Disorders in which there is disruption of digestion
and nutrient absorption
Steatorrhea (bulky, light colored stools)
Fats, CHO, Water
Weight loss; muscle wasting Fats, Proteins, CHO
Iron, B12, folate
Paresthesias, tetany, Calcium, Vit D
Bone pain pathological fractures, deformities Calc
Bleeding tendencies Vitamin K
Increase in fecal fats
Decreased albumin and proteins
Decreased Ca, Iron, B12, red cell folate
Prolonged prothrombin time
Abnormal D-Xylose absorption
Decreased Vitamin A, carotene levels
Intraluminal phase: Nutrients are hydrolyzed
fats: monoglycerides and fatty acid
proteins: di- and tri-peptides, amino acids
CHO: di- and mono-saccharides
Defects in intra-luminal phase
Decreased pancreatic enzymes
Chronic pancreatitis, cystic fibrosis, Z-E syndrome
Insufficient bile salts
Resection and /or diseases of terminal ileum
Produce significant steatorrhea. Protein and CHO
digestion is affected less
Sufficient surface area of intestinal epithelium
Brush border enzymes
Defects in mucosal phase
Deficiency of brush border enzymes
Short bowel syndrome
Malabsorption of all nutrients; fats, CHO, and
Majority of nutrients are directly absorbed from
epithelial cells into blood stream
Chylomicrons and lipoproteins are absorbed through
lymphatics; lymphatic obstruction can impair their
Leads to steatorrhea and protein losing enteropathy
Routine blood tests in
Microcytic anemia (iron deficiency)
Macrocytic anemia(folate or B12 deficiency)
Increased prothrombin time (vit. K def)
Hypocalcemia and Vit. D def
Deficiencies of zinc, phosphate, and magnesium
Ms. Sakina is 22years of age and came to her
physician with complaints of weakness, easy
fatiguability and body aches and pains.
She passes 2-3 loosely formed, pale and bulky stools
per day, and has abdominal bloating for the last six
She has a reasonable appetite; has no food fads; and
belongs to middle socioeconomic class.
No past H/O abdominal complaints.
No associated fever or constitutional symptoms.
No H/O abdominal surgery or radiation therapy.
One elder sister has related symptoms.
What is the possible cause?
Intra-luminal phase defects?
Mucosal phase defects?
Absorptive phase defects?
Ms. Sakina was found to be pale. Her BMI was 19.6.
She neither had edema nor any skin bruises. She had
bone tenderness and a positive Chvostek’s sign.
The abdomen was distended, soft, non tender, with
no organomegaly; it was hyper-resonant on
Can you make a diagnosis now?
What is this history, physical examination, and lab
data suggestive of?
Malabsorption due to ?
Further lab tests are needed to find a possible
Establishing the cause
Small intestinal biopsy
Normal histology with well formed
villous pattern almost excludes diffuse
small intestinal mucosal disease
Biopsy is usually abnormal in
Establishing the cause
Small intestinal radiography is usually diagnostic
in diseases with a gross anatomical abnormality as
jejunal diverticulosis precipitating bacterial
overgrowth, diffuse Crohn’s disease, and lymphoma.
Hydrogen breath test
Plain X-rays, USG, CT scan, and ERCP
Usual causes of generalized
Post infectious malabsorption / tropical sprue
Celiac disease (Non-tropical sprue)
Diverticulosis, blind loops, hypo motile states
Short gut syndrome
Ms. Sakina had a normal Plain X-ray of abdomen.
Her abdominal USG was also normal.
A small bowel enema was done and it did not reveal
Hydrogen breath test after 50 gm lactose was also
Duodenal biopsy from D2 revealed a blunting and
shortening of villous pattern and infiltration of lamina
propria with plasma cells and lymphocytes.
Antibodies against gliadin, reticulin, and
endomysium were present.
Ms. Sakina was treated with a short course of steroids
and was advised strict gluten free diet. Her symptoms
improved dramatically and steroids were withdrawn,
after tapering, in six weeks
Four months later, the duodenal biopsy was found to
If the abdominal USG shows calcification in the
region of pancreas and D-xylose test is abnormal?
Ms. Sakina has a past H/O Hodgkin’s Lymphoma and
H/O abdominal radiation?
Duodenal biopsy shows villous atrophy but antibody
screen is negative
Small bowel enema shows jejunal diverticulosis and
hydrogen breath test is positive?
Small bowel enema is normal but hydrogen breath
test is positive?
Ms. Sakina has normal lab tests, USG abdomen, and
Take home message
In a case of chronic diarrhea first establish the
presence of malabsorption and if present the
work up the cause of malabsorption