Malabsorption Syndrome

Dr. Md. Golam Kibria Khan Associate Professor of Medicine Medicine Unit IV MMCH
July 25, 2005 Dr. Md. Golam Kibria Khan 1

Introduction
Malabsorption is a wide term used in the clinical practice to denote a state of complex disorders of digestion and absorption of food staff, such as fat, protein, carbohydrate, minerals, electrolytes and vitamins, resulting in diarrhoea, abdominal pain and distension, loss of weight, anaemia or other evidence of specific deficiency.
July 25, 2005 Dr. Md. Golam Kibria Khan 2

Introduction (contd...)
However, some patients may only complain only of vague ill health and diagnosis may not be made for many years. Malabsorption may be of selective absorption defect of a particular food staff or combination of a few or all.

July 25, 2005

Dr. Md. Golam Kibria Khan

Aetiology and Pathogenesis

Malabsorption results from abnormalities of the three processes which are essential to normal digestion : Intraluminal maldigestion occurs when deficiency of bile or pancreatic enzymes results in inadequate solubilisation and hydrolysis of nutrients. Fat and protein malabsorption results. This may also occur in the presence of small bowel bacterial overgrowth.
July 25, 2005 Dr. Md. Golam Kibria Khan 4

Aetiology and Pathogenesis (Contd..)

Mucosal malabsorption results from small bowel resection or conditions which damage the small intestinal epithelium, thereby diminishing the surface area for absorption and depleting brush border enzyme activity.

July 25, 2005

Dr. Md. Golam Kibria Khan

Aetiology and Pathogenesis (Contd..)

Postmucosal lymphatic obstruction prevents the uptake and transport of absorbed lipids into lymphatic vessels. Increased pressure in these vessels results in leakage into intestinal lumen, leading to protein losing enteropathy.

July 25, 2005

Dr. Md. Golam Kibria Khan

Classification of Malabsorption Syndrome

A. Inadequate Digestion Postgastrectomy Deficiency or inactivation of pancreatic lipase Exocrine pancraetic insufficiency
Chronic pancreatitis Pancreatic carcinoma Cystic fibrosis Pancreatic insufficiency Congenital Acquired

Gastrinoma acid inactivation of lipase Drugs - Orlistat

July 25, 2005 Dr. Md. Golam Kibria Khan 7

Classification (contd...)
B. Reduced intraduodenal bile acid concentration / impaired micelle formation: Liver disease Parenchymal liver disease Cholestatic liver disease Bacterial overgrowth in small intestine Anatomic stasis / blind loop / stricture / fistulae Functional stasis Diabetes Scleroderma July 25, 2005 8 Intestinal pseudo obstruction

Classification (contd...)
Interrupted enterohepatic circulation of bile salts Ileal resection Crohns Disease Drugs (binds or precipitates bile salts)
Neomycin Cholestyramine Calcium carbonate
July 25, 2005 Dr. Md. Golam Kibria Khan 9

Classification (contd...)
C. Impaired mucosal absorption / mucosal loss or defect: Intestinal resection or bypass Inflammation infiltration or infection
Crohns Disease Amyloidosis Scleroderma Lymphoma Eosinophilia enteritis Mastocytosis Tropical sprue
Dr. Md. Golam Kibria Khan 10

July 25, 2005

Classification (contd...)
Coeliac disease Collagenous sprue Whipples disease Radiation enteritis Folate and Vitamin B12 deficiency Infections Salmonellosis Giardiasis Graft vs host disease
July 25, 2005 Dr. Md. Golam Kibria Khan 11

Classification (contd...)
C. Impaired mucosal absorption (contd...) Genetic disorders
Disaccharidase deficiency Agammaglobulinemia Abetalipoproteinemia Harnup disease Cystinuria

July 25, 2005

Dr. Md. Golam Kibria Khan

12

Classification (contd...)
D. Impaired nutrient delivery to and/or from intestine
Lymphatic obstruction Lymphoma Lymphangiectesia Circulatory disorders Congestive heart failure Constrictive pericarditis Mesenteric artery atherosclerosis Vasculitis
July 25, 2005 Dr. Md. Golam Kibria Khan 13

Classification (contd...)
E. Endocrine and metabolic disorders: Diabetes Hypoparathyroidism Adrenal insufficiency Hyperthyroidism Carcinoid syndrome

July 25, 2005

Dr. Md. Golam Kibria Khan

14

Clinical Manifestations
Lethargy, Depression Weight loss, malnutrition, Diarrhoea, steatorrhoea Flatus Glossitis, Cheilosis, Stomatitis Abdominal pain Bone pain Tetany, paresthesia, Osteomalacia, rickets. Nocturia Azotemia,
Dr. Md. Golam Kibria Khan 15

July 25, 2005

Clinical Manifestations (contd...)

Hypotension Amenorrhea, decreased libido Anaemia Bleeding (purpura, bruising) Nightblindness / Xerophthalmia Peripheral neuropathy Dermatitis Acrodermatitis enteropathica Koilonychia Clubbing.
Dr. Md. Golam Kibria Khan 16

July 25, 2005

Investigations
A) Routine Blood tests: a) Haematology: Microcytic anaemia (Iron deficiency) Macrocytic anaemia (Folate or B12) Increased prothombin time (Vitamin K deficiency) b) Biochemistry Hypoalbuminaemia Hypocalcaemia and vitamin D deficiency Hypomagnesaemia Deficiencies of phosphate, zinc
July 25, 2005 Dr. Md. Golam Kibria Khan 17

Investigations (Contd...)
B) For Steatorrhoea: Blood tests:

Full blood count Clotting time Urea and electrolyte Immunoglobulins Calcium Magnasium Albumin Folate Coelic antibodies
July 25, 2005

14C-triolein

breath

test. Feacal fat estimation: Confirmatory. In malabsorption fat excretion >7gm/day.

Dr. Md. Golam Kibria Khan

18

Investigations (Contd...)
C) Investigate the small intestine: Duodenal biopsy Barium studies Sugar permeability D) Investigate the pancreas: Pancreatic function tests Ultrasound scan / CT scan MRCP or ERCP E) Consider bile salt malabsorption: SeHCAT scan Serum 7-hydroxycholesterone
July 25, 2005 Dr. Md. Golam Kibria Khan 19

Management:
A) General:1.Correction of deficiency, such as fluid, electrolyte, vitamine,blood,iron etc. 2.Fat restricted diet in case of steatorrhoea. B) Specific measures:-Treatment of cause such as (1) Tropical sprue: a) Folic acid 5mg t.d.s. for 2 weeks Capsule Tetracycline 250mg 6 hourlyfor 1 month. C) If remission,Folic acid 5 mg daily as maintenance dose for life long.Mulitivitamins are helpful.
July 25, 2005 Dr. Md. Golam Kibria Khan 20