UC, Kumar S, Misra A, Choudhuri G (2013). "Pathogenesis of tropical sprue: a pilot study of antroduodenal manometry, duodenocaecal transit time & fat-induced ileal brake". Indian J Med Res. 137 (1): 63–72. PMC 3657900. PMID 23481053.

[BrownBettington2014-2] Brown, Ian S.; Bettington, Andrew; Bettington, Mark; Rosty, Christophe (2014). "Tropical Sprue". The American Journal of Surgical Pathology. 38 (5): 666–672. doi:10.1097/PAS.0000000000000153. ISSN 0147-5185.

[pmid12702046-3] Ghoshal UC, Ghoshal U, Ayyagari A, Ranjan P, Krishnani N, Misra A; et al. (2003). "Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time". J Gastroenterol Hepatol. 18 (5): 540–7. PMID 12702046.

[pmid14278662-4] SWANSON VL, THOMASSEN RW (1965). "PATHOLOGY OF THE JEJUNAL MUCOSA IN TROPICAL SPRUE". Am J Pathol. 46: 511–51. PMC 1920377. PMID 14278662.

[1]

[2]

[3]

[4]

@@ Line 1: / Line 1: @@
+<div style="-webkit-user-select: none;">
+{| class="infobox" style="position: fixed; top: 65%; right: 10px; margin: 0 0 0 0; border: 0; float: right;"
+|-
+| {{#ev:youtube|https://https://www.youtube.com/watch?v=In1uajyiSxE|350}}
+|-
+|}
 __NOTOC__
 {{Tropical sprue}}
-{{CMG}}; {{AE}}
+{{CMG}}; {{AE}}  {{AKI}}
 ==Overview==
+The exact pathophysiology of [[tropical sprue]] is unclear but is thought to be related to [[intestinal]] [[inflammation]] following an episode of [[diarrhea]]. The inflammation damages the [[intestinal villi]] and also result in [[lymphocytosis]] in the intestinal wall. Deficiency of [[lactase]] enzyme in results in [[malabsorption]] of [[carbohydrates]] and the dysfunctional [[enterocytes]] cause [[steatorrhea]].
 ==Pathophysiology==
 ===Pathogenesis===
-Pathogenesis of tropical sprue is unclear and multiple theories are proposed.The factors involved in the pathogenesis of tropical sprue include:<ref name="pmid23481053">{{cite journal| author=Ghoshal UC, Kumar S, Misra A, Choudhuri G| title=Pathogenesis of tropical sprue: a pilot study of antroduodenal manometry, duodenocaecal transit time & fat-induced ileal brake. | journal=Indian J Med Res | year= 2013 | volume= 137 | issue= 1 | pages= 63-72 | pmid=23481053 | doi= | pmc=3657900 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23481053  }} </ref>
+[[Tropical sprue]] leads to villous atrophy which primarily affects the proximal and the distal gastrointestinal tract including the terminal [[ileum]] causing [[Vitamin B12 Deficiency|vitamin B12]] and [[Folate deficiency|folate]] deficiencies. The pathogenesis of [[tropical sprue]] is unclear and multiple theories have been proposed. The pathogenesis of [[tropical sprue]] includes:<ref name="pmid23481053">{{cite journal| author=Ghoshal UC, Kumar S, Misra A, Choudhuri G| title=Pathogenesis of tropical sprue: a pilot study of antroduodenal manometry, duodenocaecal transit time & fat-induced ileal brake. | journal=Indian J Med Res | year= 2013 | volume= 137 | issue= 1 | pages= 63-72 | pmid=23481053 | doi= | pmc=3657900 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23481053  }} </ref>
-* The most accepted theory is the small intestinal bacterial overgrowth affecting the enterocyte brush border activity, duodenal morphology causing villous atrophy and lymphocytosis in the intestinal cells.
+*Post infectious [[diarrhea]] theory is the most supported due to:
-*Impaired host immune response results in prolonged inflammation of the small bowel affecting the enterocyte function.
+**The occurrence of the disease following an episode of acute [[gastroenteritis]].
-*Reduced gut defense mechanisms resulting in increased bacterial over growth damages the enterocytes and crypt cells to cause intestinal villous atrophy. This causes chronic diarrhea.
+**Occurrence of the disease in epidemics in rural areas with poor [[sanitation]].
-*Bile acid deconjugation affects the enterohepatic circulation and cause steatorrhea.
+**Susceptibility of visitors from developed countries to endemic regions in developing countries.
-*Vitamin B12 deficiency can occur if the ileum is involved and the megaloblastic change in the intestinal mucuosal epithelium results in the formation of dysfunctional epithelial cells.
+**The frequency of [[small bowel bacterial overgrowth]] in patients with [[tropical sprue]].
-*Slow mouth to ceacum transit due to intestinal stasis promotes small intestinal bacterial over growth and patients with tropical sprue have higher levels of enteroglucagon, peptide YY, and neurotensin which decrease the motility of intestine all these can predispose to the development of tropical sprue.
+***The [[small intestinal bacterial overgrowth]] affects the [[enterocyte]] brush border activity, duodenal morphology causing [[Villous folds|villous]] atrophy and [[lymphocytosis]] in the intestinal cells.
-*Mucosal disaccharidase deficiency is also a potential cause as patients with tropical sprue have higher levels of urinary lactulose excretion suggesting a deficiency of lactase enzyme.
+*Other factors that can result in [[tropical sprue]] include the following:<ref name="BrownBettington2014">{{cite journal|last1=Brown|first1=Ian S.|last2=Bettington|first2=Andrew|last3=Bettington|first3=Mark|last4=Rosty|first4=Christophe|title=Tropical Sprue|journal=The American Journal of Surgical Pathology|volume=38|issue=5|year=2014|pages=666–672|issn=0147-5185|doi=10.1097/PAS.0000000000000153}}</ref>
-*Post infectious diarrhea theory is supported by the occurrence of the disease following an episode of acute gastroenteritis, occurrence of the disease in epidemics in rural areas with poor sanitation, susceptibility of visitors from developed countries to endemic regions and the frequency of small bowel bacterial overgrowth in patients with tropical sprue.
+**Impaired host [[immune]] response results in prolonged [[inflammation]] of the [[small bowel]] affecting the [[enterocyte]] function.
+**Reduced gut defense mechanisms results in increased bacterial overgrowth which damages the [[enterocytes]] and crypt cells leading to intestinal [[Villous folds|villous]] atrophy and eventually chronic [[diarrhea]].
+**[[Bile acid]] deconjugation affects the [[Enterohepatic circulation|enterohepatic]] circulation and causes [[steatorrhea]].
+**[[Vitamin B12 deficiency]] can occur if the [[ileum]] is involved and the [[Megaloblastic Anemias|megaloblastic]] change in the intestinal musocal [[epithelium]] results in the formation of dysfunctional [[epithelial]] cells.
+**Slow mouth to [[cecum]] transit due to intestinal stasis promotes small intestinal bacterial over growth and patients with [[tropical sprue]] have higher levels of [[enteroglucagon]], [[peptide YY]], and [[neurotensin]] which decrease the [[motility]] of [[intestine]] all these can predispose to the development of [[tropical sprue]].<ref name="pmid12702046">{{cite journal| author=Ghoshal UC, Ghoshal U, Ayyagari A, Ranjan P, Krishnani N, Misra A et al.| title=Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time. | journal=J Gastroenterol Hepatol | year= 2003 | volume= 18 | issue= 5 | pages= 540-7 | pmid=12702046 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12702046  }} </ref>
+**Mucosal [[disaccharidase]] deficiency is also a potential cause as patients with [[tropical sprue]] have higher levels of urinary lactuose excretion suggesting a deficiency of [[lactase]] enzyme.
+* The [[bacteria]] after an episode of [[diarrhea]] damages the [[enterocytes]] resulting in small bowel stasis, bacterial over-growth, reduced gut [[motility]], [[malabsorption]] and loss of [[Folic Acid|folate]] with further damage to the [[enterocyte]]. All these factors contribute to the vicious cycle of events resulting in [[tropical sprue]].
+*Treatment with [[tetracyclines]] eliminates the bacterial overgrowth and supplementation of [[folate]] helps in regeneration of the [[intestinal epithelium]]. The diagnosis of [[tropical sprue]] is confirmed only if the patient responds to treatment with [[tetracyclines]] and [[folate]] supplementation.
-===Genetics===
+==Genetics==
-People with HLA haplotype with Aw-19 series are at higher risk of developing tropical sprue.
+People with Aw-19 [[HLA]] haplotype are at higher risk of developing [[tropical sprue]].
-===Gross Pathology===
+==Associated Conditons==
+There are no associated conditions with [[tropical sprue]].
-===Microscopic Pathology===
+==Microscopic Pathology==
-*Small bowel biospy reveals similar changes as gluten sensitive enteropathy.
+*Small bowel biopsy reveals similar changes as [[Celiac Disease|gluten sensitive enteropathy]].
-*The features demonstrated on a duodenal biopsy include :<ref name="pmid14278662">{{cite journal| author=SWANSON VL, THOMASSEN RW| title=PATHOLOGY OF THE JEJUNAL MUCOSA IN TROPICAL SPRUE. | journal=Am J Pathol | year= 1965 | volume= 46 | issue=  | pages= 511-51 | pmid=14278662 | doi= | pmc=1920377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14278662  }} </ref>
+*The features demonstrated on a [[Duodenum|duodenal]] [[biopsy]] include:<ref name="pmid14278662">{{cite journal| author=SWANSON VL, THOMASSEN RW| title=PATHOLOGY OF THE JEJUNAL MUCOSA IN TROPICAL SPRUE. | journal=Am J Pathol | year= 1965 | volume= 46 | issue=  | pages= 511-51 | pmid=14278662 | doi= | pmc=1920377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14278662  }} </ref>
-**Incomplete villous blunting
+**Incomplete [[Villous folds|villous]] blunting
-**Intra epithelial lymphocytosis
+**Intra epithelial [[lymphocytosis]]
-**Eosinophilic infilteration of the mucosa
+**[[Eosinophilic]] infilteration of the mucosa
-===Associated Conditons===
 ==References==
@@ Line 36: / Line 50: @@
 {{WS}}
 {{WH}}
+[[Category:Emergency mdicine]]
+[[Category:Disease]]
+[[Category:Up-To-Date]]
+[[Category:Infectious disease]]
+[[Category:Gastroenterology]]