Malabsorption syndromes

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Malabsorption syndromes :

Malabsorption syndromes Refers to the varied patho physiological conditions existing in a person which deprives him of the needed micro or macronutrients such as glucose, fatty acids, aminoacids, minerals and vitamins.


Causes Intra-luminal Intestinal Lymphatic miscellaneous

Intra-luminal causes:

Intra-luminal causes Enzyme deficiencies-pancreatitis,cystic fibrosis,ca-pancreas. Bile salt deficiencies-liver diseases, biliary cirrhosis,ileal resection. Bacterial over growth-increased deconjugation of bile salts.

Intestinal causes:

Intestinal causes Inadequate absorptive surface – post gastrectomy, short bowel, mesenteric infarction. Mucosal cell defect: ab lipoproteinemia, cystinuria and lactase deficiency. Diffuse disease of SI:Immunological, infections, infestation, infiltration, fibrosis.

Lymphatic causes:

Lymphatic causes Lymphangectasia Whipple’s disease Lymphoma


Miscellaneous DM Drugs Multiple mechanisms Hyperabsorptive malabs- haemochromatosis, Hypervitaminosis

Clinical evaluation:

Clinical evaluation History Symptoms and signs Fat: Greasy, foul smelling, copious stools / steatorrhoea. CHO: Flatulence, Abd distension, watery diarrhoea Protein: Edema Vit B12: Anaemia, dementia, peripheral neuropathy, neuropsychiatric manifestation. Folate: Anemia

Slide 9:

Iron: anemia, tachycardia, fatigue… Ca and Vit D: Tetany, osteomalacia Vit K: Bruises, haematoma

Physical Examination:

Physical Examination General appearance and nourishment. Vitals and PICCLE Skin: Dermatitis herpetiformis – Celiac dis EN, Pyoderma Gangrenosum – CD Bruises - Vit K def CNS: B12 def - celiac dis

Slide 11:

Arthralgia/ arthritis : CD, Whipple’s dis Ocular: CD, Whipple’s dis Osteomalacia / osteoporosis: Hypocalcemia

Lab Investigations:

Lab Investigations Haematological : Biochemical: Serological: Stool exam: Specific tests: Imaging:

Specific tests:

Specific tests CHO Malabsorption Fat Malabsbn Protein Malabsbn Vit B12 malabsn Bile acid malabsn Pancreatic func Bacterial overgrowth

Tests for CHO malabsn:

Tests for CHO malabsn Principle: Fermentation of CHO by bacteria Measurement of specific nutrients after ingesting test dose Tests: Lactose tolerance test Breath H+ test D-Xylose test D-Xylose breath test

Tests for fat malabsn:

Tests for fat malabsn Fecal fat estimation Sudan stain Acid steatocrit Carbon 14 Triolein breath test Near IR reflectance analysis

Tests for protein malabsn:

Tests for protein malabsn Fecal alpha1 AT clearance Fecal N2 by IR spectroscopy Post absorptive citrulline concentration

Tests for Vit B12 malabsn:

Tests for Vit B12 malabsn Schilling test Vit B12 assay

Test for bac overgrowth:

Test for bac overgrowth No single ideal test Gold standard: Quantitative bac count and culture of intestinal aspirate Indirect test: breath H+ estimation after glucose

Test for bile acid malabs:

Test for bile acid malabs Measurement of Tc99m – Se75 HCAT Measurement of serum 7 alpha HCO

Tests for pancreatic functions:

Tests for pancreatic functions Secretin test – gold std Pancreolauryl test Bentiromide test Fecal chymotrypsin Fecal elastase

Celiac disease:

Celiac disease Children: Retarded growth, pubertal delay, neuropsychiatric manifestations, anemia, rickets, abd distension, diarrhoea Adults: Anemia, vit K def, wt loss, peripheral neuropathy, ataxia, seizures

Slide 22:

Lab diagnosis: IDA Low Ca Low Vit D Anti endomyseal Ab Anti gliadin Ab Small bowel Bx : villous atrophy and hypertrophic crypts

C/c Pancreatitis:

C/c Pancreatitis C/F: Abd pain, Nausea, vomiting, DM, jaundice, wt loss, steatorrhoea Lab diagnosis: Increased amylase Increased lipase, Increased fecal fat, Increased Bilirubin / SAP Fibrosis

Crohns Disease:

Crohns Disease C/F: Pain, fever, wt loss, non bldy diarrhoea Perianal disease, fistula Aphthous ulcers Cholecystitis Nephrolithiasis

Slide 25:

Lab diagnosis: Elevated ESR, CRP Leucocytosis Ba series – stricture, fistula, ulceration Colonoscopy – segmental inflammation and strictures

Whipple’s disease:

Whipple’s disease C/F: Arthralgia, Migratory polyarthritis Abd pain, distension, flatulence, wt loss Myocardial or valvular abn Ocular defect Lymphadenopathy, fever

Slide 27:

Lab diagnosis Duodenal Bx : PAS +ve macrophages containing G-ve Bacilli, dilatation of lacteals

Lactose intolerance:

Lactose intolerance C/F: Bloating sensation Abd cramps Watery diarrhoea Flatulence Lab diagnosis: Abnormal breath H2 test


ZES C/F: Recc peptic ulceration Esophagitis Diarrhoea Wt. Loss Lab: Increased fasting gastrin Abnormal secretin secretion


BOS Asymptomatic C/F: wt loss, abd distension, steatorrhoea,watery stools Lab diagnosis: Abnormal fecal fat and D - Xylose

Malabsn - AIDS:

Malabsn - AIDS Oppurtunistic infcn: CMV, MAI, HSV, Giardia, Campylobacter, Salmonella, Microsporidium

Malabsn - Elderly:

Malabsn - Elderly Causes: coeliac disease Pancreatic disease Gastrectomy BOS


Management Rx of underlying disorder Rx of micro and macro nutrient def Steatorrhoea: Low fat and high prot diet Supplements

Slide 34:

Celiac dis: Gluten free diet Steroids Supplements Pancreatitis: Pancreatic enzyme replacement before meals Fat soluble vitamins

Slide 35:

Crohns disease: Medical management Surgical Nutritional support Short bowel loop: Parenteral feeds HIV / AIDS: Supportive care Treat cause

Thank you!:

Thank you!

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