malabsorption syndromes

2. INTRODUCTION
• clinical problems associated with diminished
intestinal absorption of one or more dietary
nutrients and are often referred to as
malabsorption syndromes.
Associated with steatorrhea, an increase in
stool fat excretion of >6% of dietary fat intake
Diarrhea - decrease in stool consistency, an
increase in stool volume, an increase in number
of bowel movements, or any combination of
these three changes.

3. CNTD..
• osmotic diarrhea -secondary to diminished
absorption of one or more dietary nutrients.
• secretory diarrhea diarrhea that is due to
small- and/or large-intestinal fluid and
electrolyte secretion.
• Distinction between two is not precise since
both components co exist in a same disorder.

4. CELIAC DISEASE
• Associated with environmental(gluten-
wheat,barley,oat),immunological(anti-endomysial
Ab to tissue transglutaminase),genetic(HLA
DQ2/DQ8)
• SYMPTOMS-
diarrhoea,steatorrhea,anemia,edema(protein
loss),metabolic bone disease.
• Diagnosis –small intestinal biopsy(reduced height
of villi with crypt hyperplasia,increased
lypmhocytes,plasma cells in lamina propria)

5. CNTD..
• DEFINITIVE DIAGNOSIS IS BY restoration of
normal villous architecture after gluten
restricted diet.
• REFRACTORY SPRUE-1.responding to other
dietary protein restriction(soy)2.response with
steroids3.temporary4.failure to respond to all
measures with developing INTESTINAL
LYMPHOMA

6. CNTD..
• Associated Diseases:DERMATITIS
HERPETIFORMIS,T1 DM,DOWN,TURNER
• Complications:GI/NON GI CANCERS
(LYPMPHOMA),REFRACTORY
SPRUE,COLLAGENOUS SPRUE
• IRON DEFECIENCY ANEMIA in an YOUNG with
no occult GI bleed should prompt for
evaluating CELIAC DIS. as iron is exclusively
absorbed in small intestine

7. TROPICAL SPRUE
• ETIOLOGY:INFECTIOUS-
KLEBSIELLA,E.COLI,ENTEROBACTER CLOACAE
• SYMPTOMS:diarrhea,steatorrhea,wt loss,B12 and
folate malabsorption
• SMALL INTESTINAL BIOPSY almost indifferentiable
from CELIAC DISEASE except for less villous
architectural alteration,mononuclear cell
infiltration,lack of clinical/histological
improvement after gluten restriction
• TREATMENT:TETRACYCLINE 6mnths with FOLATE
supplementation

8. BACTERIAL OVERGROWTH SYNDROME
• ETIOLOGY:STASIS-
ANATOMICAL(diverticula,jejunoileal surgeries for
obesity,fistulas and strictures) FUNCTIONAL-
scleroderma)
• Symptoms-diarrhea,steatorrhea,macrocytic
anemia(B12, not folate-because colonic microbes
consume B12 for growth)
• DIAGNOSIS:low serum cobalamine with high
folate-enteric bacteria produce more
folate),BREATH HYDROGEN TESTING WITH
Lactulose

9. CNTD..
• ANATOMICAL STASIS-SURGICAL
• FUNCTIONAL STASIS-broad spectrum
antibiotics-tetracylines drug of choice
• To avoid resistance other options are
metronidazole,amoxyclavulanic
acid,cephalosporins

10. WHIPPLE’S DISEASE
• AGENT-TROPHERYMA WHIPPLEI(G+ bacilli)
• SYMPTOMS-apart from usual malabsorptory
symptoms presents with characteristic large
joint arthropathy,abdominal pain,CNS and
cardiac symptoms(MULTISYSTEM DISEASE)
• DEMENTIA in patients who relapse after
treatment with antibiotics –extremely poor
prognostic sign(middle aged white men)
• Lymphatic obstruction by PAS positive
macrophages-steatorrhea

11. CNTD..
• DIAGNIOSIS:demonstration of PAS positive
macrophages containing bacilli in tissue
biopsies
• TREATMENT-double strength cotrimoxazole
for 1yr
• BACILLI outside macrophages an indicator of
active disease and recurrence
• Intolerance to cotrimoxazole-chloramphenicol
can be used.

12. PROTEIN LOSING ENTEROPATHY(PLE)
• Group of GI/NON GI disorders presenting with
hypoproteinemia,edema in absence of
proteinuria(RENAL FAILURE)/protein
synthesis(HEPATIC FAILURE)
• Cause –1.mucosal ulceration(eg-
APD,ULCERATIVE COLITIS
• 2.altered epithelial permeability with normal
mucosa(MENETRIER’S DISEASE)
• 3.lymphatic dysfunction(intrinsic
lymphangiectasia

13. CNTD…
• DIAGNOSIS:edema with low serum proteins with
decreased albumin and globulin fractions)
• Selective decrease of either albumin or globulin is
extremely rare in PLE’s and indicates either
LIVER/RENAL disease
• LYMPHOCYTES are lost in addition to proteins and
LYMPHOPENIA is usually assoaciated with
hypoproteinemia
• Non GI causes-RIGHT SIDED VALVULAR HEART
DIASEASE,CHRONIC PERICARDITIS

14. CNTD…
• TREATMENT is aimed at underlying disorders
• With lymphatic etiology-low fat diet with
medium chain triglycerides(do not exit via
lymphatics and enter portal vein)

16. INVESTIGATIONS
• SCHILLING TEST(B12)
• D-XYLOSE(to asses proximal small intestinal
function,false positive in blind loop
syndrome,3rd space loss
• SMALL INTESTINAL BIOPSY
• COMPLETE HEMOGRAM
• LIPID PROFILE
• RFT,LFT
• VCTC
• USG ABDOMEN,BARIUM STUDIES..