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Malabsorption Syndrome

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Breath tests e.g. 14C-Triolein Abdominal Tuberculosis Definition: the affectation of any intra-abdominal organ by tuberculosis 1 Abd.TB.: ... – PowerPoint PPT presentation

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Title: Malabsorption Syndrome


1
Malabsorption Syndrome
  • Prof. D. A. Ndububa
  • Department of Medicine
  • Faculty of Clinical Sciences
  • Obafemi Awolowo University
  • Ile-Ife

2
Definition and Classification
  • Definition impaired digestion or absorption of
    one or more nutrients in the alimentary tract
    with their subsequent loss from the body
  • Classification
  • Maldigestion impaired digestion due to lack of
    gastric acid, biliary obstruction or pancreatic
    exocrine insufficiency
  • Global malabsorption (mucosal, post-mucosal or
    mixed)
  • Specific malabsorption single nutrients affected
    (e.g. vitamin B12 or lactose or iron or bile salt)

3
Classification (Contd.)
  • Intra-luminal Maldigestion
  • Liver cirrhosis ? bile salt insufficiency ? mild
    steatorrhoea (25 100 incidence)
  • Bile duct obstruction (e.g. due to Ca head of
    pancreas) ? bile salt deficiency ? steatorrhoea
  • Pancreatic exocrine insufficiency (e.g. chronic
    pancreatitis). Loss of ? 90 exocrine secretory
    capacity of pancreas ? chronic pancreatic
    exocrine insufficiency ? malabsorption with
    weight loss in spite of good appetite
  • Drugs (e.g. cholestyramine ? binds bile acids ?
    steatorrhoea

4
Classification (Contd.)
  • B. Mucosal Malabsorption
  • Drugs (e.g. colchicine, neomycin,
    para-aminosalicylic acid fenamate class of
    NSAID) ? enterocyte damage ? malabsorption
  • Infectious diseases giardia, hookworm,
    cryptosporidium, isospora, strongyloides, Whipple
    disease (Tropheryma whippelii), mycobacterium
    avium complex, tuberculous enterocolitis
    (Mycobacterium tuberculosis)
  • Auto-immune enteropathies
  • Tropical sprue
  • Disaccharidase deficiencies (e.g. lactase,
    sucrase-isomaltase)

5
Mucosal Malabsorption (Contd.)
  • 6. Mastocytosis eosinophilic gastroenteritis ?
    fat malabsorption ? steatorrhoea and/or watery
    diarrhoea, systemic flushing, abdominal pain,
    tachycardia protein-losing enteropathy
  • 7. Coeliac sprue
  • 8. Dermatitis herpetiformis
  • 9. Abetalipoproteinaemia hypobetalipoproteinaemi
    a ? chylomicron formation defects

6
Classification (Contd.)
  • C. Post-mucosal obstruction
  • - Intestinal lymphangiectasia
  • Congenital Acquired
  • -
    Trauma

  • - Carcinoma

  • - Filariasis
  • - Whipple disease
  • Outcome ? protein-losing enteropathy with
    significant steatorrhoea

7
Classification (Contd.)
  • D. Mixed Causes
  • Bacterial overgrowth surgical gastrojejunal
    anastomoses, anatomic bowel obstruction (e.g.
    Crohns disease), small bowel diverticulosis and
    motility disorders
  • Short bowel syndrome (lt 200cm of jejunum-ileum)
  • Metabolic diseases thyrotoxicosis (due to ?
    transit time), adrenal insufficiency, autoimmune
    polyglandular syndrome (due to deficiency of
    CCK-producing enteroendocrine cells),
    protein-calorie malabsorption, prolonged fasting
    (due to villous atrophy)

8
Clinical Manifestations
  • Diarrhoea
  • Weight loss
  • Flatulence,
  • Borborygmi
  • Bulky, greasy stools (Steatorrhoea)
  • Abdominal pain
  • Bowel distension
  • Anaemia
  • Haemorrhagic diathesis
  • Leg oedema

9
Clinical Manifestations (Contd.)
  • Bone pain (osteopenic bone disease)
  • Tetany (ve Chvostek)
  • Amenorrhoea. Infertility impotence
  • 2? hyperparathyroidism
  • Cheilosis, glossitis, stomatits
  • Purpura, petechiae, bruising
  • Follicular hyperkeratosis
  • Scaly dermatitis, acrodermatitis
  • Hyperpigmented dermatitis
  • Oedema and/or ascites

10
Clinical Manifestations (Contd.)
  • Xerophthalmia night blindness
  • Peripheral neuropathy
  • Abdominal mass
  • Dermatological changes
  • Facial flush hepatomegaly
  • Neurological impairment
  • Ocular neurological changes
  • Arthralgia, lymph nodes

11
Investigations
  • 1. Stool microscopy ? ova parasites
  • 2. Stool fat estimation (gt7g/24hrs)
  • 3. Proctosigmoidoscopy
  • 4. Full blood count blood film (microcytic,
    macrocytic or dimorphic anaemia)
  • 5. Clotting profile e.g. prothrombin time
  • 6. Serum carotene
  • 7. Serum Ca2, PO42-, alkaline phosphatase
  • 8. Serum Fe2, folate vitamin B12
  • 9. Serum albumin

12
Investigations (Contd.)
  • 10. Serology e.g. anti-tissue transglutaminase
    IgA antibodies (by ELISA) in Coeliac disease
  • 11. Abdominal ultrasound scan
  • 12. Barium meal
  • 13. Duodenal biopsy (using Crosby-Kugler capsule)
  • 14. Abdominal CT scan
  • 15. Video capsule endoscopy
  • 16. Magnetic resonance cholangiopancreatography
  • 17. D-xylose test
  • 18. Schilling test
  • 19. Breath tests e.g. 14C-Triolein

13
Abdominal Tuberculosis
  • Definition the affectation of any
    intra-abdominal organ by tuberculosis
  • 1? Abd.TB. failure of lesions in an
    intra-abdominal organ involved in the septicaemic
    phase of primary infection to completely heal. It
    used to be caused by Mycobacterium bovis but now
    largely due to Mycobacterium tuberculosis.
  • 2? Abd. TB. a part of miliary spread or
    ulceration of the intestine following ingestion
    of infected coughed-up sputum.

14
Main Forms of Abdominal Tuberculosis
  1. Ulcerative tuberculous enterocolitis
  2. Hyperplastic tuberculosis or hypertrophic
    ileocaecal tuberculosis
  3. Tuberculous peritonitis
  4. Tuberculous lymphadenitis or glandular
    tuberculosis

15
Tuberculous Enterocolitis
  • Often seen with cavitary PTB is due to
    swallowing of infected coughed-up sputum
  • Terminal ileum is the commonest site (reasons
    abundance of lymphoid tissue, ?physiological
    stasis ?rate of resorption and better contact
    between the organism and the intestinal wall).
    Peyers patches often affected
  • Epithelial granulomas with caseation on
    microscopy
  • Tb ulcers are characteristically transverse with
    undermined edges, nodular margins and surfaces
    covered by a film of caseous material
  • Tiny tubercles seen on serosal surface of the
    ulcer

16
Hyperplastic TB (or hypertrophic ileocaecal TB)
  • Usually affects ileocaecal region may affect the
    appendix
  • Intestinal wall thickened due to granulomatous
    reaction fibrosis
  • There may be regional lymphadenopathy
  • Small tubercles may be seen in the serosa of the
    bowel in the mesentery
  • Intestinal lumen often narrowed mucosa
    ulcerated with pseudopolyp formation ?
    cobble-stone appearance
  • Differentials of hyperplastic TB Crohns
    disease, amoeboma, colonic carcinoma,
    schistosomiasis, actinomycosis, lymphoma and
    para-appendiceal abscess/mass

17
TB Peritonitis
  • The main forms of TB peritonitis are
  • 1. Wet type characterized by ascites or pockets
    of loculated fluid. The ascites could be gross
    may be confused with ovarian or mesenteric cyst
  • 2. Dry type dominated by caseous nodules
    adhesions the peritoneum intestine are
    plastered together by caseous tuberculous lesions
  • 3. Omental type the omentum is greatly
    thickened, fibrosed and produces a hard mass
    palpable per abdomen
  • Usually follows haematogenous spread from distant
    infected areas or contiguous spread from diseased
    lymph nodes, bowel or fallopian tubes

18
TB Lymphadenitis (Glandular TB)
  • Characteristic of primary abdominal TB
  • There is gross enlargement of abdominal lymph
    nodes with caseation minimal or no observable
    GIT lesions
  • Lymph nodes frequently involved mesenteric,
    para-aortic upper abdominal
  • May spread to the liver, spleen may be
    associated with cervical, axillary or inguinal
    lymphadenopathy
  • Lymph nodes may be firm white with yellowish
    areas of caseation or virtually replaced by
    yellow creamy pus
  • Rupture of lymph node ? TB peritonitis
    (mesenteric peritoneal surfaces studded with
    tubercles)

19
Clinical Features of Abdominal TB
  • Commonest symptom is peri-umbilical or right
    iliac fossa pain
  • Other symptoms nausea, vomiting, diarrhoea (may
    be associated with blood mucus), fever, night
    sweats, abdominal distension, weight loss,
    hepato-splenomegaly, pallor, palpable mass, signs
    of avitaminosis, steatorrhoea malabsorption and
    menstrual disorders (e.g. oligomenorrhoea or
    amenorrhoea) in females
  • Females more affected than males
  • Age group predominantly affected 20 40 years

20
Investigations
  • Full blood count ESR ?ESR occurs in about 90
    of cases
  • Ascitic fluid analysis dirty yellow or brown
    with flakes of fibrin or debris, ?protein content
    (exudative), ?specific gravity, ?leucocyte count
    with predominant lymphocytosis poor AFB yield
  • Chemistry serum and ascitic fluid albumin
    gradient lt1.1g/dl is characteristic (in addition
    to hypoalbuminaemia) positive ascitic fluid
    adenosine deaminase
  • Chest X-Ray hilar adenopathy or focal lung
    lesions may be seen even where patient has not
    been symptomatic of respiratory disease
  • Abd. USS calcified lymph nodes and/or
    hepato-splenomegaly

21
Investigations (Contd.)
  • Radiology
  • Plain x-ray of the abdomen lymph node (LN)
    calcification (rarely) or small bowel fluid
    levels
  • Barium meal accelerated transit,
    hypersegmentation of barium column, secretory
    disturbances, narrowing of terminal ileum, lack
    of barium retention in diseased segment of ileum
  • Air contrast study ileocaecal valve appears
    gaping rigid
  • Barium enema filling defect or stricture
  • Tissue biopsy
  • Peripheral LN biopsy 2. Peritoneal biopsy 3.
    Liver biopsy
  • 4. Laparoscopic biopsy 5. Exploratory
    laparotomy with biopsy of mass or LN

22
Treatment
  • Therapeutic trial 4 weeks of quadruple
    anti-tuberculous chemotherapy if symptoms
    improve, then abd. TB is confirmed
  • Definitive treatment quadruple therapy using the
    following drugs
  • Ethambutol Pyrazinamide Isoniazid (INH)
    Rifampicin for 2 months, then
  • INH Rifampicin for another 10 months
  • Total duration of therapy 12 months
  • Add pyridoxine to treatment and monitor weight,
    PCV and ESR
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