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  1. 1. Malabsorption<br />Patrick Carter MPAS, PA-C<br />February 7, 2011<br />Clinical Medicine I<br />
  2. 2. Objectives<br />List and describe the 3 phases of normal digestion and absorption.<br />Discuss the normal process of digestion and absorption including anatomical locations of absorption for:<br />Vitamins<br />Carbohydrates<br />Fats<br />Protein<br />
  3. 3. Objectives<br />Define malabsorption<br />Describe the following in terms of etiology, epidemiology, risk factors, signs and symptoms, diagnostic work-up, treatment, and complications:<br />Celiac disease<br />Whipple’s <br />Bacterial overgrowth <br />Compare and contrast the causes of short bowel syndrome, and discuss the resulting malabsorptions from each cause.<br />Describe lactase deficiency in terms of etiology, epidemiology, risk factors, signs and symptoms, diagnostic work-up, and treatment.<br />
  4. 4. Normal Digestion<br />Functions of intestinal epithelium<br />Nutrient digestion and absorption<br />Barrier and immune defense<br />Fluid and electrolyte balance<br />Production of proteins, amines, and peptides<br />
  5. 5. Normal Digestion<br />Three phases of digestion<br />Intraluminal phase (digestive)<br />Dietary fats, proteins and carbohydrates are hydrolyzed and solubilized by pancreatic and biliary secretion<br />Mucosal phase (absorptive)<br />Occurs in small intestine by brush border enzymes<br />Delivery phase (post-absorptive)<br />Dysfunction in this stage can lead to significant protein losses<br />
  6. 6. Malabsorption<br />Disruption of digestion and nutrient absorption<br />Signs and symptoms<br />Steatorrhea<br />Diarrhea<br />Weight loss, malnutrition<br />Iron deficiency anemia/megaloblastic anemia<br />
  7. 7. Malabsorption<br />Signs and symptoms<br />Bone pain and fractures<br />Paresthesia and tetany<br />Bleeding problems<br />Edema<br />Milk intolerance<br />Nocturia; abdominal distention<br />
  8. 8. Malabsorption<br />Diagnostic testing<br />Labs – CBC, PT, alkphos, CMP, folate, B12, iron, amylase, lipase<br />Fecal fat<br />Upper endoscopy with biopsy<br />Barium study of the small bowel<br />
  9. 9. Celiac Disease<br />AKA celiac sprue<br />Permanent dietary disorder caused by an immunologic response to gluten<br />The disease is present in 1:100 caucasians of Northern European descent<br />Only 60% of those will have symptoms<br />
  10. 10. Celiac Disease<br />Symptoms<br />Children < 2 years<br />Chronic diarrhea, steatorrhea, weight loss, abdominal distention, weakness, muscle wasting or growth retardation <br />Children >2 years and adults<br />Chronic diarrhea, dyspepsia, or flatulence<br />+/- weight loss<br />Many have no GI symptoms but present with fatigue, depression, Fe def anemia, osteoporosis, short stature, delayed puberty or reduced fertility<br />
  11. 11.<br />
  12. 12. Celiac Disease<br />Signs<br />PE may be normal<br />Malabsorption signs – loss of muscle mass or subcutaneous fat, pallor, easy bruising (vit K def), bone pain or neurologic signs (vit B12 or E def)<br />Abdominal exam – may reveal distention with hyperactive bowel sounds<br />
  13. 13. Celiac Disease<br />Dermatitis herpetiformis<br />a cutaneous form of celiac disease<br />Pruriticpapulovesicles over the extensor surfaces of the extremities and over the trunk, scalp and neck<br />Occurs in <10% of patients with celiac disease<br />
  14. 14. Dermatitis Herpetiformis<br />
  15. 15. Celiac Disease<br />Laboratory findings<br />Microcytic anemia or megaloblastic anemia on CBC<br />Low calcium or elevated alkphos<br />Increased prothrombin time<br />Specific tests<br />Stool for fecal fat<br />Serologic tests for celiac disease<br />IgAendomysial antibody and IgAtTG antibody<br />
  16. 16. Celiac Disease<br />Special tests (cont’d)<br />Endoscopic mucosal biopsy of the distal duodenum or proximal jejunum<br />Confirms the diagnosis in pt with positive serologic tests<br />Differential diagnosis<br />IBS<br />Bacterial overgrowth<br />Lactose intolerance<br />
  17. 17. Celiac Disease<br />Treatment<br />Gluten-free diet (wheat, rye, barley)<br />Clinical improvement on gluten-free diet after a few weeks<br />Dietary supplements (folate, iron, Ca, Vit A, B12, D and E) should be provided in the initial stages of therapy<br />Prognosis – excellent once diagnosed<br />
  18. 18. Whipple’s Disease<br />Rare multisystemic illness caused by infection with the bacillus Tropherymawhippelii<br />Commonly affects white men 30 – 50 years old<br />Source of infection is unknown<br />Will not spread human-to-human<br />
  19. 19. Whipple’s Disease<br />Symptoms<br />Weight loss (most common presenting symptom)<br />Arthalgias or migratory non-deforming arthritis<br />GI symptoms – abdominal pain, diarrhea, malabsorption, flatulence, steatorrhea<br />Intermittent low-grade fever<br />Signs<br />Enteric protein loss with edema and hypoalbuminemia<br />Generalized LAD<br />Enlarged and warm peripheral joints<br />
  20. 20. Whipple’s Disease<br />Signs (cont’d)<br />Ocular symptoms (uveitis, retinitis, etc.)<br />Congestive heart failure or valvular regurgitation<br />Diagnostic studies<br />Labs may show malabsorption<br />Diagnosis is made by endoscopic biopsy of the duodenum showing the Whipple bacillus<br />
  21. 21. Whipple’s Disease<br />Differential diagnosis<br />Other malabsorptive conditions<br />FUO<br />Celiac sprue<br />Mycobacterium avium complex (MAC) infection<br />Sarcoidosis and other autoimmune diseases<br />
  22. 22. Whipple’s Disease<br />Treatment <br />Antibiotic therapy for at least one year<br />IV Rocephin (ceftriaxone) 2 g daily for 2 weeks <br />Bactrim DS (TMP-SMX) 1 po bid for 1 year<br />Doxycycline if allergic to sulfa<br />Prognosis<br />Fatal if untreated<br />Patients must be followed closely for recurrence<br />
  23. 23. Bacterial Overgrowth<br />Overgrowth damages mucosa of small intestine and interferes with absorption<br />Causes of overgrowth<br />Gastric achlorhydria<br />Anatomic abnormalities with stagnation<br />Motility disorders<br />Gastrocolic or coloenteric fistula<br />
  24. 24. Bacterial Overgrowth<br />Signs and symptoms<br />Most patients are asymptomatic<br />S/S of malabsorption – distention, weight loss and steatorrhea or watery diarrhea<br />Diagnostic testing<br />Fecal fat<br />Aspiration and culture of proximal jejunum secretions (invasive)<br />Lactose breath test (noninvasive)<br />
  25. 25. Bacterial Overgrowth<br />Treatment<br />Correction of anatomic defect if needed<br />Broad-spectrum antibiotics for 1-2 weeks<br />Cipro 500 mg PO bid<br />Amoxicillin clavulanate 875 mg PO bid<br />May need cyclic antibiotic therapy (1 week out of every 4 weeks)<br />
  26. 26. Short Bowel Syndrome<br />Malabsorptive condition that arises secondary to removal of significant segments of small intestine<br />Crohn’s disease<br />Mesenteric infarction<br />Trauma<br />Radiation enteritis<br />Tumor resection<br />Trauma<br />Can usually tolerate resection of 40-50% of the small intestine<br />
  27. 27. Short Bowel Syndrome<br />Terminal ileum resection<br />Malabsorption of bile salts and B12<br />Treatment is low-fat diet, cholestyramine, and vitamins<br />Extensive small bowel resection<br />Weight loss and diarrhea<br />Treatment<br />Parenteral vitamin and mineral supplementation<br />Lperamide – slows transit and reduces diarrheal volume<br />TPN in most severe cases<br />
  28. 28. Lactase Deficiency<br />Lactase is a brush border enzyme that hydolyzes lactose into glucose and galactose<br />Lactase enzyme levels decline with age in most people of non-European ancestry<br />50 million Americans<br />95% of Native Americans<br />90% of Asian Americans<br />70% of African Americans<br />60% of Jewish Americans <br />50% of Mexican Americans<br /><25% Caucasian Americans<br />
  29. 29. Lactase Deficiency<br />Foods high in lactose<br />Milk (12g/cup)<br />Ice cream (9g/cup)<br />Cottage cheese (8g/cup)<br />Aged cheeses (0.5g/cup)<br />
  30. 30. Lactase Deficiency<br />Signs and symptoms<br />Vary with severity of deficiency and amount of lactose ingested<br />Most can drink one or two 8 oz glasses of mild daily without symptoms, if taken with food and at wide intervals<br />Bloating, abdominal cramps, flatulence and diarrhea after lactose ingestion<br />No weight loss<br />Laboratory findings<br />Hydrogen breath test<br />
  31. 31. Lactase Deficiency<br />Differential diagnosis<br />IBD<br />Malabsorptive disorders<br />IBS<br />Treatment<br />Goal is patient comfort<br />Limit lactose containing foods to threshold <br />Lactase enzyme replacement (Lactaid)<br />
  32. 32. Questions?<br />