Malabsorption syndrome

1. Pokhara University
School of Health and Allied Sciences
Malabsorption Syndrome
Presented by : Deepa kumari
karn
First Semester, M Pharm
School of Health and Allied Sciences
Pokhara University, Dhungepatan, Lekhnath-12,
Kaski, Nepal

2. Pokhara University
School of Health and Allied Sciences
Contents
• General overview of GIT
• Introduction of Malabsorption Syndrome
• Pathophysiology
• Consequence
• Risk
• Diagnosis
• Treatments
• References

3. Pokhara University
School of Health and Allied Sciences
General Overview of GIT

4. Pokhara University
School of Health and Allied Sciences
Introduction
• Any alterations of the gastrointestinal tract (GIT)
affecting the digestion, absorption and transport of
nutrients across the bowel wall
• Intestinal absorption capacity falling short of 85%
• Important clinical indicator of intestinal failure,
inability of the GIT to digest and absorb sufficient
nutrients to maintain the GIT, mucosa integrity, fluid
balance, nutritional status and overall health

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School of Health and Allied Sciences
• Malabsorption is a clinical term that encompasses
defects occurring during digestion and absorption of
food nutrients
• It mainly involves
– Maldigestion: deficiency or inactivation of pancreatic
enzymes and bile salt. Primary pancreatic exocrine
insufficiency
– Malabsorption: inability to absorb dietary food. Mucosal
barrier to absorption: disease of small intestine

6. Pokhara University
School of Health and Allied Sciences
Pathophysiology
• Can be described in terms of :
– Premucosal aberration
Diseases and conditions that result in impaired
digestion
Clinical settings include chronic pancreatitis,
cystic fibrosis and pancreatic cancer,
Inadequate pancreatic enzyme secretion as well
as cholestatic liver disease and bacterial
overgrowth that could lead to lack of solubilising
bile salts

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School of Health and Allied Sciences
– Mucosal aberration
Condition that affect gut mucosa itself, and
result in a reduced absorptive area
Examples include coeliac disease, inflammatory
bowel diseases and Whipple’s disease
– Postmucosal aberration
Conditions that result in altered nutrient
transport, i.e. vascular or lymphatic obstruction

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School of Health and Allied Sciences
Premucosal Mucosal Postmucosal
Impaired digestion Reduced absorption Altered nutrient transport
Bile acid/enzyme
deficiencies
Bowel resection Vascular or lymphatic
abnormalities
Diseases affecting
absorption
Table :- Pathophysiology of malabsorption

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Consequences
• Abdominal pain and bloating (due to bacterial gas
production and bacterial overgrowth)
• Diarrhea and steatorrhoea, fluid and electrolyte
losses, anemia (iron, folate and vitamin B12)
• Growth retardation and osteopenia (malabsorption of
calcium, vitamin D, phosphate and magnesium results
in secondary hyperparathyroidism)

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• Significantly greater risk of developing
– Infectious complications,
– Respiratory failure,
– Cardiac arrest, cardiac failure, arrhythmias
– Wound
• Malnourished patients also had a significantly longer
duration of hospitalisation, regardless of the
underlying disease and its course of treatment

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Risk factors
Unintentional weight loss Low or inadequate nutrient
intake
Increased nutrient losses or
decreased absorption
> 5% body weight over one
month
Hypocaloric feeding Excessive diarrhoea
> 10% body weight over six
months
Starvation Excessive vomiting
Anorexia nervosa Chronic pancreatitis
Chronic alcoholism Gastrointestinal surgery
Elderly Gastrointestinal inflammatory
conditions
Oncology patients Uncontrolled diabetes mellitus
Postoperative patients Chronic use of laxatives,
diuretics or antacids

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Diagnosis
Premucosal Mucosal Postmucosal
Serum electrolyte,
mineral and vitamin
values
Bowel resection Ultrasound/contrast
for fistulae
Faecal fat excretion,
hydrogen breath test
Endoscopy and
histology
Ultrasound for
obstructions/calcific
ations
Xylose test,
Schilling test
Table : Diagnostic tests for malabsorption

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School of Health and Allied Sciences
• Serum levels of electrolytes, minerals and vitamins
may serve as a good proxy marker of nutritional
status and hence low values can serve as an indicator
of impaired digestion and premucosal malabsorption
• Faecal fat excretion test is a simple and quick test to
measure fat malabsorption, where a fat content of less
than 7 g/day following a 100 g fat intake for 72 hours
is regarded as normal
• The hydrogen breath test can be used to identify
carbohydrate malabsorption (lactose intolerance test)

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School of Health and Allied Sciences
– Various carbohydrates may be measured, but glucose and
lactulose are probably most commonly used for the
identification of bacterial overgrowth and hence
carbohydrate maldigestion
– Irrespective of the type of carbohydrate used, exhaled
hydrogen is measured in parts per million (ppm), and an
increase of more than 20 ppm above baseline values is
considered a positive result
– Results may be influenced by various factors, for example
the use of antibiotics or laxatives, periods of fasting, diet
over the previous 24 hours, and therefore adequate
patient preparation before the test is important

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 Carbohydrate absorption can be measured through
the amount of xylose excreted in the urine over a
five-hour period, because xylose is a form of
carbohydrate that is not metabolised
 A Schilling test, with and without adding intrinsic
factor (IF), can be used to identify vitamin B12
malabsorption

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School of Health and Allied Sciences

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• Diagnosis algorithism
– Take careful history including drug intake, travelling and
special foods, drinks or sweets
– Consider family history
– Notice hints for malabsorption from physical examination
and look at stool for volume, appearance, admixtures of
mucus, blood, parasites
– Draw blood for screening laboratory examination to find
additional hints
– If the case warrants further exploration, go on with

18. Pokhara University
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H2-breath tests for carbohydrate malabsorption (lactose,
fructose)
Abdominal ultrasound
Oesophago-Gastro-Duodenoscopy including biopsies from
stomach and duodenam
Ileocolonoscopy including biopsies of colon and ileum
1. If pancreatic disease with secretory insufficiency is
suspected,
– tests for secretory function e.g. elastase or chymotrypsin in
stool

19. Pokhara University
School of Health and Allied Sciences
2. If small bowel disease is still within the differential
diagnostic scope
– Schilling-test (Vit B12)
– Glucose-H2-test (bacterial overgrowth)
– a1-antitrypsin clearance (intestinal protein loss)
– Small bowel X-ray (fistulae, diverticula, blind
loops, short bowel, etc.)
– Angiography of celiac and mesenteric arteries
(ischemic bowel damage)

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Fig: Hydrogen breath test

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Treatment
• Two basic principles underlie the management of
patients with malabsorption, as follows:
1) Correction of nutritional deficiencies
2) Treatment of causative diseases.

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School of Health and Allied Sciences
1) Correction of nutritional deficiencies
• Supplementing various minerals, such as calcium,
magnesium, iron, and vitamins, which may be
deficient in malabsorption
• Caloric and protein replacement
• Medium-chain triglycerides can be used as fat
substitutes because they do not require micelle
formation for absorption and their route of transport
is portal rather than lymphatic

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• In severe intestinal disease, such as massive resection
and extensive regional enteritis, parenteral nutrition
may become necessary.

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School of Health and Allied Sciences
2) Treatment of causative diseases
 A gluten-free diet helps treat celiac disease
 A lactose-free diet helps correct lactose intolerance;
supplementing the first bite of milk-containing food
products with Lactaid also helps
 Protease and lipase supplements are the therapy for
pancreatic insufficiency

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School of Health and Allied Sciences
 Antibiotics are the therapy for bacterial overgrowth
 Corticosteroids, anti-inflammatory agents and other
therapies are used to treat regional enteritis
 Cholestyramine or other bile acid sequestrant will
help reducing diarrhoea in bile acid malabsorption

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• The treatment plan for malabsorption must be, by
necessity, cause specific, with appropriate adaptation
to a diet that would best support a given setting
• Pancreatic enzymes may be added to food to aid its
absorption
• In the case of altered nutrient transport caused by
obstruction, surgery is the best option

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Premucosal causes Mucosal causes Post mucosal causes
Partially digested food Partially digested food Surgery for obstruction
Pancreatic enzyme
supplementation
Disease-specific treatment
Surgery for obstruction
Table : Treatment of malabsorption

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• Paterson, concludes that certain dietary factors,
notably wheat gluten, are effective in initiating
deleterious changes i e, increased secretion of mucus
and decreased motility of the villi
• Low fat, gluten-free diet that otherwise adheres as
closely as possible to a normal diet should be
followed, along with a well-planned therapy which
includes the correction of anemia

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• Patients should be encouraged to have two servings
of fruit or fruit juice daily, including a satisfactory
source of ascorbic acid
• Serving of meat, fish or poultry daily, with liver
included once a week, is important as a source of
protein, iron and other essential food nutrients

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Breakfast Lunch Dinner
Orange juice Vegetable soup Tomato juice
Puffed rice Sliced beef Roasted veal
Milk , sugar Totomato , cucumber Baked potato
Soft boiled egg Pudding Fluffy squash ginger
Unimix toasted Skim milk Fresh asparagus
Celery hearts
Fresh rubrab
Table: Suggested gluten free meal pattern

31. Pokhara University
School of Health and Allied Sciences
Puffed rice Sliced beef
Skim milk
Roasted veal Fresh rubrab Fresh asparagus

32. Pokhara University
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Fig :- Treatment algorithism of tropical malabsorption

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References
1. Blaauw R (2011) Malabsorption: causes, consequences,
diagnosis and treatment, S Afr J Clin Nutr, 125-127
2. Harrison T (2008) Principles of Internal Medicine ((17th Ed),
Mc Graw Hill Lange Medical Publication, United State
America (1872-1882)
3. WGO Practice Guideline: Malabsorption
4. Elizabeth M, Upton M A and Barbara A (1963) Dietary
Management of the Malabsorption Syndrome, Canad Med
Ass J , 323- 325.

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5) Ramakrishna S B, Venketaraman S, Mukhopadhya A (2006)
Tropical Malabsorption, Post Graduate Medical Journal , 779-
787
6) URL:http://emedicine.medscape.com/article/180785-
treatment (Assessed on April 2, 2017)

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School of Health and Allied Sciences