useful lecture about malapsorbtion disorders and mcqs included in the lecture hope you enjoy the lecture Dr/ Sameer Sawaed

1. GastroenterologyGastroenterology
Ziv medical centerZiv medical center
Sameer Sawaed, MD , GCP .
Division of Internal Medicine

3. Clinical ManifestationsClinical Manifestations
Nutrient Malabsorbed Manifestation
Protein Wasting , edema
Carbohydrtaes and fat Weight loss, diarrhea, abd. Cramps
and bloating
Iron Anemia, angular stomatitis, nausea
Calcium/Vit. D Bone pain, tetany
Magnesium Paresthesia, tetany
Vit. B12/Folate Anemia, glossitis, paresthesias,
ataxia
Vit. E Peripheral neuropathy, ataxia,
retinopathy
Vit. A Night blindness
Vit. K Ecchymosis
Riboflavin Angular stomatitis
Selenium Cardiomyopathy

4. Diagnostic MethodsDiagnostic Methods
 Stool analysis for fat
– Qualitative: Positive sudan stain indicates excretion of more than
15 gm/day.
– Quantitative: 72-hour fecal fat collection (abnormal if more than
20 gm/day while on a diet with 100-gm/day of fat
 D-xylose absorption test
– This is a 5-carbon sugar which does not require digestion for
absorption. It is used to assess the intestinal mucosal integrity (25
gm oral dose…..5-hour urine sugar more than 5 gm or 2-hour
serum sugar more than 20 % of the oral dose
 Testing for unabsorbed carbohydrate
– A stool pH less than 5 is virtually diagnostic

5. Diagnostic Methods-2Diagnostic Methods-2
 Pancreatic function testing
– Measurement of HCO3 + total fluid output from the
duodenum after secretin stimulation
– Pancreatic chymotrypsin (Bentiromide test) to release
Paraaminobenzoic acid (PABA), which is excreted in
the urine; less than 60 % urinary excretion suggests
pancreatic insufficiency
– Measurement of stool pancreatic chymotrypsin and
elastase
 Small bowel biopsy

6. Histopathology of Mucosal MalabsorptionHistopathology of Mucosal Malabsorption
SyndromesSyndromes
 Normal: Villus to crypt ratio 3:1, columnar epithelial cells,
scattered mononuclear cells in the lamina propria
 Disorders in which small intestinal biopsy is diagnositc
– Whipple’s disease: Blunting of villi, PAS-positive
macrophages in the lamina propria; bacteria by electron
microscopy
– Hypogammaglobulinemia: Partial villous atrophy; lack
of plasma cells and lymphcytic infiltrate; sometimes
nodular lymphoid hyperplasia
– Abetalipoproteinemia: enterocytes filled with lipid
droplets
– Amyloidosis: Amyloid deposition in the mucosa and
submucosa

7. Diagnostic Methods-3Diagnostic Methods-3
 Bacterial overgrowth testing
– Direct culture of jejunal aspirates (+ if more than 100.000
organisms/ml)
– Bile acid Breath test
– Measurement of tryptophan metabolites(increased levels of
indacan and 5-HIAA
 Small bowel x-rays
– Celiac disease: Pooling or flocculation of barium
– Whipple’s, lymphoma, amyloidosis, eosinophilic gastroenteritis:
Thick folds
 Wireless capsule endoscopy

8. Causes of Intestinal Bacterial OvergrowthCauses of Intestinal Bacterial Overgrowth
 Structural abn. Producing stasis of intestinal
contents (e.g. small bowel diverticula)
 Fistulas (gastrocolic, jejunoileal,…)
 Intestinal hypomotility (e.g.scleroderma,
amyloidois, DM,…)
 Miscellaneous: hypogammaglobulinemia,
pernicious anemia,…

9. Major Malabsorptive DisordersMajor Malabsorptive Disorders
 Pancreatic insufficiency
 Celiac Disease
 Tropical sprue
 Whipple’s disease
 Abetalipoproteinemia
 Hapogammaglobulinemia/Giardiasis
 Intestinal lymphangectasia
 Eosinophilic gastroenteritis
 Non-granulomatous gastroenteritis

10. Pancreatic Exocrine InsufficiencyPancreatic Exocrine Insufficiency
 A common cause of maldigestion of fat and proteins, leading
to steatorrhea and muscle wasting
 Most common cause is chronic pancreatitis (mostly
secondary to alcohol use). Other causes include pancreas
divisum, hyperparathyroidism, cystic fibrosis and chronic
idiopathic pancreatitis
 The diagnosis is established with both functional and
structural tests
 The mainstay of treatment of the maldigestion and resulting
malabsorption is low-fat diet and pancreatic enzymes
 Acid inhibition may be necessary to prevent inactivation of
lipase

11. Celiac SprueCeliac Sprue
 Also called celiac disease and non-tropical sprue
 A disorder characterized by malabsorption, abnormal small
bowel structure and intolerance to gluten
 Prevalence: 1/150 to 1/300
 Genetics:
– Increased incidence in siblings
– Possibly dominant gene of incomplete penetrance
– High prevalence of HLA-B8, DQ2 and DW3
 Pathopysiology: Hypersensitivity to gluten and gliadin,
which are high-moplecular weight proteins found in wheat
– Toxic mechanism
– Immunologic mechanism
– Possible role of viral infection as a trigger

12. Celiac SprueCeliac Sprue
Effects of Gluten HypersensitivityEffects of Gluten Hypersensitivity
 Damaged mucosa causes impaired absorption
 Impaired secretion of secretin and CCK, causing
relative pancreatic insufficiency
 Increased permeability of jejunal mucosa, leading
to increased secretion of water and electrolytes
 Unabsorbed fatty acids cause increased colonic
secretion of water and electrolytes

13. Celiac SprueCeliac Sprue
Clinical FeaturesClinical Features
 1/3 of cases with onset in the pediatric age, and
2/3 with onset in the adult/elderly
 Diarrhea and iron-deficiency anemia are the most
common presenting manifestations
 Other manifestations: weight loss, fatigue,
abdominal distension/bloating, steatorrhea,
emotional disturbances, splenic atrophy, dermatitis
herpetiformis,…

14. Celiac SprueCeliac Sprue
HistopathologyHistopathology
 Duodenum and proximal jejunum most commonly
involved
 Lesions may be patchy; false negatives possible
 Typical findings:
– Flat mucosa (short or absent villi)
– Hypertrophied crypts
– Damaged surface epithelium
– Mononuclear infiltrate

19. Celiac SprueCeliac Sprue
SerologySerology
 Anti-gliadin Ab (IgG and IgA)
 Anti-endomysial Ab (IgG and IgA)
 Anti-TTG (Tissue TransGlutaminase): most
specific
 Always check total serum IgA….Selective IgA
deficiency can be an issue

20. Celiac SprueCeliac Sprue
Diagnostic criteriaDiagnostic criteria
Histopathology is NOT pathognomonic
3 criteria are needed:
– Evidence of malabsorption
– Abnormal biopsy
– Clinical, biochemical, and histological
improvement on gluten-free diet

21. Celiac SprueCeliac Sprue
ComplicationsComplications
 Collagenous sprue
 Intestinal lymphoma
 GIT adenocarcinoma
 Lactose intolerance
 Sideroblastic anemia
 Peripheral neuropathy
 Alveolar fibrosis
 Intestinal ulcers or strictures

22. Celiac SprueCeliac Sprue
TreatmentTreatment
 80 % of patients improve on gluten-free diet
 Non-responders should raise the suspicion for:
– Incorrect diagnosis
– Noncompliance with the diet
– Associated disease (e.g. pancreatic insufficiency)
– Complicated disease (e.g. lymphoma, collagenous
sprue, ….
 50 % of non-responders will respond to
glucocorticoids

23. Q.1Q.1
. A 25-year-old dental technician has noticed a 10-pound. A 25-year-old dental technician has noticed a 10-pound
weight loss despiteweight loss despite
increased appetite, generalized weakness, andincreased appetite, generalized weakness, and
constipation with infrequent butconstipation with infrequent but
unusually voluminous and malodorous stools. On physicalunusually voluminous and malodorous stools. On physical
examination, he is thin,examination, he is thin,
pale, and appears tired. His abdomen is protuberant butpale, and appears tired. His abdomen is protuberant but
soft. Labs reveal asoft. Labs reveal a
microcytic anemia. Which of the following ismicrocytic anemia. Which of the following is leastleast likely tolikely to
be helpful?be helpful?

24. A. Upper endoscopy
B. 72-hour stool collection for fecal
fat
C. CT scan of the abdomen
D. Anti-endomysial antibodies
E. Colonoscopy

25. Q.2Q.2
.. A 56-year-old man has had profuseA 56-year-old man has had profuse
watery diarrhea for three months.watery diarrhea for three months.
Measured stool electrolytes are asMeasured stool electrolytes are as
follows: Na_ 30 mmol/L, K+ 85 mmol/L,follows: Na_ 30 mmol/L, K+ 85 mmol/L,
Cl− 15Cl− 15
mmol/L, and HCO3mmol/L, and HCO3
− 18 mmol/L. Which diagnosis is− 18 mmol/L. Which diagnosis is leastleast
likely?likely?

26. A. VIPoma
B. Lactose intolerance
C. Laxative abuse
D. Celiac sprue

27. Q.4Q.4
A 46-year-old man had profuse diarrhea for two months. He notes that the
diarrhea continues throughout the day. Fasting does not decrease the
diarrheal episodes. He has tried using loperamide, but the relief is
temporary. He notes a – 10 pound weight loss over the last two months. He
notes that he is not taking any medications except for the loperamide.
Upon questioning, he recently quit smoking and has been chewing a lot of
sugarless gum. You measure his stool electrolytes.
The results are as follows:
 Na+ 40 mmol/L
 K+ 90 mmol/L
 Cl− 15 mmol/L
 HCO3
 − 18 mmol/L
What is the most likely diagnosis?

28.  A. Lactase deficiency
 B. Sucrase deficiency
 C. VIPoma
 D. Inadvertent excess sorbitol ingestion (e.g., through gum
chewing)

29. Tropical SprueTropical Sprue
 Malabsorption disorder caused by traveling to
tropical regions, probably secondary to E. coli,
klebsiella pneumonia or folic acid deficiency
 The histology and manifestations are similar to
celiac disease, but less severe.
 The entire small intestine is involved on histology
 The anemia is megaloblastic, NOT microcytic
 Treatment is with tetracyclineor bactrim for at
least 6 months + folic acid and vit B12

30. Q.3Q.3
A 40-year-old man complains of crampy abdominal pain associated with
intermittent loose stools for the last three months. He had been healthy
until he developed a week of severe diarrhea while visiting India. He then
took tronidazole for a week.
The diarrhea was resolving by then but evolved soon afterward into his
current symptoms. He finds that eating precipitates his symptoms although
his
weight is stable. Physical examination is unremarkable. Stool microscopy is
negative
and labs are unrevealing. Which of the following diagnoses is the most likely
explanation for his current symptoms?

31. A. Irritable bowel syndrome
B. Giardiasis
C. Crohn’s disease
D. Lactose intolerance

32. Q.6Q.6
 . A 62-year-old man presents complaining of abdominal pain and
diarrhea. He notes that the symptoms have been going on for three
months now and he has lost about 20 pounds over that span. He also
complains of migratory arthralgias for the past year. He denies any
past medical history. He never smoked cigarettes and drinks about two
beers per week. He denies use of illicit drugs. A review of records
from an evaluation done by another physician reveals a normal
thyroid-stimulating hormone level, negative ANA, a normal
sedimentation rate, and a negative HIV test.
 He had a flexible sigmoid oscopy done, which failed to reveal any
abnormalities. You refer him for upper endoscopy and a duodenal
biopsy is done, which reveals extensive PAS-positive material in the
lamina propria and villous atrophy. What is
 the most appropriate therapy for this patient?

33. A. A gluten-free diet
B. A lactose-free diet
C. Cholestyramine
D. Trimethoprim/sulfamethoxazole
E. Prednisone

34. WhippleWhipple’’s Diseases Disease
 Systemic disease caused by Tropheryma
Whippleii
 Adult males most commonly affected
 Manifestations: Diarrhea, weight loss, abdominal
pain, arthralgias, non-deforming arthritis, fever,
lymphadenopathy, neurological and cardiac
manifestations
 Histology: Dilated lacteals and lamina propria
containing PAS-positive macrophages
 Treatment: Bactrim for 1 year

35. Q.9Q.9
 A 55-year-old white man presents with a 6-month
history of weight loss and arthralgias. He reports no
anorexia but has had diarrhea with up to 4 loose stools
daily. He has migratory pain involving the shoulders,
elbows, and knees. On physical examination, he has
skin hyperpigmentation and oculomasticatory
myorhythmia.
 A 72-hour stool collection shows 32 g of fat per 24
hours. Which test is most likely to be positive or
diagnostic for this patient?

36. a. Measurement of serum IgA and IgG tissue
transglutaminase antibodies .
b. Measurement of serum IgA and IgG
deamidated gliadin antibodies.
c. Small bowel biopsy showing enlarged villi
with periodic acid-Schiff (PAS)-positive
macrophages
d. Small bowel biopsy showing villous atrophy
and crypt hyperplasia
e. Duodenal aspirates showing more than
100,000
colony-forming units (CFU)/mL

37. Q.8Q.8
 A 40-year-old woman who has iron defi ciency
anemia began receiving oral iron therapy
without response. She reports no
gastrointestinal tract complaints or heavy
menses. She has a normal appetite and reports
no weight loss. Th ere is no family history of
colon cancer or infl ammatory bowel disease.
Fecal occult blood testing of the stool is
negative. Which test should be performed next?

38.  A. Measurement of serum IgA and IgG tissue
transglutaminase antibodies
 B. Upper endoscopy with small bowel biopsies
 C. Capsule endoscopy
 D. Small bowel follow-through
 E. Stool evaluation for ova and parasites

39. HypogammaglobulinemiaHypogammaglobulinemia
 Malabsorption occurs, especially with IgA
deficiency
 Clinico-pathologic features:
– Nodular lymphoid hyperplasia
– Presence of Giardia lamblia
– Flattened or absent villi
– Absent plasma cells
– Increased lymphocytic infiltration
 Treatment: Metronidazole and IVIG

40. Non-granulomatous ulcerativeNon-granulomatous ulcerative
jejunoileitisjejunoileitis
 Rare condition of unknown etiology and poor
prognosis
 Clinical features: fever, weight loss, crampy
abdominal pain, bloating, diarrhea, splenomegaly
 D. D. with Crohn’s disease and intestinal
lymphoma

42. MRI showing an
enterocutaneous fistula (arrow)
in a patient with ileocolic
Crohn's disease.
contrast enema shows a contracted
ulcerated rectum (large arrow),
with stricture formation involving
the distal rectum (smaller arrows).
The contrast is seen to fill the

43. Q.5Q.5
 All of the following are extra intestinal
manifestations that are associated with ulcerative
colitis except :

44. A. Arthritis
B. Sclerosing cholangitis
C. Autoimmune hemolytic anemia
D. Uveitis
E. Perianal fistula formation

45. What is this ?????What is this ?????

46. Eosinophilic GastroenteritisEosinophilic Gastroenteritis
Etiology unknown
Histology: Normal or blunted villi, mucosa
infiltrated by mature eosinophils and
neutrophils
Peripheral eosinophilia
Urticaria is not uncommon
Treatment is with glucocorticoids

47. Q.10Q.10
 A 44-year-old woman complains of 6 months of epigastric
pain that is worst between meals. She also reports symptoms
of heartburn. The pain is typically relieved by over-the-
counter antacid medications. She comes to clinic after noting
her stools darkening. She has no signiicant past medical
history and takes no medications. Her physical examination
is normal except for difuse midepigastric pain. Her stools
are heme positive. She undergoes EGD, which demonstrates
a wellcircumscribed,
2-cm duodenal ulcer that is positive for H pylori. Which of the
following is the recommended initial therapy given these
findings?

48.  A. Lansoprazole, clarithromycin, and metronidazole for 14 days
 B. Pantoprazole and amoxicillin for 21 days
 C. Pantoprazole and clarithromycin for 14 days
 D. Omeprazole, bismuth, tetracycline, and metronidazole for 14 days
 E. Omeprazole, metronidazole, and clarithromycin for 7 days

49. Q.12Q.12
All of the following are direct
complications of short bowel syndrome
EXCEPT:

50. A. Cholesterol gallstones
B. Coronary artery disease
C. Gastric acid hypersecretion
D. Renal calcium oxalate calculi
E. Steatorrhea

51. Q .13Q .13
 . A 54-year-old man is evaluated by a gastroenterologist
for diarrhea that has been present for approximately 1
month. He reports stools that loat and are dificult to lush
down the toilet; these can occur at any time of day or
night but seem worsened by fatty meals. In addition, he
reports pain in many joints lasting days to weeks and not
relieved by ibuprofen. His wife notes that the patient has
had dificulty with memory for the last few months. He
has lost 30 pounds and reports intermittent low-grade
fevers. He takes no medications and is otherwise
healthy. Endoscopy is recommended. Which of the
following is the most likely binding on small bowel
biopsy?

52. A. Dilated lymphatics
B. Flat villi with crypt hyperplasia
C. Mononuclear cell iniltrate in the lamina propria
D. Normal small bowel biopsy
E. Periodic acid–Schif (PAS)–positive
macrophages containing small bacilli

53. Good Luck