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24 Cards in this Set

  • Front
  • Back
Malabsorption
Impaired absorption of individual or multiple nutrients caused by the pathologic disruption of the normal physiological processes of digestion and intestinal transport
general Sx of malabsorption
Diarrhea- CHO, protein, fat
Steatorrhea-fat
Weight Loss > 10% (calorie loss)
Bloating, gassiness, flatulence-sugars
Specific Sx of malabsorption
Peripheral edema-protein
Pica; symptoms of anemia -iron, B12, folate
Neuropathy-B12
Night blindness-Vit A
Accelerated osteoporosis-Vit D Ca++
Causes of Malabsoprtion (3)
Disaccharaide malabsorption, Maldigestion (slective fat malabsorption), global malabsorption.
Disaccharide malabsorption
Lactase Deficiency (common)
Fructose Intolerance (uncommon)
Sucrase Deficiency (rare)
Makdigestion (selective fat malabsorption)
Gastric resection or bypass
Bile salt deficiency - ileal resection/disease, SIBO
Pancreatic Insufficiency
Global malabsorption (CHO, protein, fat)
Short Bowel Syndrome
Mucosal Disease - Crohn's, Celiac, Whipple's, amyloidosis, lymphoma, radiation enteritis
Clues from the Hx that lead to malabsorption
GI Surgery
Ulcer operations (esp. vagotomy & antrectomy)
Gastric resection or bypass
Cholecystectomy
Small bowel resection (esp. terminal ileum)
Right colon resection (esp. ileo-cecal valve)
Pancreatitis or Hx of heavy EtOH abuse
Abdominal or pelvic irradiation
Collagen vascular disease
Lactose Intolerance
Most common cause of chronic diarrhea in USA
Primary
Absence of the lactase persistence SNP
Highest incidence in persons of Asian, Native-American, and African-American ancestry
Secondary
Aging
Post-infectious (enterovirus)
Chemotherapy
Celiac disease, Tropical Sprue, Giardiasis
Bacterial Overgrowth
Rapid transit syndromes
Dx and Tx of lactose intolerance
Diagnosis
Presumptive
Trial of a low-lactose or lactose-free diet (may give a false negative result)
Lactose-Hydrogen Breath Test
Treatment
Dietary lactose restriction
Lactase-treated milk (Lactaid®, DairyEase®)
Lactase enzyme supplements
Lactose hydrogen breath test
when there is a lactase deficiency, lactose is not broken down and H2 is emitted
Sucrase deficiency
Very rare autosomal recessive disorder
Sx: diarrhea appearing in early infancy
Dx: sucrose hydrogen breath test
Rx: lifelong sucrose free diet
Dietary Fructose Intolerance
Mild dysfunction of the GLUT 5 transporter
Sx: diarrhea with ingestion of fruit and products containing high fructose corn syrup
Dx: fructose hydrogen breath test
Rx: dietary fructose restriction
physiological requisites for fat absorption
Gastric Mixing (emulsification)
Bile Salts (solubilization in mixed micelles)
Pancreatic Lipase (triglyceride lipolysis)
Mucosal Integrity (FA uptake, packaging, export)
Disruption of fat digestion and absorption can be due to
Gastric resection or dysmotility (gastroparesis)
Bile Salt Malabsorption or deficiency (bacterial overgrowth, TI resection, cholecystectomy)
Pancreatic insufficiency: chronic pancreatitis
Mucosal Diseases
Maldigestion: Bacterial Overgrowth
Increased bacterial colonization of the small intestine (N.B. no part of the GI track is sterile)
Major Causes
Hypomotility (DM, scleroderma, visceral myopathy)
Achlorhydria (gastrectomy, atrophic gastritis)
Jejunal diverticulosis
Ileo-cecal valve resection
Pathophysiology
Bile salt deconjugation  bile salt malabsorption  decreased bile salt pool  fat malabsorption
Chronic mucosal inflammation
Dx and Tx of bacterial Overgrowth
Diagnosis
Suspicion
Jejunal aspiration for quantitative culture (gold standard, but not widely available)
14C-Glycocholate Breath Test
Glucose-Hydrogen Breath Test*
Treatment
Oral systemic or non-absorbable antibiotics
Usually requires chronic treatment
Antibiotic rotation to prevent resistance
glucose Hydrogen breath Test
x
Pancreatic insufficiency Causes and Pathophysiology
Causes
Chronic pancreatitis (common)
Pancreatic cancer with duct obstruction (rare)
ZE Syndrome - lipase denaturation (rare)
Pathophysiology
Steatorrhea occurs when the secretion of pancreatic lipase falls to < 10% of normal
Disease also destroys  and  cells, resulting in decreased insulin and glucagon secretion
Brittle diabetes appears in advanced disease
Dx and Tx of Pancreatic Insufficiency
Diagnosis
Presumption
Stimulated pancreatic secretion analysis
Pancreatic imaging by CT, EUS, ERCP*
Treatment
Pancreatic enzyme supplements containing at least 30,000 units of lipase at each meal
Enteric coated tablets
PPIs, H2 blockers, or NaHCO3 keep gastric pH > 5 to prevent enzyme denaturation
Reduced fat diet
Global Malabsorption: Small bowel Mucosal Disease
Celiac disease (upper small bowel)
Crohn’s disease (terminal ileum)
Whipple’s disease (duodenum, jejunum)
Intestinal lymphoma
Chronic giardiasis
Other rare disorders:
Tropical sprue
Eosinophilic gastroenteritis
Abetalipoproteinemia
Amyloidosis
Lymphangectasia
Radiographic String sign
indicative of crohns disease
Whipples disease histology
foamy macrophages in lamina propria
Fecal Fat
x