Malabsorption And Cronic Diarrhea Flashcards
MALABSORPTION
Malabsorption can result from a defect in the nutrient
digestion in the intestinal lumen or from defective
mucosal absorption. Maldigestion: Defective intraluminal hydrolysis of
nutrients. Impaired breakdown of nutrients - Carb → mono , di , oligosaccharides - Protein → amino acids , oligopeptides - Fat → fatty acids , monoglycerides Malabsorption: Defective mucosal uptake and
transport of digested nutrients , vit , minerals.
Causes
Carbohydrate malabsorption
Carbohydrate malabsorption Pancreatic insufficiency (amylase) Absence or reduction of the brush border disaccharidases . Transient reduction of these enzymes is common after an infection. Lack of sucrase and isomaltase. Congenital lactase deficiency A congenital deficiency in the glucose galactose transporter (SGLT-1) Small bowel bacterial overgrowth of normal flora
Fat malabsorption
Exocrine pancreatic insufficiency(Pancreatitis,
pancreatic cancer, pancreatic resection, cystic
fibrosis, Schwachman-Diamond syndrome, Johnson-
Blizzard syndrome, Impaired bile production or secretion Abetalipoproteinemia
Protein malabsorption
exocrine pancreatic enzyme deficiency, as occurs in
patients with cystic fibrosis.
congenital enterokinase deficiency is well-described
but rare.
Creatorrhea (ie, protein-losing enteropathy), is often
caused by the leakage of protein from the serum due
to inflammation of the mucosa, as in Crohn disease,
celiac disease, and protein sensitivity syndromes.
Congenital lymphangiectasia
Cp of malabsorption
Clinical Presentation Malabsorption may involve: – a broad range of nutrients i.e. panmalabsorption. – only a single nutrient or a class of nutrients i.e. specific malabsorption. Symptoms and signs of the disease depend on the deficiency of the nutrient(s) that is malabsorbed. -Steatorrhea: bulky, floating, malodorous stool-difficult to flush. - Weight loss. Diffuse abdominal pain. - Flatulence. Symptoms of anemia. - Weakness and fatigue. Bone aches. - Paresthesia. Abnormal bruising. - Tetany. Milk intolerance. - Night blindness. Amenorrhea & infertility. Symptoms
Signs of malabsorption
Signs
Pallor. Glossitis, stomatitis, cheilosis. Clubbing. Ecchymosis and purpura. Dermatitis. Dehydration and hypotension. Abdominal distention Edema. Peripheral neuropathy. Perianal excoriation
Malabsorption hx and PE
Approach and management
History GI tract symptoms: Stool characteristics: Diet history: Other symptoms:(Systemic symptoms:weakness, fatigue, and failure to
thrive, past medical history family history (especially for systemic and gastrointestinal conditions), medications , surgeries radiation exposure/treatments, caustic substance ingestion , allergies social history
Physical examination
Physical exam should include a full abdominal examination
hyper/hypoactive bowel sounds, abdominal distention, abdominal
tenderness
pallor muscle wasting,
abnormal deep tendon reflexes, skeletal deformities,
rashes, cardiac arrhythmia, Ecchymosis poor wound healing, , decreased visual acuity peripheral neuropathy , auditory disturbances, or cognitive impairment failure to thrive
Malnutrition delayed puberty.
Borborygmi, a significant increase in peristaltic activity
Dehydration
Malabsorption labs
Stool analysis reducing substances, pH , stool bile acids, quantitative stool fat, large serum proteins, ova and parasites, Testing for other chronic intestinal infections (Clostridium difficile, Cryptosporidium species)
Urinalysis: CBC Total serum protein and albumin levels fat-soluble vitamin levels levels of the low-density lipoprotein (LDL) cholesterol ESR& C-reactive protein level liver function tests &RFT +Electrolytes
Iron ,Magnesium , Zinc ,Phosphorous
Immunoglobulin G (IgG) and immunoglobulin A (IgA) antigliadin and IgA antiendomysial antibodies, or especially tissue transglutaminase antibodies
Imaging of malabsorption
Imaging
Computed tomography (CT): Pancreatitis Magnetic resonance cholangiopancreatography (MRCP):Exocrine pancreatic
insufficiency Magnetic resonance (MR) elastography: liver stiffness, liver fibrosis, hepatic
amyloidosis, and other conditions that increase liver stiffness. Endoscopic retrograde cholangiopancreatography (ERCP):Pancreatic insufficiency
- Crohn disease - visualized duodenal mucosa cobblestoning.
Endoscopy with biopsy (indicated for diagnoses that require both visualization
and biopsy): - Celiac disease - visualized reduced duodenal folds or mucosal scalloping.
Treatment & Management
Of malabsorption
Medical Care (antibiotics, cholestyramine(bile acid malabsorption) oral supplements( loss of pancreatic enzymes), Immunosuppressive medications, elimination diet) Surgery ? Diet Associated symptoms: Fever Vomiting Pain Distention Jaundice Concurrent problem: Joint pain and swelling skin rash dysphagia oral ulcer perianal fistula
Osmotic diarrhea
Osmotic diarrhea is caused by nonabsorbed nutrients in the intestinal
lumen as a result of one or more of the following mechanisms: (1)intestinal damage (e.g., enteric infection); (2) reduced absorptive surface area (e.g., active celiac disease); (3) defective digestive enzyme or nutrient carrier (e.g., lactase deficiency) (4) decreased intestinal transit time (e.g., functional diarrhea); (5) nutrient overload, exceeding the digestive capacity (e.g., overfeeding, sorbitol in fruit juice).
Etiology of chronic diarrhea
Infection o E-coli ◦ Giardia lamblia ◦ Entamoeba histolytica ◦ Cryptosporidium parvum Inflammatory ◦ Cow milk protein intolerance ◦ Food allergy ◦ IBD Malabsorption ◦ Celiac disease ◦ Cystic fibrosis ◦ Bacterial overgrowth ◦ Short bowel syndrome ◦ Defective sodium absorption ◦ Congenital chloride losing diarrhea ◦ Bile deficiency or chronic cholestasis Osmotic Lactase deficiency (Primary or Secondary post- infectious) Excessive fructose intake Laxative overuse Others Toddler diarrhea (functional diarrhea) Endocrinal e.g., thyrotoxicosis Immunodeficiency Neoplastic e.g., neuroblastoma
Hx of chronic diarrhea
◦ When did it start? Duration? ◦ What is the patient usual bowel habit? ◦ Consistency? Frequency? Volume of stool? ◦ Are the lose motion interspersed by normal ones? ◦ Content: Undigested food? Blood? Mucous? fatty? ◦ Foul smelling?
◦ previous similar attack? ◦ Contact with sick patient? ◦ Antibiotic use? ◦ Travelling? ◦ Oral intake? Weight loss? Activity? ◦ Urine output?
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◦ Past medical history: Antenatal history in detail (prenatal U/S, NICU admission and course, neonatal screening).
recurrent infections
previous hospitalization ◦ Past surgical:
bowel resection
congenital GIT anomalies repaired ◦ Medications:
laxative or antibiotics ◦ Allergy: cow milk
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o Nutritional history in detail (fructose, lactose, gluten,
carbonated drinks, water source) o Family history
Consanguinity
Similar case in the family
Immunodeficiency
Celiac disease
IBD
o Social history (any stress at home or school).
Complete physical examination
In chronic diarrhea
Complete physical examination
◦ General, start with GIT then other systems ◦ Examine stool
Cronic diarrhea examination
Hydration status
Weight and height should be measured and put on the appropriate
charts. • Weight loss is seen in many disorders like CF, Coeliac disease, IBD. weight and height are usually normal in toddlers diarrhoea.
• Pallor - CF, Coeliac disease.
• Fever- Infection, TB, CF and HIV.
• Clubbing- CF
Hyperpigmentation- Addison’s disease, Celiac
disease • Generalized lymphadenopathy- Lymphoma, HIV. • Stomatitis and Perianal fistula- Crohn’s disease. • Hepatomegaly -lymphomas, metastatic carcinoid,
IBD. • Ascites - TB and lymphoma Poor weight gain or weight loss. • Signs of systemic diseases like fever, rash and
arthritis.
