31: Nutritional Disorders II

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  Transcribed by Anam Khalid Tuesday, October 7 th , 2014 1 Nutritional Disorders –  General Pathology by Dr. Phelan [2 nd  hour] [Slide #24] –  [Thiamin (B1) Deficiency (Beri-beri)] [Dr. Phelan]   –  It's 4:02 for thos e of you that are here. Let’s move on, okay? I’d like you to know … when there's a name of a disease associated with a vitamin deficiency I expect you to know the name and I do expect you to know the name of the vitamin associated with -- or the name of the chemical ... let's put it this way …  associated with the deficiency. So it's thiamin that is B1 and the deficiency is called Beri-beri. The introductory statement on vitamin B1 for you as future dentists is that it is the one of the B vitamins that doesn't have oral manifestations. You’ll  see that every other one of them has very similar oral manifestations. This does not, okay? So the oral manifestations are not here. It’s a good test question because thiamin does not have the oral manifestations of the other ones. And the clinical manifes tations, polyneorpathy, or the cardiac ... not cardiac … the CNS  problems ... edema, cardiac failure, weight loss, and muscle wasting, are all part of the clinical manifestations of thiamin deficiency. And I said already that the oral manifestations of other vitamin B deficiencies are not seen with this one. Uncontrolled vascular dilatation or dilation--they're used interchangeably — will give you what? Hyperemia is what I’m  looking for. If you increase the size of the lumen or the lumina of the blood vessels you’re going to get hyperemia. And remember you can’t really di late large vessels. You’re going to have a mechanism for doing it. So when we talk about uncontrolled vascular dilation or di latation, you’re talking about the microcirculation because that’s the part of the circulation that has the ability to do this. It also, in addition to vascular dilation or dilation, you also have an increase in permeability. and you can see that up on the top list, there's something that would b related to that-- which one is? The edema. When we talked about the edema before, we were talking about ... we had not ... we didn't talk about vascular permeability. We talked about the increase in protein. So you have a different reason for the edema, when we are talking about the protein-calorie malnutritions than when we're talking about this one. This one, you actually have a change in the vascular structure that causes the edema. And the dia gnosis here is difficult because there really isn’t a test. It is the clinical manifestations that lead the clinician to suspect a thiamin deficiency and the diagnosis of that condition is that the patient response to thiamin. And again, the list on the bottom is going to be very similar all the way through the vitamin B deficiencies, you’ll see the same list almost always. Not always, I’ll try to hi ghlight when it’s different. [Slide #25] –  [N/A] [Dr. Phelan]   – Here is a diagram, if you will, that indicates the changes associated with Beri-beri. Encephalopathy is a CNS problem that was srcinally described by somebody named Wernicke but I would like you mostly to remember that there are neurologic features. I don’t need you to remember that specific name for the encephaloptathy. There’s cardiac problems. Again, cardiac dilation is related to  Transcribed by Anam Khalid Tuesday, October 7 th , 2014 2 some of the structural problems that happen when there’s vi tamins missing. Patients have weight loss. Again, peripheral neuropathy is going to be part of the CNS phenomena. Muscle wasting and edema. [Slide #26] –  [Riboflavin (B2) Deficiency] [Dr. Phelan]   –  B2 is riboflavin and with riboflavin there isn't a name of the deficiency except riboflavin deficiency. Makes it easier — one less name to know but here we have the classical oral manifestations of most of the vitamin B deficiencies and that's angular che ilitis, which you'll see on the diagram I’m going to give you, called cheilosis. And in the European countries, it usually called cheilosis. In this country, it’s called cheilitis. And glossitis is the second one and that is an atrophic --because of the epithelia of the papillae have disappeared and the epithelium becomes much thinner and this is a use of the term atrophic. And the smooth tongue is because you’ve lost the papillae. And it’s erythematous usually because the epithelium is thinner and because the epithelium is thinner, the vascular connective tissue shows through that very thin epithelium and makes the tongue look red. In some instances there is some inflammation in the tongue. And you're going to get the inflammatory changes in the microcirculation that is in the connective tissue, just underneath the epithelium that gives you this very red, flat, or smooth depapillated tongue that is characteristic of vitamin B deficiencies. Also, in addition to the tongue being atrophic, the rest of the epithelium is atrophic also, and so it very easily ulcerates. Dermatitis is part of this and some changes in the eye related to some of the epithelial changes that are caused by the decreasedness in this vitamin. And if you look at the causes down at the bottom, we have just about the same ones. We can substitute it for all of them. [Slide #27] –  [N/A] [Dr. Phelan]   – Here's the diagram again with ... here is a child with all of the oral signs of riboflavin deficiency. The angular cheilitis and the very smooth, bald tongue, as it’s sometimes called.  [Slide #28] –  [N/A] [Dr. Phelan]   – Here is our diagram ... changes in the cornea, dermatitis, glossitis, which is the entire complex for you guys. More sophisticated than this diagram. All of the components of the or al mucosa so it’s mucosal atrophy, tongue mucosa or tongue epithelium atrophy and then the changes in the corners of the mouth. They also have problems with thyroid and again it's related to epithelial changes. Anemia because of the bone marrow changes and the missing component necessary for the development of red blood cells and … [Slide #29] –  [Niacin Deficiency (B3)- Pellagra) [Dr. Phelan]   – Okay. Next one that has a name--niacin deficiency is B3. And that's pellagra. And the clinical manifestations here-- there's a classic triad that’s usually mentioned with niacin deficiency an d it doesn’t include the oral manifestations  here.  Transcribed by Anam Khalid Tuesday, October 7 th , 2014 3 But it’s  dermatitis, diarrhea, and dementia, the three D ’ s that go with niacin deficiency. The oral manifestations, same thing. Stomatitis and glossitis are the atrophy of the oral mucosa and the atrophy of the epithelium of the tongue, the loss of papillae and the thinning of the epithelium on the tongue. Angular cheilitis. And then a long-term niacin deficiency is going to lead to death. [Slide #30] –  [N/A] [Dr. Phelan]   –  Here is a diagram of all of the components that I need you to know on this deficiency. [Slide #31] –  [Pyridoxine (B6) Deficiency] [Dr. Phelan]   –  Pyridoxine deficiency is associated with CNS disorders and seizures. The oral manifestations are the same thing, again, okay? And then there is a anemia that looks like iron deficiency anemia. The laboratory findings would mimic iron deficiency anemia but in attempting to treat this deficiency it doesn't respond to the admin of iron. It responds to the admin istration of pyridoxine. And so it’s called the pyridoxine-responsive anemia. And again, the physician or the healthcare provider differential diagnosis is this is iron deficiency anemia. it is associated with some medications and isoniazid and cycloserine are both tuberculosis medications so of course if you’re a primary medical care provider and you have a patient that develops anemia and the patient’s taking TB meds, you sho uld and especially if you’re prescribing the meds, you should be on the lookout for this and probably should increase pyridoxine. Penicillamine is used for some patients to treat rheumatoid arthritis. There’s another unusual disease where there’s an increa se in copper that this drug is used for. Again, these interfere with pyridoxine absorption and will lead to a pyridoxine deficiency. Alcoholics can, again, have this deficiency. [Slide #32] –  [Vitamin B12 Deficiency- Pernicious Anemia: poor absorption of vitamin B12] [Dr. Phelan]   – Vitamin B12 deficiency is a little bit more complex than the others. There is a vitamin B 12 deficiency that can be nutritional because we talked about the need for animal products in order to have a sufficient intake of vitamin B12. But there is a vitamin B12 deficiency that is called pernicious anemia. In pernicious anemia the problem is that the individual cannot absorb vitamin B12. And there are a couple of different reasons that this can happen. One of them is the autoimmune disease. And the autoimmune disease involves a destruction of the parietal cells in the stomach. And you will remember from last year that the parietal cells secrete intrinsic factor. And without intrinsic facto r you don’t   have the ability to absorb vitamin B 123 into the ilium. So the loss of those parietal cells in the stomach interferes with the uptake of vitamin B12. So for this individual, no matter how much vitamin B12 this individual takes, the individual is not going to absorb vitamin B12 so the vitamin B12 is given usually as an injection in order to make it available.  Transcribed by Anam Khalid Tuesday, October 7 th , 2014 4 In individuals that have gastrointestinal bypass surgery, a component of stomach is removed and parietal cells are removed with that portion of the stomach so that individual is not able to secrete intrinsic factor and will not be able to absorb vitamin B12. In a chronic gastritis you can actually destroy, with chronic inflammation of the stomach, the stomach lining loses the parietal cells. We were having a conversation about vegetarian diets vs. vegan diets and … you need to have vitamin B12 and I don’t know if … I’m not an expert on vegetarian diets. I do know that vegans do not eat any animal products at all and they would need to find some way of replacing it. But that is not an absorption problem, that  ’ s a nutritional problem. Okay? And so watch vitamin B12 deficiency. The difference between pernicious anemia and nutritional deficiency. And I think that this slide, I should probably move the vegetarian diet or vegan diet out of that list because that's not pernicious anemia, okay? I’m going to correct this slide because I think it’s misleading because I put that underneath there. And that's not an absorption problem. Pernicious anemia is the absorptive problem. For whatever reason it’s occurring, it’s the absorptive problem, not the nutritional problem. Not taking in vitamin B12 is a different problem all together. And the correction of that problem is to increase vitamin B12 intake. The problem with pernicious anemia is that you have to give it by injection because no matter ho w much you give by supplement, you’re not going to be able to give enough to be able to override the lack of absorption. Yes? [Student] — Between autoimmune destruction, B12 deficiency and not taking B12, would you still get pernicious anemia if you’re not getting …   [Dr. Phelan] — Well you still get vitamin B12 deficiency but it’s just not called pernicious anemia. That’s all. Pernicious anemia is the name that’s used for the absorptive problem. [Student] — But you get the similar symptoms? [Dr. Phelan] —You get the same symptoms. Everything’s the same except the treatment, okay? And the diagnosis. You have to figure out whether or not the vitamin B12 deficiency is due to the lack of intake or the problem in absorption, okay? And the absorptive problem … it’s an interesting question, it’s asking my own question … in a malabsorptive disease that isn’t due to this problem with the stomach, that vitamin B12 deficiency would usually not be called pernicious anemia, okay? Because you can usually override it. That one you can override with an increase in nutritional intake. I’m asking my own question there. I’m going to double-check that to make sure I’m right, okay?  In folic acid, the clinical manifestation of folic acid are just about identical to vitamin B12. This is important because pregnancy increases the requirement for folic acid. And so pregnant women receive folic acid supplements as a part of prenatal care.
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