NUTRITION IN

MALABSORPTION
SYNDROME
Boerhan Hidayat
Department of Child Health
Medical Faculty-Airlangga University
Dr.Soetomo General Hospital
Surabaya

What is Malabsorption?
The integrated processes of digestion and absorption
have 3 phases:
Luminal phase- dietary carbohydrates, proteins and
fats are hydrolysed and solubilized
largely by pancreatic and biliary
secretions
Mucosal phase - final hydrolysis and uptake by
epithelial cells prior to cellular export
Transport phase - absorbed nutrients enter vascular
or lymphatic circulation
Disturbances of these processes lead to malabsorption

Some causes of malabsorption

Luminal
Inadequate mixing
e.g. post-gastric
surgery

Mucosa

Transport

Mucosal damage
Lymphatic disease
or disease
e.g. lymphangiectasia
e.g. resection
coeliac disease
Enzyme deficiency
Crohns disease
e.g. pancreatic disease
infections
Bile salt
deficiency e.g.
cholestasis
deconjugation
excessive loss

Common luminal causes

Post-gastric surgery
Chronic pancreatitis
Bile salt deficiency -chronic liver disease
- contaminated
bowel
syndrome
- ileal
disease
(Crohns/resection)

Common Intestinal
Symptoms

Intestinal gas and flatulence

Constipation
Diarrhea
Steatorrhea
Gastrointestinal strictures and
obstruction

Normal Function GI

Absorption

Most nutrients absorbed in jejunum

Small amounts of nutrients absorbed
in ileum
Bile salts & B12 absorbed in terminal
ileum
Residual water absorbed in colon

Principles of Nutritional
Care
Dietary modifications

To alleviate symptoms
Correct nutritional deficiencies
Address primary problem
Must be individualized

Steatorrhea

Dietary Modification

Increase kcal to meet needs,

especially protein and carbohydrate
Control fat level
Give only level tolerated
Use MCT oil to meet kcal needs
with caution

Vitamin and mineral supplements

Use fat-soluble vitamins; add extra
Ca, Mg, Zn, Fe

Steatorrhea
MCT Oil

8 to 10 carbons long
Bile not needed for absorption
Delivered to liver via blood
8.3 kcal/g
1 T = 116 kcal
Expensive
Increases osmolality of tube
feedings

Celiac Disease
Gluten-Sensitive Enteropathy

Adverse reaction to glutengliadin

fraction
Intestinal mucosa damaged
Malabsorption of nutrients
Iron deficiency
Osteomalacia
Growth failure
Projectile vomiting

Celiac DiseaseCause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

Celiac
DiseasePathophysiology

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenisis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations in
mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L.
Beyer, 2002.

Celiac DiseaseMedical and

Nutritional Management

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter
L. Beyer, 2002.

Celiac Disease
Gluten-Sensitive Enteropathy

Treatment
Remove gluten from the diet:
Wheat
Rye
Buckwheat
Barley

Tropical Sprue

Cause unknown; imitates celiac disease

Results in atrophy and inflammation of villi
Sx: diarrhea, anorexia, abdominal distention
Rx: tetracycline, folate 5 mg/d, B12 IM

Intestinal Brush Border

Enzyme Deficiencies

Lactose intolerance
Causes: genetic or secondary deficiency of milk
sugar enzyme, lactase
Blacks, Asians, Native Americans
Aging: damage to GI tract
Dx: lactose tolerance test or breath hydrogen
test
Rx: avoid large amounts of lactose
(milk protein allergy requires milk-free diet);
take lactase enzyme; processed dairy
sometimes OK

Inflammatory Bowel
Disease

Crohns disease or ulcerative colitis

Both involve damage to the intestine
Crohns: may damage either small or
large intestine
Disease progression varies
Ulcerative colitis: begins at rectum
and progresses up the large intestine

Inflammatory Bowel
DiseaseCause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

Inflammatory Bowel Disease

Pathophysiology

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

Inflammatory Bowel
DiseaseMedical and
Nutritional Management

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

Inflammatory Bowel
Diseases

Rx:
Diet depends on patients status
Nutrition assessment
Select route of feeding
Fiber is beneficial except during
flareups.

Disorders of the Large

Intestine
1. Irritable bowel syndrome

Common syndrome involving altered

intestinal motility, increased sensitivity
of
the GI tract, and increased
awareness and
responsiveness of
the viscera to internal
and external
stimuli
Alternating constipation and diarrhea,
abdominal pain, and bloating

Disorders of the Large

Intestine contd
2. Diverticular disease
Herniations of the colon, chronic
diverticulosis, acute
diverticulitis
Diverticulosis
High-fiber diet: fruits, vegetables,
whole grains (2 tsp bran daily)
Diverticulitis
Low-residue or elemental diet
Possibly low-fat diet

Disorders of the Large

Intestine contd
3. Colon cancer and polyps
Colon cancer is the second most
common cancer among US
adults
Polyps are considered precursors
of
colon cancer.

Short Bowel Syndrome

Follows removal of more than two

thirds of small intestine
Causes weight loss; diarrhea;
decreased transit time;
malabsorption; dehydration; loss of
electrolytes; hypokalemia

Short Bowel Syndrome

contd
Removal of ileocecal valve causes

more complications.
Fat malabsorption frequent
Steatorrhea
Saponify calcium, zinc, and
magnesium
Remove ileum and lose B12 and bile
salt absorption

Short Bowel Syndrome

contd
Factors Affecting Severity of Malabsorption, Number
of Complications, and Dependence on Parenteral
Nutrition

Length of remaining small intestine

Loss of ileum, especially distal one third
Loss of ileocecal valve
Loss of colon
Disease in remaining segments(s) of
gastrointestinal tract
Radiation enteritis
Coexisting malnutrition
Older age surgery

Short Bowel Syndrome

Nutritional Care

Step 1
Parenteral only for most patients

Step 2
Gradually introduce enteral
nutrition.
Glutamine is an important nutrient
for the gut.
Narcotic drugs for pain cause GI
problems and should be evaluated.

Short Bowel Syndrome

Eventually the remaining bowel

increases absorptive surface, and
problems decrease.
Nutrition support is designed to
meet each patients needs.

Other Bowel Diseases

Irritable bowel syndrome

Alternating diarrhea and constipation
Rx:
High-fiber diet: be careful with wheat
bran
Elimination of stimulants
Evaluate for food allergies or
intolerances

Blind Loop Syndrome

Bacterial overgrowth from stasis in

intestine, obstruction, radiation
enteritis, fistula, or surgical repair
Treatment (Rx):
Appropriate needs for malabsorption
Antibiotics for bacterial overgrowth

Diet Modification of Fiber

in Diets

Restricted-fiber diet
5 to 10 g/day
High-fiber diet
25 to 35 g/day
Minimal-residue diet or elemental
formulas

Causes of Constipation
Gastrointestinal

Diseases of the upper gastrointestinal tract

Celiac disease
Duodenal ulcer
Diseases of the large bowel resulting in:
Failure of propulsion along the colon
(colonic inertia)
Failure of passage though anorectal
structures (outlet obstruction)
Irritable bowel syndrome
Anal fissures or hemorrhoids
Laxative abuse

Causes of Constipation
Systemic

Side effect of medication

Metabolic endocrine abnormalities, such as

hypothyroidism, uremia, and
hypercalcemia

Lack of exercise

Ignoring the urge to defecate

Vascular disease of the large bowel

Systemic neuromuscular disease leading to

deficiency of voluntary muscles

Poor diet, low in fiber

Pregnancy

Fistula
Abnormal Opening Between Organs

Causes: birth defects; trauma;

inflammatory disease; malignant
disease
Rx:
For fluid loss
For electrolyte loss
Aggressive nutritional support

Ileostomy or Colostomy
Surgical Opening of Intestine to
Outside

Causes: ulcerative colitis; Crohns

disease;
colon cancer; trauma
Rx:
Nutrition needs vary with location
and individual
Avoid gas- or odor-forming foods
Fluid and electrolyte needs

Hemorrhoidectomy

Delay stool formation until healing can

take place
Rx:
Minimal-residue diet or elemental diet
After recovery
High-fiber diet to prevent

High-Fiber Diets

Most Americans = 10 15 g/day

Recommended = 25 g/day
More than 50g/day = no added
benefit, may cause problems

Low- or Minimum Residue

Diet

Foods completely digested, well absorbed

Foods that do not increase GI secretions
Used in:
Maldigestion
Malabsorption
Diarrhea
Temporarily after some surgeries, e.g.
hemorrhoidectomy

IBD Nutritional
Management
(acute)

Low-residue, low-fiber liquid diet

Bowel rest with parenteral
nutrition
Enteral nutrition may have better
success at inducing remission
Diet tailored to individual pt:

Minimal residue for reducing diarrhea

Limited fiber to prevent obstruction
Small, frequent feedings
Supplements , MCT with fat
malabsorption

IBD Nutritional
Management (chronic)

High protein, high calorie diet with

oral supplements
Monitor vitamin-mineral status of
iron, calcium, selenium, folate,
thiamin, riboflavin, pyridoxine,
vitamin B12, zinc, magnesium,
vitamins A, D, E
High fiber diet as tolerated
Avoid unnecessary restrictions

Diverticulosis

High fiber diet (increase gradually)

Supplement with psyllium,
methylcellulose may be helpful
2 3 qt water daily with high fiber
intake
Low fat diet may be helpful
? Avoid seeds, nuts, skins of plants

Colon Cancer/Polyps:
dietary risk factors

Increased meat intake, esp. red

meats
Increased fat intake
Low intakes of vegetables, high
fiber grains, carotenoids
Low intakes of vits D, E, folate
Low intakes of calcium, zinc,
selenium

Colon Cancer/Polyps:
possible dietary protective
factors
Omega-3 fatty acids fish oils,

flaxseed, etc
Wheat bran
Legumes
Some phytochemicals (plants)
Butyric acid dairy fats,
bacterial fermentation of fiber in
colon
Calcium

Summary

Lower GI conditionsimportant for

nutritional consequences
Important to note where obstruction
or surgery has taken place to
determine impact on specific
nutrients
Most dramatic: short bowel
syndrome, which may require longterm TPN

Summary

Food intolerances should be dealt

with individually
Patients should be encouraged to
follow the least restrictive diet
possible
Patients should be re-evaluated
frequently and the diet advanced as
appropriate