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Malabsorption

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Malabsorption Tory Davis, PA-C * * * * Iron defiency causes microcytic anemia, B12 and folate causes macrocytic anemia D-xylose sugar that is not absorbed with ... – PowerPoint PPT presentation

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Title: Malabsorption


1
Malabsorption
  • Tory Davis, PA-C

2
To Be Covered
  • Malabsorption overview
  • Small bowel bacterial overgrowth
  • Carbohydrate intolerance
  • Celiac Disease
  • Short Bowel Syndrome
  • Not covered in this lecture tropical sprue,
    Whipples disease, secondary causeslook-em-ups

3
Malabsorption
  • Inadequate assimilation of dietary substances due
    to defects in
  • Digestion
  • Absorption
  • Transport
  • Can affect micronutrients (vits and minerals) or
    macronutrients (protein/carb/fat)?

4
Malabsorption causes
  • Increased fecal excretion
  • Nutritional deficiencies
  • Common GI symptoms
  • Diarrhea
  • Steatorrhea (gt6g/d of fathallmark of
    malabsorption)?
  • Abdominal bloating
  • Gas
  • Weight loss
  • Other specific s/s with each malabsorbed nutrient

5
How to figure it out
  • Suspect malabsorption in all patients with
    chronic diarrhea, wt loss, anemia
  • Check hx for clues
  • Hx acute pancreatitis? Think chronic panc
  • Hx lifelong diarrhea exac by gluten? Rash, too?
    Think celiac disease
  • Milk makes them fart? Think lactose intolerance
  • Had most of their small bowel removed? Think
    short bowel syndrome! Okay, duh

6
Work-up
  • If you suspect specific cause, test for it
  • Details to follow, and more details from Brendas
    lab lectures
  • And/or check CBC (anemia), ferritin, lytes
  • Confirm malabsorption
  • 72 h fecal fat collection
  • Sudan III stool stain for fat
  • D-xylose test (assesses mucosal integrity to
    differentiate between mucosa and pancreatic
    etiology)?

7
Diagnosis of Malabsorption
  • Endoscopy with small bowel bx
  • Culture small bowel aspirate for bac-t overgrowth
  • Small bowel xrays to look for anatomical
    conditions that may predispose to bac-t
    overgrowth (fistulas, surgical blind loops,
    strictures, ulcerations)?
  • Schilling test (B12)?

8
Causes of Malabsorption
9
Bacterial Overgrowth Syndrome
  • Usually secondary to anatomic alterations or
    motility disorders (congenital or acquired) that
    promote stasis of intestinal contents
  • Normal small bowel has lt105 bact/mL
  • Low count maintained by peristalsis, gastric
    acid, mucus, intact ileocecal valve function

10
What Extra Bacteria Do
  • Consume nutrients, especially B12 and carbs
  • B12 (cyanocobalamin) deficiency
  • Calorie deprivation/weight loss
  • Produce folate, so this is NOT a cause of folate
    deficiency (folate def causes macrocytic anemia)
  • Deconjugate bile salts
  • Fat malabsorption
  • Steatorrhea and diarrhea

11
Bac-t Overgrowth Dx
  • Frequently, empiric antibiotic therapy resulting
    in improvement is basis for diagnosisbut abx can
    worsen many conditions on the ddx
  • Better quantitative culture of intestinal fluid.
    Look for bac-t countgt105/mL
  • Or C-xylose breath test (less invasive)?

12
Bact Overgrowth Tx
  • 10-14 days oral abx
  • Tetracycline
  • Amox/clavanulate
  • Cephalexin
  • TMP/SMX
  • Metronidazole
  • Correct underlying condition
  • Correct nutritional deficiencies

13
Carbohydrate Intolerance
  • Inability to digest certain carbs due to lack of
    one or more enzymes
  • Sx watery diarrhea, abdominal distention,
    flatulence, nausea, borborygmi, abd cramping
    (hooray for lactaid!)?
  • Etiology
  • Acquired (primary)?
  • Secondary
  • Congenital (rare)?

14
Lactase Deficiency
  • Primary adult hypolactasia
  • Most common carb intolerance
  • Lactase normally in high levels in neonates but
    decrease after weaning in most ethnic groups
  • 80 blacks and hispanics
  • Near 100 Asians
  • Only 15-20 Caucasians

15
Lactose intolerance
  • So, 75 of the world adult population lacks
    lactase, and we call it abnormal

16
Secondary Lactase Deficiency
  • Seen with small bowel mucosal damage, such as in
    celiac disease, acute small bowel infections,
    tropical sprue

17
Dx/Tx
  • Dx by
  • Careful hx
  • Dietary challenge
  • H2 breath test
  • Tx with
  • Lactose avoidance
  • Lactase supplements
  • Ca supplements

18
Celiac Disease
  • Aka
  • Celiac Sprue
  • Non-tropical sprue
  • Gluten Enteropathy
  • Immunologically mediated disease caused by
    intolerance of gluten, which causes mucosal
    inflammation and malabsorption

19
Celiac
  • Hereditary insensitivity to gliadin fraction of
    gluten
  • Gluten-sensitive T cells activated by exposure,
    cause inflammatory responseleads to mucosal
    villous atrophy and crypt hyperplasia
  • N. America 1/5000, (1/150 in SW Ireland)?
  • Female 21 male

20
Presentation
  • There is no typical
  • Infants
  • Sx appear after cereals introd
  • FTT (failure to thrive), anorexia, pallor,
    hypotonia, abdominal distention
  • Older kids
  • Anemia, growth delays, anorexia, diarrhea

21
Adults
  • Anorexia, weakness,
  • Diarrhea, steatorrhea,
  • Anemia
  • Glossitis, angular stomatitis, aphthous ulcers
  • Decreased fertility
  • Lactose intolerance (Why?)?
  • Will lactose avoidance help the sx?
  • Evidence of ? Ca/vit D (like what?)?
  • Dermatitis herpetiformis (10)?

22
Diagnosis
  • Clinical suspicion
  • Use clues like unexplained Fe deficient anemia
  • FHX
  • Labs
  • 72 hr fecal fat
  • D-xylose absorption test
  • Tissue transglutaminase (IgA)?
  • Anti gliaden antibody (IgA)?
  • Anti reticulin antibody (IgA)?
  • Total IgA (check to make sure there is no IgA
    deficiency)?
  • Antibody levels decrease with gluten-free diet,
    so you can use this to determine if the pt is
    really following the diet

23
Small Bowel Biopsy
  • Not specific
  • Villous atrophy
  • Lack of or shortening of villi
  • Increased epithelial cells
  • Crypt hyperplasia

24
Celiac Treatment
  • Gluten free diet
  • No wheat, rye, barley or anything that has gluten
    in it
  • No breads, bagels, pastries, pasta and pizza
  • Gluten used as thickener frequently, so need
    education to facilitate avoidance
  • Must do dietitian referral, advise support group
  • Sx will resolve in 1-2 weeks (usually)?

25
Prognosis Complications
  • Prog 10-30 mortality without tx
  • Complications
  • Intestinal lymphomas
  • Refractory disease
  • Increase in other GI malignancies

26
Short Bowel Syndrome
  • Malabsorption due to extensive small bowel
    resection (often because of Crohns, mesenteric
    infarction, radiation enteritis)?
  • Symptom severity depends on length and function
    of remaining bowel
  • Diarrhea and nutritional deficiencies

27
Jejunum
  • Primary digestive and absorptive site for most
    nutrients
  • BUT
  • If removed, the ileum will adapt by changing
    villous structure
  • Gradual clinical improvement as adaptive process
    continues

28
Ileum
  • Primary site for B12 and bile acid absorption
  • No compensatory mechanism for loss of ileum
  • Malabsorption of fats, fat-soluble vitamins, and
    B12
  • Bile acids in large intestine cause secretory
    diarrhea

29
SBS Tx
  • Small feedings
  • Anti-diarrheals
  • TPN if needed
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