• Maldigestion is defined as defective intraluminal

(1)

MALABSORPTION SYNDROME

Haider Husaini Assistant Professor

Department of Medicine

(2)

Definition

• Maldigestion is defined as defective intraluminal

hydrolysis of nutrients such as carbohydrates, proteins and fats into absorbable

oligosaccharides, amino acids and fatty acids

• Malabsorption is defined as defective mucosal

absorption and transport of digested nutrients

(3)

• Malabsorption syndrome encompasses both

maldigestion and malabsorption of nutrients such as protiens, fats, carbohydrates, vitamins, minerals and water

• Malabsorption can be caused by many

diseases of the small intestine, diseases of the

pancreas, liver, biliary tract and stomach

(4)

• The clinical challenge is to recognize

malabsorption despite its subtle clinical

manifestations and unavailable diagnostic

tests

(5)

Classification

1. Inadequate digestion

• Post gastrectomy

• Exocrine Pancreatic Insufficiency i.e chronic pancreatitis, cystic fibrosis, CA pancreas

• Gastrinoma

• Drugs like Orlistat

(6)

2. Reduced Intra duodenal bile acid

concentration/impaired micelle formation

• Liver ds

• Small Intestinal Bowel Overgrowth (SIBO)

• Interrupted enterohepatic circulation of bile salts i.e ileal resection, crohn’s ds

• Drugs binding or precipitating bile salts like

calcium carbonate, cholestyramine

(7)

• Impaired mucosal absorption/mucosal defect

due to inflammation i.e Crohn’s ds, Celiac ds, Whipple’s ds, Tropical sprue etc

• Genetic disorders like Abetalipoproteinemia, Agammaglobulinemia, Dissacharide

deficiency, Hartnup ds, Cystinuria

(8)

3. Impaired nutrient delivery to/from intestine

• Lymphatic obstruction i.e Lymphoma,

Lymphangiectasia

• Circulatory disorders i.e CHF, Constrictive

Pericarditis, mesenteric artery atherosclerosis

(9)

4. Endocrine and metabolic disorders

• Diabetes

• Hypoparathyroidism

• Adrenal Insufficiency

• Hyperthyroidism

• Carcinoid syndrome

(10)

Pathophysiology of Maldigestion

MECHANISM MALABSORBED NUTRIENT CAUSES

Conjugated Bile Acid Deficiency

Fat, Fat soluble Vitamins, Calcium, Magnesium

Liver ds, Biliary

obstruction, SIBO with bile acid deconjugation, ileal bile acid malabsorption, CCK deficiency

Pancreatic Insufficiency

Fat, Protein, Carbohydrate, Fat soluble Vitamins, Vit B12

Chronic Pancreatitis, CA pancreas, ZES syndrome

Reduced Mucosal Digestion

Carbohydrate, Protein Congenital defects, Celiac ds, Crohn’s ds

Intraluminal

Consumption of Nutrients

Vitamin B12 SIBO, Helminthic infections like Diphyllobothrium

latum

(11)

Pathophysiology of Malabsorption

MECHANISM MALABSORBED NUTRIENT CAUSES

Reduced Mucosal Absorption

Fat, Protein, Carbohydrate, Vitamins, Minerals

Congenital transport defects, Generalized

mucosal ds like Celiac ds, Crohn’s ds, Intestinal resection, Infections, intestinal Lymphoma

Decreased

Transport from the Intestine

Fat, Protein Intestinal

Lymphangiectasia, Solid tumors, Whipple’s ds, Lymphomas, CHF

(12)

Clinical Features

SYMPTOM/SIGN MECHANISM

Weight loss/Malnutrition Anorexia, Malabsortion of nutrients

Diarrhea Impaired absorption or secretion of water

& electrolytes, Colonic fluid secretion

secondary to unabsorbed bile salts & fatty acids

Flatus Bacterial fermentation of unabsorbed

carbohydrates

Glossitis, Cheilosis, Stomatitis Deficiency of Iron, Vit B12, Folic acid, Vit A

Abdominal pain Bowel distention or inflammation,

pancreatitis

Bone pain Calcium, Vit D malabsorption, protein

deficiency, Osteoporosis

Tetany, Paresthesias Calcium and Magnesium malabsorption

(13)

SYMPTOM/SIGN MECHANISM

Weakness Anemia, Potassium depletion

Azotemia, Hypotension Fluid & electrolyte depletion

Amenorrhea, decreased libido Protein depletion, decreased calories, secondary hypopituitarism

Anemia Impaired absorption of iron, folate, vit

B12

Bleeding Vitamin K malabsorption,

hypoprothrombinemia Night blindness/Xerophthalmia Vitamin A malabsorption

Peripheral Neuropathy Vitamin B12 & Thiamine deficiency

Dermatitis Deficiency of vitamin A, Zinc, essential

fatty acids

(14)

SIGNS/SYMPTOMS MECHANISM

Steatorrhoea

(Pale, bulky, malodorous stool,

floating oil droplets on top of water, difficult to flush)

Fat malabsorption

Oedema Hypoalbuminemia, extensive

lymphatic obstruction

(15)

Approach to Malabsorption

NUTRIENTS PART OF GUT INVOLVED IN ABSORPTION

Calcium Iron

Folic acid

Exclusively absorbed in Proximal Small intestine (Duodenum)

Bile Acids Vitamin B12

Exclusively in Ileum

Glucose

Amino Acids Lipids

Absorbed throughout Small Intestine

(16)

Investigations

• CBC

• Prothrombin time

• TSP A:G

• Alkaline Phosphatase

• Serum Cholesterol

• Serum Iron

• Serum Folate

• Serum Cobalamin

• Timed Quantitative

Stool Fat determination

• Fat Soluble Vitamins A,D,E,K

• Schilling test

• Urinary D-Xylose test

• Radiology

• Small Intestinal biopsy

(17)

Radiology

• Barium Studies

• CT enteroclysis/enterography

• MR enterography

(18)

Biopsy of Small Intestinal Mucosa

• Indications

➢ Steatorrhea

➢ Chronic Diarrhea

➢ Diffuse or focal abnormalities on barium

(19)

LESIONS PATHOLOGIC FINDINGS

DIFFUSE, SPECIFIC

1.) Whipple’s disease

2.) Agammaglobulinemia 3.) Abetalipoproteinemia

Lamina propria shows macrophages containing PAS positive stain

No plasma cells, absent or flat villi Normal villi, epithelial cells vacoulated with fat postprandially

PATCHY, SPECIFIC

1.) Intestinal Lymphoma

2.) Intestinal Lymphangiectasia 3.) Eosinophilic gastroenteritis 4.) Amylodosis

5.) Crohn’s disease 6.) Mastocytosis

Malignant cells in lamina propria &

submucosa

Dilated lymphatics, clubbed villi

Eosinophilic infiltration in lamina propria Amyloid deposits

Non caseating granulomas

Mast cell infiltration of lamina propria

(20)

LESIONS PATHOLOGIC FINDINGS

DIFFUSE, NONSPECIFIC

1.) Celiac disease

2.) Tropical Sprue 3.) SIBO

4.) Folate/Vit B12 deficiency/Radiation enteritis

5.) Zollinger Ellison Syndrome 6.) PEM

Short or absent villi, mononuclear infiltrate, epithelial cell damage, hypertrophy of crypts

Same as celiac ds

Patchy damage to villi, lymphocytic infiltration

Short villi, decreased mitosis in crypts, megalocytosis

Mucosal ulceration, erosion fom acid Villous atrophy, secondary bowel overgrowth

(21)

(22)

MALABSORPTION SYNDROME

Haider Husaini Assistant Professor

Department of Medicine

(23)

Nutritional Assessment Techniques

• There’s no single parameter to sufficiently assess PEM. All the tools have to be used in combination. They are

➢ Weight

➢ Height

➢ Skin fold thickness

(24)

➢ Mid arm Circumference

➢ Serum Protein concentrations

➢ CBC

➢ Absolute lymphocyte count

➢ 24 hr urinary creatinine

➢ BUN

(25)

HISTORY PHYSICAL EXAMINATION

Weight loss Mild = < 5%

Moderate = 5-10%

Severe = > 10%

over past 6months

Hydration status i.e tachycardia, postural

hypotension, dry mucosa

Food Intake Fatty tissue depletion i.e

hollowness of cheeks, buttocks, quadriceps, temporalis muscles Evidence of malabsorption like

steatorrhea

Muscle function i.e strength testing

Evidence of specific nutrient deficiency

Specific nutrient deficiencies

Functional status

(26)

Anthropometry

BODY MASS INDEX (Kg/m²)

NUTRITIONAL STATUS

< 16 Severly malnourished

18.5 – 24.9 Normal

25 – 29.9 Overweight

30 – 34.9 Obese

> 40 Morbidly obese

(27)

CELIAC DISEASE

(28)

• Also known as

➢ Non Tropical Sprue

➢ Adult Celiac Disease

➢ Gluten Sensitive Enteropathy

➢ Idiopathic Steatorrhea

➢ Primary Malabsorption

(29)

• Celiac disease is characterized by small

intestinal malabsorption of nutrients after the ingestion of wheat gluten or related proteins from wheat, rye and barley

• There is villous atrophy of the small bowel

• Prompt clinical and histological improvement

on strict adherence to a gluten free diet

(30)

Presentations of CD

• Fully expressed CD enteropathy

• Classic GI symptoms of malabsorption like chronic diarrhea, weight loss, steatorrhea

TYPICAL

• Fully expressed CD enteropathy

• Only extraintestinal symptoms & signs

• Anemia, Osteoporosis, Infertility, short stature

ATYPICAL

• Fully expressed CD enteropathy

• Asymptomatic patient

• Diagnosed on serology

SILENT

(31)

Etiology of CD

ENVIRONMENTAL FACTORS

• Gluten associated sensitivity

• Wheat, Rye &

Barley

IMMUNOLOGIC FACTORS

• Adaptive & Innate immunity

• IgA Antigliadin ab

• Antiendomysial ab

• Anti tTG ab

GENETIC FACTORS

• HLA-DQ2

• HLA-DQ8

• 10% among 1

^st

degree relatives

(32)

Small Intestinal Biopsy

• Increase in number of intraepithelial lymphocytes

• Absent or reduced height of villi

• Flat appearance with increased crypt cell proliferation and hyperplasia

• Increased number of lymphocytes & plasma cells

in lamina

(33)

(34)

Diagnosis of CD

Clinical Symptoms & Signs Revert to Normal

Serology Becomes

Negative SI Biopsy Becomes Normal

Serology Proved CD

Small Intestinal Biopsy

Proved CD Gluten Free Diet Initiated

(35)

Associated Diseases

• Dermatitis herpetiformis (DH)

(36)

• Type 1 DM

• IgA deficiency

• Down Syndrome

• Turner’s Syndrome

• GI and non GI neoplasm

• Intestinal T cell Lymphoma

(37)

Management

GLUTEN CONTAINING GRAINS

GLUTEN FREE GRAINS

Wheat Rice

Rye Maize

Barley Millet (Jowar)

Beers, Ale, Lager, Stouts Sorghum All potential sources of hidden

gluten

Oats

(38)

TROPICAL SPRUE

(39)

• A major cause of malabsorption found in adults in

tropical countries

• Parasitic infections of the small bowel are the

next most common cause of chronic diarrhea and malabsorption in the tropics

• Present in 5-10% of population of tropics

• Western visitors to the tropics are also affected

(40)

Epidemiology

• Epidemic tropical sprue was responsible for

deaths in the 2 ^nd world war, in South India in the 60’s

• Sporadic cases are now reported in South India

• Present in Southeast Asia, Central America,

Caribbean Islands, Africa and tropical Australia

(41)

Etiology

• Unknown

• Overgrowth of toxin forming coliforms

• Ingestion of excessive amounts of LCFA

• Bacterial Overgrowth

• Viruses

• Infection by EPEC, Giardia, Cyclospora

(42)

Clinical Features

• Chronic diarrhea

• Steatorrhea

• Weight loss

• Nutritional deficiencies

• Peripheral oedema

(43)

Diagnosis

• Diagnosis of exclusion

• Abnormal small intestinal biopsy in a patient having malabsorption

• Normal serum Folate levels

• Decreased serum B12 levels

• Histopathology is indistinguishable from celiac disease

(44)

Management

• No response to gluten free diet

• Deficient vitamin supplementation

• Broad spectrum antibiotics like Doxycycline 100mg OD for 3-6 months

• Folic acid supplementation

(45)

WHIPPLE’S DISEASE

(46)

• Rare chronic multi system disorder caused by

a gram positive bacillus Tropheryma whipplei

• Affects white middle aged men who work

outdoors like farmers and carpenters

• An oral route of infection is suggested

• There’s no evidence for person to person

transmission

(47)

Clinical Features

• Diarrhea

• Abdominal pain

• Steatorrhea

• Weight loss

• Migratory large joint arthropathy

• Dementia

• Cardiovascular manifestations

(48)

Diagnosis

• Small bowel shows yellow plaque like patches

that has PAS positive macrophages

• T. whipplei has been isolated from heart

valves, ocular vitreous fluid, CSF, synovial fluid,

muscle tissue, mesenteric lymph nodes

(49)

Management

• Double strength Trimethoprim- Sulfamethoxazole for 1yr

• Cloramphenicol is a second choice

(50)