mal absorption

7/25/2019 Mal Absorption

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Malabsorption


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Malabsorptionis a state arising from

abnormality in absorptionof food nutrients

across the gastrointestinal(GI) tract.

Impairment can be of single or multiple

nutrients depending on the abnormality.

This may lead to malnutritionand variety

of anaemias.
http://c/wiki/Absorption_(small_intestine)http://c/wiki/Nutrienthttp://c/wiki/Gastrointestinal_tracthttp://c/wiki/Malnutritionhttp://c/wiki/Anemiahttp://c/wiki/Anemiahttp://c/wiki/Malnutritionhttp://c/wiki/Gastrointestinal_tracthttp://c/wiki/Gastrointestinal_tracthttp://c/wiki/Nutrienthttp://c/wiki/Absorption_(small_intestine)


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Classification

Some prefer to classify malabsorption clinically into

three basic categories:

(1) selective, as seen in lactose malabsorption

(!) partial, as observed in a"#eta"lipoproteinemia,

($) totalas in coeliacdisease.
http://c/wiki/Coeliac_diseasehttp://c/wiki/Coeliac_diseasehttp://c/wiki/Coeliac_diseasehttp://c/wiki/Coeliac_disease


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Pathophysiology

The main purpose of the gastrointestinal tractis to digest

and absorbnutrients (fat, carbohydrate,and protein),micronutrients (vitaminsand trace minerals), %ater, and

electrolytes.

&igestioninvolves both mechanical and en'ymaticbreado%n of food.

Mechanical processesinclude che%ing, gastric churning,

and the to"and"fro miing in the small intestine. Enzymatic

hydrolysisis initiated by intraluminal processes re*uiring

gastric, pancreatic, and biliary secretions. The final products

of digestion are absorbed through the intestinal epithelial

cells.
http://c/wiki/Gastrointestinal_tracthttp://c/wiki/Digestionhttp://c/wiki/Absorption_(small_intestine)http://c/wiki/Fathttp://c/wiki/Carbohydratehttp://c/wiki/Proteinhttp://c/wiki/Vitaminhttp://c/wiki/Dietary_mineralhttp://c/wiki/Electrolyteshttp://c/wiki/Digestionhttp://c/wiki/Enzymehttp://c/wiki/Small_intestinehttp://c/wiki/Epitheliumhttp://c/wiki/Epitheliumhttp://c/wiki/Small_intestinehttp://c/wiki/Enzymehttp://c/wiki/Digestionhttp://c/wiki/Electrolyteshttp://c/wiki/Dietary_mineralhttp://c/wiki/Vitaminhttp://c/wiki/Proteinhttp://c/wiki/Carbohydratehttp://c/wiki/Fathttp://c/wiki/Absorption_(small_intestine)http://c/wiki/Digestionhttp://c/wiki/Gastrointestinal_tract


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+alabsorption constitutes the pathological

interference %ith the normal physiological

se*uence of digestion (intraluminal

process), absorption (mucosal process)

and transport (postmucosal events) of

nutrients.


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Intestinalmalabsorption can be de to!

+ucosal damage (enteropathy)

ongenitalor ac*uired reduction in absorptive

surface

&efects of specific hydrolysis

&efects of iontransport

-ancreaticinsufficiency

Impaired enterohepaticcirculation
http://c/wiki/Intestinehttp://c/wiki/Enteropathyhttp://c/wiki/Congenital_disorderhttp://c/wiki/Hydrolysishttp://c/wiki/Ionhttp://c/wiki/Pancreashttp://c/wiki/Enterohepatic_circulationhttp://c/wiki/Enterohepatic_circulationhttp://c/wiki/Enterohepatic_circulationhttp://c/wiki/Enterohepatic_circulationhttp://c/wiki/Pancreashttp://c/wiki/Ionhttp://c/wiki/Hydrolysishttp://c/wiki/Congenital_disorderhttp://c/wiki/Enteropathyhttp://c/wiki/Intestine


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Cases

"e to infective agents

hipple/s disease Intestinal tuberculosis 0I1related malabsorption Tropicalsprue traveller/sdiarrhoea

-arasites.e. g. Giardialamblia, fish tape %orm(#2!malabsorption) round%orm, hoo%orm(Ancylostomaduodenaleand Necator americanus)
http://c/wiki/Whipple's_diseasehttp://c/wiki/Tuberculosishttp://c/wiki/HIVhttp://c/wiki/Tropical_spruehttp://c/wiki/Tropical_spruehttp://c/wiki/Traveller's_diarrhoeahttp://c/wiki/Traveller's_diarrhoeahttp://c/wiki/Parasiteshttp://c/wiki/Giardiasishttp://c/wiki/Giardiasishttp://c/wiki/Diphyllobothriumhttp://c/wiki/Strongyloides_stercoralishttp://c/wiki/Hookwormhttp://c/wiki/Hookwormhttp://c/wiki/Strongyloides_stercoralishttp://c/wiki/Diphyllobothriumhttp://c/wiki/Giardiasishttp://c/wiki/Giardiasishttp://c/wiki/Parasiteshttp://c/wiki/Traveller's_diarrhoeahttp://c/wiki/Traveller's_diarrhoeahttp://c/wiki/Tropical_spruehttp://c/wiki/Tropical_spruehttp://c/wiki/HIVhttp://c/wiki/Tuberculosishttp://c/wiki/Whipple's_disease


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"e to strctral defects

#lind loops

Inflammatory bo%el diseases commonly in rohn/s&iseaseIntestinal hurry from -ost"gastrectomy post"vagotomy,gastro"3e3unostomy

4istulae, diverticulaeand strictures,Infiltrative conditions such as amyloidosis, lymphoma,5osinophilicgastroenteropathy

6adiation enteritisSystemic sclerosisand collagen vascular diseasesShort gut syndrome
http://c/wiki/Blind_loop_syndromehttp://c/wiki/Crohn's_Diseasehttp://c/wiki/Crohn's_Diseasehttp://c/wiki/Gastrectomyhttp://c/wiki/Vagotomyhttp://c/w/index.phphttp://c/wiki/Fistulaehttp://c/wiki/Diverticulumhttp://c/wiki/Strictureshttp://c/wiki/Amyloidosishttp://c/wiki/Lymphomahttp://c/w/index.phphttp://c/w/index.phphttp://c/wiki/Radiation_enteritishttp://c/wiki/Systemic_sclerosishttp://c/wiki/Systemic_sclerosishttp://c/wiki/Radiation_enteritishttp://c/w/index.phphttp://c/w/index.phphttp://c/wiki/Lymphomahttp://c/wiki/Amyloidosishttp://c/wiki/Strictureshttp://c/wiki/Diverticulumhttp://c/wiki/Fistulaehttp://c/w/index.phphttp://c/w/index.phphttp://c/wiki/Vagotomyhttp://c/wiki/Gastrectomyhttp://c/wiki/Crohn's_Diseasehttp://c/wiki/Crohn's_Diseasehttp://c/wiki/Blind_loop_syndrome


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"e to mcosal abnormality

oeliac7eliac disease

o%s/ mil intolerance Soya mil intolerance 4ructose malabsorption
http://c/wiki/Coeliac_diseasehttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Coeliac_diseasehttp://c/wiki/Coeliac_disease


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"e to enzyme deficiencies

8actase deficiency inducing lactose intolerance

(constitutional, secondary or rarely congenital) Sucrose intolerance

Intestinal disaccharidase deficiency

Intestinal enteropeptidase deficiency
http://c/wiki/Lactose_intolerancehttp://c/wiki/Sucrose_intolerancehttp://c/wiki/Sucrose_intolerancehttp://c/wiki/Lactose_intolerance


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"e to other systemic diseasesaffecting #I tract0ypothyroidismandhyperthyroidism

9ddison/s disease&iabetes mellitus0yperparathyroidismand 0ypoparathyroidismarcinoidsyndrome

+alnutrition

9beta"lipoproteinemia
http://c/wiki/Systemic_diseasehttp://c/wiki/Hypothyroidismhttp://c/wiki/Hyperthyroidismhttp://c/wiki/Addison's_diseasehttp://c/wiki/Diabetes_mellitushttp://c/wiki/Hyperparathyroidismhttp://c/wiki/Hypoparathyroidismhttp://c/wiki/Carcinoid_syndromehttp://c/wiki/Carcinoid_syndromehttp://c/wiki/Abetalipoproteinemiahttp://c/wiki/Abetalipoproteinemiahttp://c/wiki/Carcinoid_syndromehttp://c/wiki/Carcinoid_syndromehttp://c/wiki/Hypoparathyroidismhttp://c/wiki/Hyperparathyroidismhttp://c/wiki/Diabetes_mellitushttp://c/wiki/Addison's_diseasehttp://c/wiki/Hyperthyroidismhttp://c/wiki/Hypothyroidismhttp://c/wiki/Systemic_disease


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Clinical featres

Small intestine : ma3or site of absorption

It can present in variety of %ays and features might give clue to

underlying condition. Symptoms can be intestinalor etra"intestinal " the

former predominates in severe malabsorption.

&iarrhoea, often steatorrhoeais the most common feature. atery,

diurnal and nocturnal, buly, fre*uent stools are the clinical hallmar of

overt malabsorption. It is due to impaired %ater, carbohydrateand

electrolyteabsorption or irritation from unabsorbed fatty acid. 8atter also

results in bloating, flatulenceand abdominal discomfort. ramping painusually suggests obstructive intestinal segment e.g. in rohn/sdisease,

especially if it persists after defecation.
http://c/wiki/Intestinehttp://c/wiki/Diarrhoeahttp://c/wiki/Steatorrhoeahttp://c/wiki/Carbohydratehttp://c/wiki/Electrolytehttp://c/wiki/Fatty_acidhttp://c/wiki/Bloatinghttp://c/wiki/Flatulencehttp://c/wiki/Crohn's_diseasehttp://c/wiki/Crohn's_diseasehttp://c/wiki/Crohn's_diseasehttp://c/wiki/Crohn's_diseasehttp://c/wiki/Flatulencehttp://c/wiki/Bloatinghttp://c/wiki/Fatty_acidhttp://c/wiki/Electrolytehttp://c/wiki/Carbohydratehttp://c/wiki/Steatorrhoeahttp://c/wiki/Diarrhoeahttp://c/wiki/Intestine


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Clinical featres ( continued )

eight loss can be significant despite increased oral intae ofnutrients.Gro%th retardation, failure to thrive, delayed pubertyin children

S%elling or oedemafrom loss of protein

9naemias, commonly from vitamin #2!, folic acidand iron deficiencypresenting as fatigue and %eaness.+uscle crampfrom decreased vitamin &, calciumabsorption. 9lsolead to osteomalaciaand osteoporosis

#leeding tendencies from vitamin and other coagulation factor

deficiencies.

8o% serum tryptophanand clinical depression, as can happen %ithfructosemalabsorption
http://c/wiki/Pubertyhttp://c/wiki/Oedemahttp://c/wiki/Proteinhttp://c/wiki/Anaemiahttp://c/wiki/Vitamin_B12http://c/wiki/Folic_acidhttp://c/wiki/Iron_deficiency_(medicine)http://c/wiki/Cramphttp://c/wiki/Vitamin_Dhttp://c/wiki/Calciumhttp://c/wiki/Osteomalaciahttp://c/wiki/Osteoporosishttp://c/wiki/Vitamin_Khttp://c/wiki/Coagulation_factorhttp://c/wiki/Tryptophanhttp://c/wiki/Clinical_depressionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Fructose_malabsorptionhttp://c/wiki/Clinical_depressionhttp://c/wiki/Tryptophanhttp://c/wiki/Coagulation_factorhttp://c/wiki/Vitamin_Khttp://c/wiki/Osteoporosishttp://c/wiki/Osteomalaciahttp://c/wiki/Calciumhttp://c/wiki/Vitamin_Dhttp://c/wiki/Cramphttp://c/wiki/Iron_deficiency_(medicine)http://c/wiki/Folic_acidhttp://c/wiki/Vitamin_B12http://c/wiki/Anaemiahttp://c/wiki/Proteinhttp://c/wiki/Oedemahttp://c/wiki/Puberty


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"iagnosis

There is no specific test for +alabsorption.

9s for most medical conditions, investigation

is guided by symptomsand signs. +oreover,tests for pancreatic function are comple

and varies %idely bet%een centres.
http://c/wiki/Symptomhttp://c/wiki/Symptom


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$lood %ests

6outine blood testsmay reveal anaemia, high 5S6or lo% albumin

%hich has high sensitivity for presence of organic disease In this

setting, microcyticanaemiausually implies iron deficiency andmacrocytosiscan be from impaired folic acidor #2!absorption or

both.

8o% cholesterol or triglyceride may give clue to%ard fat

malabsorption as lo% calcium and phosphate to%ard osteomalacia

from lo% vitamin &.

Specific vitamins lie vitamin &or micro nutrientlie 'inclevels

can be checed. 4at soluble vitamins (9, &, 5 ; ) are affected in

fat malabsorption. -rolonged prothrombintimecan be from

vitamin deficiency.

&erological stdies

Specific tests are carried out to determine underlying cause.

Ig9tissue trans glutamate or Ig9 antiendomysium assayfor

gluten sensitiveenteropathy.
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&tool stdies

+icroscopy is particularly useful in diarrhoea, may sho%

proto'oa lie giardia, ova, cyst and other infective agents.4ecal fat studyto diagnose steatorrhoeais less fre*uently

performed no%adays.

8o% elastaseis indicative of pancreatic insufficiency.

hymotrypsinand pancreolauryl can be assessed as %ell
http://c/wiki/Fecal_fathttp://c/wiki/Steatorrhoeahttp://c/wiki/Elastasehttp://c/wiki/Chymotrypsinhttp://c/wiki/Chymotrypsinhttp://c/wiki/Elastasehttp://c/wiki/Steatorrhoeahttp://c/wiki/Fecal_fat


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'adiological stdies

#arium follo% throughis useful in delineating small intestinal

anatomy. #arium enemamay be undertaen to see colonic

or ileal lesions.

T abdomen is useful in ruling out structural abnormality,

done in pancreatic protocol %hen visualising pancreas.

+agnetic resonancecholangiopancreatography(+6-) tocomplement or as an alternative to 56-
http://c/wiki/Barium_follow_throughhttp://c/wiki/Small_intestinehttp://c/wiki/Anatomyhttp://c/wiki/Barium_enemahttp://c/wiki/Colon_(anatomy)http://c/wiki/Lesionhttp://c/wiki/Pancreashttp://c/wiki/Magnetic_resonance_cholangiopancreatographyhttp://c/wiki/Magnetic_resonance_cholangiopancreatographyhttp://c/wiki/ERCPhttp://c/wiki/ERCPhttp://c/wiki/Magnetic_resonance_cholangiopancreatographyhttp://c/wiki/Magnetic_resonance_cholangiopancreatographyhttp://c/wiki/Pancreashttp://c/wiki/Lesionhttp://c/wiki/Colon_(anatomy)http://c/wiki/Barium_enemahttp://c/wiki/Anatomyhttp://c/wiki/Small_intestinehttp://c/wiki/Barium_follow_through


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Interventional stdies

#iopsy of small bo%elsho%ing coeliacdiseasemanifestedby blunting of villi,

crypt hyperplasia, and lymphocyteinfiltration of crypts.

5ndoscopyis fre*uently undertaen, but to visualise small

intestine, %hich can be

up to


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ther investigations

6adio isotopetests e.g. Se09T, ?>mTc to eclude terminal ileal

disease.

Sugar probes or sub >2r"5&T9 to determine intestinal permeability@$A.

Glucose hydrogen breath test for bacterial overgro%th

&"yloseabsorption test. lo%er level in urine after ingestion indicates

bacterial overgro%th or reduced absorptive surface. normal in pancreatic

insufficiency.

#ile saltbreath test to determine bile saltmalabsorption.

Schilling testto establish cause of #2! deficiency.

8actose0! breath test for lactose intolerance
http://c/wiki/Radionuclidehttp://c/wiki/SeHCAThttp://f/Malabsorption.htmhttp://c/wiki/Bacterial_overgrowthhttp://c/wiki/D-xylosehttp://c/wiki/Bile_salthttp://c/wiki/Bile_salthttp://c/wiki/Schilling_testhttp://c/wiki/Lactosehttp://c/wiki/Lactose_intolerancehttp://c/wiki/Lactose_intolerancehttp://c/wiki/Lactosehttp://c/wiki/Schilling_testhttp://c/wiki/Bile_salthttp://c/wiki/Bile_salthttp://c/wiki/D-xylosehttp://c/wiki/D-xylosehttp://c/wiki/Bacterial_overgrowthhttp://f/Malabsorption.htmhttp://c/wiki/SeHCAThttp://c/wiki/Radionuclide


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Management

Treatment is directed largely to%ards management of underlying cause.

6eplacement of nutrients, electrolytesand fluid may be necessary. In severe

deficiency, hospital admission may be re*uired for parenteral administration, often

advice from dietitianis sought. -eople %hose absorptive surface are severely

limited from disease or surgery may need long term total parenteral nutrition.

-ancreatic en'ymes are supplemented orally in insufficiencies.

&ietary modification is important in some conditions. 8ife"long avoidance of

particular food or food constituent may be needed in eliac disease or lactose

intolerance.

#acterial overgro%th usually respond %ell to course of antibiotic. Bse of

cholestyramine to bind bile acid %ill help reducing diarrhea in bile acid

malabsorption.
http://c/wiki/Electrolytehttp://c/wiki/Dietitianhttp://c/wiki/Dietitianhttp://c/wiki/Electrolyte


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mal absorption

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