malabsorption tory davis, pa-c. to be covered malabsorption overview small bowel bacterial...
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Malabsorption
Tory Davis, PA-C
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To Be Covered Malabsorption overview Small bowel bacterial overgrowth Carbohydrate intolerance Celiac Disease Short Bowel Syndrome Not covered in this lecture: tropical
sprue, Whipple’s disease, secondary causes…look-em-ups
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Malabsorption Inadequate assimilation of dietary
substances due to defects in– Digestion– Absorption– Transport
Can affect micronutrients (vits and minerals) or macronutrients (protein/carb/fat)
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Malabsorption causes… Increased fecal excretion Nutritional deficiencies Common GI symptoms:
– Diarrhea– Steatorrhea (>6g/d of fat…hallmark of
malabsorption)– Abdominal bloating– Gas– Weight loss– Other specific s/s with each malabsorbed
nutrient
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How to figure it out Suspect malabsorption in all patients with
chronic diarrhea, wt loss, anemia Check hx for clues:
– Hx acute pancreatitis? Think chronic panc– Hx lifelong diarrhea exac by gluten? Rash, too?
Think celiac disease– Milk makes them fart? Think lactose intolerance– Had most of their small bowel removed? Think
short bowel syndrome! Okay, duh…
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Work-up If you suspect specific cause, test for it
– Details to follow, and more details from Brenda’s lab lectures
And/or check CBC (anemia), ferritin, lytes Confirm malabsorption:
– 72 h fecal fat collection– Sudan III stool stain for fat– D-xylose test (assesses mucosal integrity to
differentiate between mucosa and pancreatic etiology)
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Diagnosis of Malabsorption
Endoscopy with small bowel bx Culture small bowel aspirate for bac-t
overgrowth Small bowel xrays to look for anatomical
conditions that may predispose to bac-t overgrowth (fistulas, surgical blind loops, strictures, ulcerations)
Schilling test (B12)
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Causes of Malabsorption
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Bacterial Overgrowth Syndrome
Usually secondary to anatomic alterations or motility disorders (congenital or acquired) that promote stasis of intestinal contents
Normal small bowel has <105 bact/mL Low count maintained by peristalsis,
gastric acid, mucus, intact ileocecal valve function
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What Extra Bacteria Do Consume nutrients, especially B12 and
carbs– B12 (cyanocobalamin) deficiency– Calorie deprivation/weight loss
Produce folate, so this is NOT a cause of folate deficiency (folate def causes macrocytic anemia)
Deconjugate bile salts– Fat malabsorption– Steatorrhea and diarrhea
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Bac-t Overgrowth Dx Frequently, empiric antibiotic therapy
resulting in improvement is basis for diagnosis…but abx can worsen many conditions on the ddx
Better: quantitative culture of intestinal fluid. Look for bac-t count>105/mL
Or C-xylose breath test (less invasive)
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Bact Overgrowth Tx 10-14 days oral abx
– Tetracycline– Amox/clavanulate– Cephalexin– TMP/SMX– Metronidazole
Correct underlying condition Correct nutritional deficiencies
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Carbohydrate Intolerance Inability to digest certain carbs due to lack of
one or more enzymes Sx: watery diarrhea, abdominal distention,
flatulence, nausea, borborygmi, abd cramping (hooray for lactaid!)
Etiology:– Acquired (primary)– Secondary – Congenital (rare)
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Lactase Deficiency Primary adult hypolactasia Most common carb intolerance Lactase normally in high levels in
neonates but decrease after weaning in most ethnic groups– 80% blacks and hispanics– Near 100% Asians– Only 15-20% Caucasians
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Lactose intolerance So, 75% of the world adult population
lacks lactase, and we call it abnormal…
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Secondary Lactase Deficiency
Seen with small bowel mucosal damage, such as in celiac disease, acute small bowel infections, tropical sprue
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Dx/Tx Dx by:
– Careful hx– Dietary challenge
– H2 breath test
Tx with:– Lactose avoidance– Lactase supplements– Ca+ supplements
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Celiac Disease Aka:
– Celiac Sprue– Non-tropical sprue– Gluten Enteropathy
Immunologically mediated disease caused by intolerance of gluten, which causes mucosal inflammation and malabsorption
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Celiac Hereditary insensitivity to gliadin fraction of
gluten Gluten-sensitive T cells activated by
exposure, cause inflammatory response…leads to mucosal villous atrophy and crypt hyperplasia
N. America 1/5000, (1/150 in SW Ireland) Female 2:1 male
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Presentation There is no typical Infants
– Sx appear after cereals intro’d– FTT (failure to thrive), anorexia, pallor,
hypotonia, abdominal distention Older kids
– Anemia, growth delays, anorexia, diarrhea
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Adults Anorexia, weakness, Diarrhea, steatorrhea, Anemia Glossitis, angular stomatitis, aphthous
ulcers Decreased fertility Lactose intolerance (Why?)
– Will lactose avoidance help the sx? Evidence of Ca/vit D (like what?) Dermatitis herpetiformis (10%)
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Diagnosis Clinical suspicion
– Use clues like unexplained Fe deficient anemia FHX Labs
– 72 hr fecal fat– D-xylose absorption test– Tissue transglutaminase (IgA)– Anti gliaden antibody (IgA)– Anti reticulin antibody (IgA)– Total IgA (check to make sure there is no IgA
deficiency)– Antibody levels decrease with gluten-free diet,
so you can use this to determine if the pt is really following the diet
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Small Bowel Biopsy Not specific Villous atrophy
– Lack of or shortening of villi Increased epithelial cells Crypt hyperplasia
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Celiac Treatment Gluten free diet
– No wheat, rye, barley or anything that has gluten in it
– No breads, bagels, pastries, pasta and pizza – Gluten used as thickener frequently, so need
education to facilitate avoidance– Must do dietitian referral, advise support group
Sx will resolve in 1-2 weeks (usually)
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Prognosis & Complications
Prog 10-30% mortality without tx Complications:
– Intestinal lymphomas– Refractory disease– Increase in other GI malignancies
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Short Bowel Syndrome Malabsorption due to extensive small
bowel resection (often because of Crohn’s, mesenteric infarction, radiation enteritis)
Symptom severity depends on length and function of remaining bowel
Diarrhea and nutritional deficiencies
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Jejunum Primary digestive and absorptive site
for most nutrients BUT If removed, the ileum will adapt by
changing villous structure Gradual clinical improvement as
adaptive process continues
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Ileum Primary site for B12 and bile acid
absorption No compensatory mechanism for loss
of ileum Malabsorption of fats, fat-soluble
vitamins, and B12 Bile acids in large intestine cause
secretory diarrhea
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SBS Tx Small feedings Anti-diarrheals TPN if needed