Malabsorption

- It is a state arising from abnormality in absorption of food nutrients across the

gastrointestinal tract(GIT).
-Impairment can be of single or multiple nutrients depending on the abnormality.
-This may lead to malnutrition and a variety of anaemias.
Pathology
- Malabsorption constitutes the pathological interference with the normal
physiological sequence of digestion (intraluminal process), absorption
(mucosal process) and transport (postmucosal events) of nutrients.
- Intestinal malabsorption can be due to:
o digestive failure caused by enzyme deficiencies
o structural defects
o mucosal abnormality
o infective agents
o systemic diseases affecting GI tract
Symptoms

Diarrhoea
Decreased weight
Lethargy
Steatorrhea (stool fat increased; hard to flush away) due to impaired water,
carbohydrate and electrolyte absorption
Bloating, flatulence, abdominal discomfort
Growth retardation in children
Swelling or edema from loss of protein
Anemias commonly from vit B12, folic acid and iron deficiency presenting as
fatigue and weakness
Muscle cramp from decreased vit D and calcium absorption. Can lead to
osteomalacia and osteoporosis
Bleeding tendencies from vit K and other coagulation factor deficiency

Deficiency signs

Anemia - iron, B12, folic acid

Bleeding disorders - vitamin K
Oedema - low protein
Metabolic bone disease - vitamin D
Neurological features e.g. neuropathy

Causes

Celiac disease

Chronic pancreatitis
Chron's disease

Decreased bile

Pancreatic
insufficiency
Small bowel mucosa

Bacterial overgrowth

Infection

Intestinal hurry

Primary biliary cirrhosis

ileal resection
Biliary obstruction
Colestyramine
Pancreatic cancer
Cystic fibrosis
Whipple's disease
Tropical sprue
Radiation enteritis
Small bowel resection
Brush border enzyme deficiencies e.g. lactase insufficiency
Drugs - metformin, neomycin, alcohol
Amyloid
Spontaneous
In jejunal diverticula
Post op blind loops
PPI treatment and DM are also risk factors
*Try metronidazole or oxytetracycline
Giardiasis
Diphyllobothriasis - Diphyllobothrum latum
Strongyloidiasis
Post gastrectomy dumping
Post vagotomy
Gastrojejunostomy

Due to digestive failure

a) Pancreatic insufficiencies

b) Bile salt insufficiency

Due to structural defects

a) Small bowel mucosa

Cystic fibrosis
Carcinoma pancreas
Chronic pancreatitis
Obstructive jaundice
Primary biliary cirrhosis
Colestyramine
Ileal resection
Inflammatory bowel diseases
Whipple's disease
Tropical sprue
Radiation enteritis
Small bowel resection
Brush border enzyme deficiencies e.g.
lactase insufficiency

Drugs - metformin, neomycin, alcohol

Amyloid
Post gastrectomy dumping
Post vagotomy
Gastrojejunostomy

b) Intestinal hurry

Due to mucosal abnormality

Due to enzyme insufficiencies

Due to infective agents

Due to other systemic diseases affecting

GI tract

Bacterial overgrowth

Celiac disease
Lactase deficiency including lactose
intolerance
Disaccharidase deficiency
Enteropeptidase deficiency
Whipples disease
Giardiasis
Diphyllobothriasis - Diphyllobothrum
latum
Strongyloidiasis
Intestinal TB
Hypothyroidism and hyperthyroidism
Diabetes mellitus
Hyperparathyroidism and
hypoparathyroidism
Carcinoid syndrome
Malnutrition
Spontaneous
In jejunal diverticula
Post op blind loops
PPI treatment and DM are also risk
factors
*Try metronidazole or oxytetracycline

Deficiency syndromes and sites of nutrient malabsorption

Vitamin
A
B1
thiamine
B2
Riboflavin
B6
Pyridoxine
B12
C

Site of
absorption
SI
SI

Deficiency syndrome

Proximal SI

Angular stomatitis, cheilitis

SI

Polyneuropathy

Terminal ileum
Proximal ileum

Macrocytic anemia, neuropathy, glossitis

Scurvy

Xerophtalmia
Beri beri, Wernicke's encephalopathy

D
E
K
Folic acid
Nicotinami
de
Mineral
Calcium
Copper
Fluoride
Iodine
Iron
Magnesiu
m
Phosphate
Selenium
Zinc

Jejunum
SI
SI
Jejunum
Jejunum

Rickets, osteomalacia
Hemolysis, Neurological deficit
Bleeding disorders
Macrocytic anemia
Pellagra

Site of
absorption
Duo + jejunum
Stomach +
jejunum
Stomach
SI
Duo + Jejunum
SI

Deficiency syndrome

SI
SI
Jejunum

Osteoporosis, anorexia, weakness

Cardiomyopathy
Acrodermatitis enterohepatica, poor wound healing

Hypocalcemia
Menkes' kinky hair syndrome
Dental caries
Goitre, cretinism
Microcytic anemia
Hypomagnesemia

Investigations

FBC
Calcium
Iron
B12 and folic acid
INR
Lipid profile

Celiac tests (see below)

Stool
o Sudan stain for fat globules
o Stool microscopy (infestation)
o alpha I antitripysin
o Elastase
Barium follow through
o Diverticula
o Chron's
o Radiation enteritis
Breath hydrogen analyser
o For bacterial overgrowth
o Take samples of end expired air
o Give glucose, take more samples at 30mins interval
o increased exhaled hydrogen = overgrowth
Endoscopy and small bowel biopsy, ERCP

o Biliary obstruction
o Chronic pancreatitis
Tropical sprue
Giardia lamblia, Cryptosporidum parvum, Isospora bellim Cyclospora
cayetanensis, Microsporidia
Villous atrophy plus malabsorption occuring in Far and Middle East and
Carribean - cause is unknown
Tetracycline + folic acid + optimum nutrition

Celiac disease

Suspect in all with diarrhoea + weightloss/anemia

T cell mediated autoimmune disease of the small bowel in which prolamin
(alcohol soluble proteins in wheat, barley, rye oats) intolerance causes
villous atrophy and malabsoption
associated with HLA DQ2, autoimmune disease, dermatitis herpetiformis
Occurs at any age - peak in infancy and 50-60 years, M=F
10% prevalence in 1st degree relatives and 30% relative risk for siblings
Presentation
Steatorrhea
Diarrhoea
Abdominal pain
Bloading
N&V
Apthous ulcers
Angular stomatitis
Loss of weight
Fatigue and weakness
Iron deficiency anemia
Osteomalacia
Failure to thrive in children
1/3 are asymptomatic
Diagnosis
antibodies : -gliadin, transglutaminase and anti endomysial - an anti IgA
antibody
Duodenal biopsy done at endoscopy
o Subtotal villous atrophy
o Increased intraepithelial WBC and crypt hyperplasia
Reversing on gluten free diet (along with decrease symptoms and antibodies)
Exclude celiac disease in any patient with suspected IBS
Treatment
Lifelong gluten free deit
Rice, maize, soya, potatoes, oats, sugar are OK
Gluten free biscuits, flour, bread and pasta are prescribable

 Verify diet by endomysial antibody tests

Complications
Anemia
Secondary lactose intolerance
GI T cell lymphoma (rare)
Icnreased risk of malignany (gastric, esopageal, bladder, breast, brain)
Myopathies
Neuropathies,
Hyposplenism
Osteoporosis