Radiologic Manifestations of Malabsorption:

A Nonspecific Finding

Zvi Weizman, MD, David A. Stringer, BSc, MBBS, DRCOG, FRCR,

FRCP(C), and Peter R. Dune, MD, FRCP(C)

From the Division of Gastroenterology, Department of Pediatrics, and Department of

Radiology, The Hospital for Sick Children; and Department of Pediatrics, The University of
Toronto, Toronto

ABSTRACT. Children demonstrating a radiologic mal- the malabsorption pattern in patients with no din-
absorption pattern on small bowel follow-through study ical evidence of steatorrhea. When a small bowel
performed for other reasons are frequently subjected to
follow-through examination is undertaken for other
intensive gastrointestinal investigations, even in the ab-
sence of clinical manifestations of malabsorption. To reasons and a malabsorption pattern is discovered
determine the usefulness of this radiologic finding, the unexpectedly, such patients are commonly sub-
clinical fmdings of all patients with the typical malab- jected to further investigations, even in the absence
sorption pattern on small bowel follow-through exami- of major clinical features of malabsorption. In view
nation were reviewed retrospectively. The presence of a
of noting a number of persons with typical radio-
malabsorption pattern was based on three radiologic cri-
teria: flocculation and segmentation of barium, thicken- logic features of malabsorption, but without evi-
ing of mucosal folds, and dilation of intestinal loops. dence of clinical steatorrhea, we undertook a ret-
Thirteen patients fulfilled the criteria for radiologic mal- rospective analysis of all small bowel follow-
absorption pattern, but six (46%) had no clinical evidence through studies, to evaluate the usefulness of this
of malabsorption, according to 3- to 5-day fecal fat anal-
test.
ysis. In addition, five of these patients had normal mu-
cosal histologic findings on duodenal biopsy. It was con-
cluded that radiologic malabsorption pattern is a nonspe- METHODS AND SUBJECTS
cific finding, and in the absence of other clinical features
suggestive of malabsorption or growth failure further All small bowel follow-through studies performed
investigations may not be justified. Pediatrics during the period of June 1979 through March 1983
1984;74:530-533; malo,bsorption, radiologic malabsorption were reviewed retrospectively for the presence of
pattern, enteropathy.
malabsorption pattern. Each barium examination
consisted of a meal of 56% wt/wt (100% wt/vol)
barium sulfate (Gel-Unix, Therapix Unik mc, An-
jou, Quebec) diluted with two parts water or sugar
The term “malabsorption pattern” has been used solution. Flavoring consisting of Hawaiian Punch
to describe changes on small bowel follow-through (RJR Foods Ltd, Toronto) was mixed with the
which are often seen in patients with malabsorp- barium to make it more palatable for children >1
tion. It has been previously demonstrated that a year of age. After fluoroscopy of the esophagus,
significant percentage of adults with documented stomach, or duodenum, follow-up films were taken
malabsorption may have normal findings on small at 30-minute intervals for 90 minutes or until bar-
bowel follow-through examination, indicating the ium reached the cecum. If transit time was longer
poor sensitivity of this test.’ There have been no than 90 minutes, delayed follow-through films were
reports, however, of the incidence of “abnormal” taken at longer times; intervals were dependent on
small bowel follow-through studies demonstrating the rate of transit as assessed by the monitoring
radiologist. Patients who were receiving medica-
Received for publication Aug 30, 1983; accepted Jan 4, 1984. tions known to affect intestinal motility (#{228}nticho-
Reprint requests (P.R.D.)
to Division of Gastroenterology, The linergic agents, narcotics, etc), and patients who
Hospital for Sick Children, 555 University Aye, Toronto, On-
had had surgery were excluded. All of the patients
ta.rio, Canada M5G 1X8
PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the had normal serum potassium levels.
American Academy of Pediatrics. We assessed the roentgenograms with no prior

530 PEDIATRICS Vol. 74 No. 4 October1984

Downloaded from http://pediatrics.aappublications.org/ by guest on December 21, 2017
knowledge of the clinical findings. Three criteria because the clinical condition of the patient war-
were used to define the presence of radiologic mal- ranted further investigation unrelated to the small
absorption pattern in the small bowel: flocculation bowel follow-through findings. All patients had
and segmentation of the barium column, dilation stool studies performed for bacterial culture, ova,
of loops, and thickening of mucosal folds. Each and parasites, and electron microscopic studies
study was graded using a scale of 0, +, ++, or +++ were performed to detect the presence of viral par-
for each of the three features. The presence of at tides.
least 2/3 criteria and a minimum total score of 3+
were required to be included in the malabsorption
RESULTS
pattern group. In addition, transit time, defined as
the time required for the barium head to reach the Thirteen patients fulfilled the above mentioned
cecum, was evaluated but not considered as a en- criteria of radiologic malabsorption pattern on
tenon. Using 3- to 5-day pooled fecal collection, fat small bowel follow-through examinations. Clinical
output was estimated by the method of van den details and radiologic scores are presented in Table
Kamer et al,2 and it was expressed as percentage of 1. Seven of the 13 patients had clinical evidence of
fat intake determined by recording and weighing malabsorption with abnormal fecal fat output; pa-
food and reference to standard content tables. The tients 1 to 6 had an abnormal duodenal biopsy.
dietary fat intake exceeded 50 g/d in patients >2 Patient 7 had proven steatorrhea, and a biopsy was
years of age. Daily fat intake in four patients <2 not performed due to the patient’s critical state.
years of age exceeded 6 g/kg of body weight. No The remaining six patients (patients 8 to 13) had
patients received a diet containing medium-chain no clinical evidence of steatorrhea, and 5/6 had
triglycerides. Patients were considered to have fat normal duodenal biopsies. However, patient 8 had
malabsorption when fecal fat losses exceeded 7% of Salmonella heidelberg gastroentenitis, and patients
fat intake or 12% in the case of infants <1 year of 9 and 10 had systemic diseases with no evidence of
age. gross involvement of the intestinal tract on the
In 1 1/13 patients, suction biopsy specimens were duodenal biopsy. In all six patients without stea-
obtained from the duodenal mucosa within I week torrhea, follow-up after at least 6 months revealed
of the small bowel follow-through examination. normal growth pattern and disappearance of all
Well-oriented specimens, in which at least three previous gastrointestinal symptoms and signs. Pa-
adjacent crypt-villus units could be seen, were eva!- tients with and without steatorrhea are compared
uated for evidence of villus atrophy. It should be in Table 2. There were no significant differences
noted, that in most cases, biopsies were performed between the two groups regarding age, total radio-

TABLE I. Clinical and Radiologic Data*

Patient Age Sex Final Diagnosis Steator- Duodenal Stool Cultures Radiology
No. (yr) rhea Biopsy and Electron . . . .
Microscopic Flocculation Thickened Dila- Transit
Segiflentation Folds tion Time (h)
Studies

1 4.0 F Celiac disease + TVA - +++ +++ 0 4.5

2 3.0 F Celiac disease + TVA - ++ + ++ 4.0
3 5.0 M Celiac disease + TVA - +++ + + 4.5
4 8.0 F Celiac disease + TVA - +++ ++ 0 1.0
5 1.3 M Celiac disease + TVA - +++ + + 1.0
6 0.8 M Rotavirus enteritis + PVA Rotavirus + + + 1.0
7 0.3 F Malabsorption-NYD, + . . . Astrovirus +++ ++ +++ 3.5
gastroentenitis
8 0.2 M Gastroenterititis - N Salmonella ++ + + 3.0
heidelberg
9 10.0 M Toxocaniasis - N - + + + 3.5
10 5.0 M Rheumatoid arthritis, - N - ++ ++ 0 0.5
RAP
11 6.0 F Failure to thrive due - N - +++ ++ + 3.0
to poor intake
12 2.0 F Abdominal disten- - N - ++ ++ ++ 1.5
sion, no diagnosis
13 9.0 M RAP - . . . - +++ + 0 2.5
* Abbreviations used are: NYD, not yet diagnosed; N, normal; TVA, total villus atrophy; PVA, partial villus atrophy;
RAP, recurrent abdominal pain.

ARTICLES 531
Downloaded from http://pediatrics.aappublications.org/ by guest on December 21, 2017
TABLE 2. Findings in Seven Patients With and Six #{149}
Patients Without Steatorrhea*
With Without
Steatorrhea Steatorrhea
(3M/4F) (4M/2F)
Age (yr) 3.2 ± 2.7 5.4 ± 38
(0.3-8.0) (0.2-10.0)
Radiologic score 4.8 ± 1.7 4.5 ± 1.2
(3-8) (3-6)

Transit time (h) 2.8 ± 1.7 2.3 ± 1.1

1.0-4.5 0.5-3.5
* Values are means ± SD. Range is shown in parentheses.
P = NS in all cases.

logic score, or transit time. Representative views

from small bowel follow-through studies are shown
in the Figure: malabsorption pattern in patient 3
(top) with celiac disease and poor growth due to
poor intake and no clinical malabsorption in patient
11 (bottom).

DISCUSSION
Radiologic malabsorption pattern on small bowel
follow-through studies was noted in patients 1 to 7
with documented steatorrhea, six of whom had
documented enteropathy. However, the same pat-
tern was also demonstrated in patients 8 to 13 who
had no evidence of steatorrhea, five of whom had
normal mucosal histology on duodenal biopsy. In
patients 9 and 10 who had systemic disease and in
patient 8 with proven enteral infection, it is possible
that some of these radiologic changes resulted from
disordered gastrointestinal motility or excessive
pooling of fluid due to the primary process. As for
the patients with no particular illness, several
mechanisms such as emotional tension or nonspe-
cific allergic response affecting intestinal motility
or excessive mucus production have been proposed.3
In the first months of life, clumping and segmen-
tation of the barium column are quite common.3
This may be due to the relative steatorrhea in this
age group. However, only one of our patients with
false-positive findings was in this age range.
We have used the three specific radiologic criteria
to define malabsorption pattern because these are
the most frequently used in the literature and have
been ascribed to celiac disease4 and to other dis-
ease entities producing malabsorption.7 Other mi-
nor nadiologic features associated with malabsorp-
tion are prolonged transit time, transient intussus-
ception, and the moulage sign.8 However, none of
our patients demonstrated either transient intus-
susception or the moulage sign. Transit time was Figure. Typical small bowel follow-through studies re-
vealing flocculation and segmentation of barium, thick-
less than 4#{189} hours in all patients, and this is
ening of mucosal folds, and dilation of loops, demonstrat-
considered normal.3 ing the similarity between clinical malabsorption or celiac
As mentioned earlier, the small bowel follow- disease (top) and false-positive test or no clinical mal-
through examination is well described as a diagnos- absorption (bottom).

532 RADIOLOGIC MANIFESTATIONS OF MALABSORPTION

Downloaded from http://pediatrics.aappublications.org/ by guest on December 21, 2017
tic test with poor sensitivity for determining abnor- REFERENCES
mality in malabsorption.’ In contrast, the present
1. Isbell RG, Carlson HC, Hoffman HN: Roentgenologic-
study demonstrates that radiologic alterations
pathologic correlation in malabsorption syndrome. AJR
suggestive of malabsorption may be a nonspecific 1969;107:158-169
finding: 45% (6/13) of our patients had no clinical 2. van der Kamer HH, Huinick H, Weyers HA: Rapid method
for determination of fat in feces. J Biol Chem 1949;177:347-
evidence of malabsorption and five of these had
355
normal findings on duodenal biopsy. 3. Coffey J: Pediatric X-ray Dragnosis. Chicago, Year Book
We conclude that due to the nonspecific nature Publishers, 1972, pp 627-634
4. Hamilton JR, Lynch MJ, Reilly BJ: Active celiac disease in
of this test, children who demonstrate the radiologic
childhood. Q J Med 1969;150:135-158
malabsorption pattern on a small bowel follow- 5. Kumar P, Bartram CI: Relevance of the barium follow
through study performed for other reasons, should through examination in the diagnosis of adult coeliac dis-
ease. Gastrointest Radiol 1979;4:285-289
not be subjected to major gastrointestinal investi-
6. Haworth EM, Hodson CJ, Pringle EM, et al: The value of
gations in the absence of clinical features suggestive radiological investigations of the alimentary tract in chil-
of malabsorption. then with celiac syndrome. Clin RadiOl 1968;19:65-76
7. Munyer TP, Moss AA: Radiologic evaluation of the malab-
ACKNOWLEDGMENT sorption syndrome. Practical Gastroenterol 1980;4:12-17
8. Masterson JB, Sweeney EC: The role of small bowel follow
We thank A. Hooda for her assistance in the prepara- through examination in the diagnosis of celiac disease. Br J
tion of this manuscript. Radiol 1976;49:660-664

PROVIDING HEALTH CARE

Quite a short time ago the rhetoric of health care seemed to assume that
society had a duty to provide all the health care from which each of its members
could conceivably benefit. That idea might have been tenable in the middle
years of this century, when technical complexity was less and costs were far
below those now obtaining-though certainly no country reached that level of
provision even then. Now such a goal is beyond the reach of any nation, partly
through lack of means and partly because an open-ended commitment would
always lead to some hypothetical, marginal benefit from care or probability in
diagnosis that would offer minimal return for the effort expended. As a result,
some form of rationing exists for almost everyone, either by ability to pay or by
queuing for a share of a limited service to which everyone has access. Excessive
zeal in either diagnosis or therapy may indeed be inimical to the well-being of
the individual. latrogenic illness or excessively distressing procedures of doubt-
ful benefit to the patient are more common than many physicians will admit,
and some diagnostic procedures have been applied to population screening with
greater regard to satisfying curiosity in the observer than to improving the life
prospects of the observed. The objective of providing all possible care strictly
in accordance with need must remain. The compromise now must be to provide
the most for the most and not everything for a few.

From Godber G: Striking the balance: Therapy, prevention and social support. World Health Forum
1982;3:258-265.

ARTICLES 533
Downloaded from http://pediatrics.aappublications.org/ by guest on December 21, 2017
 Radiologic Manifestations of Malabsorption: A Nonspecific Finding
Zvi Weizman, David A. Stringer and Peter R. Dunrie
Pediatrics 1984;74;530

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/74/4/530
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its
entirety can be found online at:
https://shop.aap.org/licensing-permissions/
Reprints Information about ordering reprints can be found online:
http://classic.pediatrics.aappublications.org/content/reprints

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
1984 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on December 21, 2017

 Radiologic Manifestations of Malabsorption: A Nonspecific Finding
Zvi Weizman, David A. Stringer and Peter R. Dunrie
Pediatrics 1984;74;530

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/74/4/530

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
1984 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on December 21, 2017