MALABSORPTION SYNDROME INTRODUCTION

Malabsorption is the failure of the body to properly absorb vitamins, minerals, and other nutrients from food. Even though his or her diet is adequate, an individual with mal absorption develops various nutritional deficiencies. This problem can result from impaired digestion, impaired absorption of nutrients into the bloodstream from the digestive tract (especially the small intestine), or both.

MEANING
Malabsorption is a condition in which the intestinal mucosa ineffectively absorbs nutrients-including carbohydrates, proteins, fats, water, electrolytes, minerals and vitamins--resulting in their excretion in the stool. Multiple bowel disorders can lead to malabsorption.

CAUSES
The etiological factors can be classified into the following: a) Biochemical or enzyme deficiencies  Lactase deficiency  Billiary tract obstruction  Pancreatic insufficiency  Cystic fibrosis  Zollinger Elison syndrome b) Bacterial proliferation  Tropical sprue  Parasitic infestations c) Small intestinal mucosal disruption  Celiac disease  Whipple¶s disease  Chron¶s disease d) Disturbed lymphatic and vascular circulation  Lymphoma  Ischemia  Lymphangiectasia  Heart failure e) Surface area loss  Billiroth II gastrotomy

Vit A deficiency  Integumentary system y Bruising²Vitamin K deficiency y Dermatitis²fatty acid. disease or bypass CLINICAL MANIFESTATIONS  Gastrointestinal system y Weight loss ± malabsorption of CHO. sodium or bile y Flatulence²bacterial fermentation of unabsorbed CHO y Steatorrhea²major symptom. fat and proteins y Diarrhea²impaired absorption of fat. Short Bowel Syndrome and Gastrointestinal Stormal Tumor etc.chelosis²deficiency of iron. K deficiency  Musculoskeletal system y Bone pain²impaired absorption of calcium. inadequate Vit D y Tetany²hypocalcemia. . cobalamin. water. Lactose Intolerance. undigested and unabsorbed fat. stomatitis. anaemia y Peripheral edema²protein malabsorption Some common malabsorption disorders in adults are Sprue. Short bowel syndrome  Distal illeal resection. cobalamin and folic acid y Hemorrhage²Vitamin C. Zinc deficiency y Brittle nails-. electrolyte depletion  Neurologic system y Altered mental status²dehydration y Paresthesia²cobalamin deficiency y Peripheral neuropathy²cobalamin deficiency y Night blindness²thiamine deficiency. y Glossitis. weakness²anaemia. hypomagnesemia y Muscle cramps. folic acid  Hematologic system y Anaemia²impaired absorption of iron.iron deficiency y Hair thinning and losing²protein deficiency  Cardiovascular system y Hypotension²dehydration y Tachycardia²hypovolumia.

A) THE CLIENT WITH SPRUE Sprue is a chronic primary disorder of small intestine in which the absorption of nutrients. including sore tongue. barley and oats. genetic factors. particularly fat is impaired. The gluten is found in wheet. rye. In immune response. Sprue is characterized by the flattening of the intestinal mucosa with a loss of villi and microvilli. When the disorder becomes chronic. Diagnostic Methods  Enteroscopy: permits the examination of intestinal mucosa and collection of tissue specimen for biopsy. although bacterial infection or toxins are thought to be contributing. TROPICAL SPRUE It is a chronic disease of unknown origin. The cells of villi are covered with microscopic hairs. The mucosa of the small intestine is arranged in microscopic folds. Pathophysiology: Most absorption of nutrients occurs in the small intestine. ankle edema. stomatitis etc are common. The pathophysioigic changes in bowel mucosa closely resemble those of celiac sprue. Manifestations: There is diarrhea. glossitis. the intestinal absorptive surface is lost and digestive enzyme production is also decreased. Gliadin acts as an antigen prompting the formation of antibodies and immune complexes. Gluten may directly damage the villi . abdominal distention. prompting an inflammatory response and lose of villi. short stature and delayed maturity. systemic manifestations include anemia. the features of megaloblastic and other deficiencies. fatigue and weight loss). environmental and immune response. It is an immunologically mediated inflammatory disorder. anorexia. which inturn contain even smaller finger like projections called villi. tetany. muscle wasting and rickets Complication: intestinal ulcer. These complexes may deposit in the intestinal mucosa. although gluten intake has no effect on this condition. called microvilli. Two major forms of sprue are celiac disease and tropical sprue. With the loss of villi. Manifestations: local manifestations include abdominal bloating and cramps. . a cereal protein. CELIAC SPRUE Celiac sprue also known as celiac disease is a chronic malabsoption disorder characterized by sensitivity to gliadin fraction of gluten . Remissions and relapse may occur. Vitamin deficiency. diarrhea and steatorrhea. Causes: unknown. intestinal lymphoma.

y Corticosteroids are used to suppress the inflammatory reactions. albumin. Barium X-ray: the typical feathery pattern in the small bowel is lost and the barium may precipitate and clump. hematocrit. muscle wasting. Interventions: Assess and document the frequency and nature of stools. y Fat content is restricted to minimize steatorrhea. Weigh the patient daily. Encourage a liberal fluid intake. Steatorrhea is suspected if it is more than 10g of fat per 24 hours. The regimen is continued for 1-2 months. Nutrition: y The client is advised to follow gluten free diet. Nursing diagnosis: 1) Impaired bowel elimination. assess for the abdominal shape. Assess and document perineal skin condition. RBC and Prothrombin time. cholesterol.  Fecal fat is measured to rule out steatorrhea. mineral supplements as well as iron and folic acid to correct anaemia. .  Serological testing is done for Ig A and Ig G antibodies. and severity of manifestations. y Prescribe the diet high in calorie and protein to make up the deficiency. 2) Imbalanced nutrition less than body requirement related to impaired absorption of nutrient elements.  Assess the Hb. electrolyte and iron is done to evaluate nutritional deficiency. duration.  Serum level of protein. manifestations of malnutrition such as small stature. contour. Monitor the intake and output and assess for skin torpor and mucous membrane for signs of dehydration. Nursing Care: Nursing assessment: Assess for the onset. diarrhea related to impaired absorption of fluid and electrolyte. y Tropical sprue may be treated with a combination of folic acid and tetracycline. Monitor the vital signs. Treatment Modalities Drug therapy: y Administer vitamin. Interventions: Maintain accurate dietary intake records.

3) Knowledge deficit regarding the management and prevention of disease process related to lack of exposure to information sources. and serum electrolyte and protein level. Interventions: Assess the level of understanding of the disease process. Encourage to take nutrient supplements.Monitor the laboratory results.  Secondary to celiac sprue. . Provide for food preference as well as nutrient intake. baked goods including cookies. CAUSES:  Usually genetic in origin. Deficiency in this enzyme can leads to lactose intolerance and manifestations of malabsorption. Lactase is the enzyme that breaks down lactose (primary carbohydrate in milk and milk products) into two simple sugars²glucose and galactose. gluten free diet for the client with celiac sprue. rye. bread. pies. Provide the prescribed high calorie. Include family members in teaching and dietary discussion. baggies. wheats. oats. including hemoglobin. irritable bowel syndrome. pizza. Encourage the patient to purchase and use a gluten free cookbook B) THE CLIENT WITH LACTASE DEFICIENCY Lactase deficiency is a condition in which the enzyme lactase is deficient or absent. Eg: barley. Provide parental nutrition as ordered.  Premature birth  Congenital lactase deficiency  Common in the ethnic groups of Asians. cakes. chron¶s disease. African Americans and Native Americans. flour. its management and the ways to prevent. Provide a detailed list of foods that contains gluten and to be avoided. high protein. it should be broken down into simple sugars. if the client is unable to absorb enteral feed. PATHOPHYSIOLOGY For carbohydrates to be absorbed from the small intestine. pasta. gastroenteritis (disorders affecting small intestine). Restrict the lactose (dietary) intake as indicated. Lactose is a primary carbohydrate in milk and milk sugars that requires enzyme lactase for its absorption and digestion. Emphasis the need to avoid stopping the medication abruptly. Arrange for dietary consultation. low fat. hematocrit.

TREATMENT MODALITIES  Primary intervention is the avoidance of lactose containing food such as milk and milk products from the diet. If lactose is digested and absorbed normally. 120 minutes. exhaled hydrogen increases following lactose administration as the sugar ferments in the bowel. legumes and calcium like sardines. NURSING CARE  Inform the family members and the patient about the importance of adhering to the dietary restrictions.CLINICAL MANIFESTATIONS     Asymptomatic ( in some cases) Lower abdominal cramping. oyster. beans. and green leafy vegetables. With lactose intolerance. ice cream. eggs. Expired hydrogen gas is measured following oral administration of 50 gm of lactose.  Inform about the food that has to be avoided like milk. cottage cheese. gravies and cream soups  Suggest a trial of lactase ±treated milk or lactase enzyme supplements. pain and diarrhea following ingestion of milk. sauces. Bloating and flatus (due to undigested lactose fermentation) Severe diarrhea (the undigested lactose draws water into the intestine which increases the gastric motility.  Calcium supplementation should be provided to compensate for the dietary restriction of milk products. 100 gm of lactose sodium is administered orally. The expected blood glucose elevation does not occur in lactose intolerance.  Non prescription lactase enzyme preparations are available to improve milk tolerance. the blood glucose rises more than 20 mg/dl. cauliflower.  Emphasis the importance of obtaining nutrients contained in dietary products from other sources.) DIAGNOSTIC METHODS Lactose breath test: The lactose breath is a non invasive test that may be used to diagnose lactase intolerance. If lactose is digested and absorbed normally. followed by measurement of blood glucose levels at intervals of 30.  Teach the patient about the importance of adhering to the dietary restriction. Lactose tolerance test: For the lactose tolerance test. then little change occurs in the amount of exhaled hydrogen from fasting to post lactose administration.  Inform about other source of proteins like meats. 60. .

the amino acid glutamine and parenteral growth hormone are recommended. cobalamin & zinc deficiency. It results from surgical resection. For many clients bowel function comes to near normal stage and in many experiences continued impairment in digestion.C) THE CLIENT WITH SHORT BOWEL SYNDROME Resection of significant portion of the small intestine is termed as short bowel syndrome.  For patients with severe malabsorption parentral nutrition is recommended. congenital defects or disease related to loss of absorption such as tumors. The remaining portion of the bowel undergoes an adaptive process in which the existing villi and crypts increase in size and the absorbing capacity is increased. vitamins and minerals. Chron¶s disease. iron. .  Proton pump inhibitors are used to decrease gastric secretions. infarction of bowel mucosa.  Bile acids stimulates intestinal fluid secretion and reduces colonic fluid absorption.  Antidiarrheal medications are used to reduce bowel motility. Transit time of ingested food and fluid is reduced and the digestive process is impaired. TREATMENT MODALITIES  Multivitamin and mineral supplementation is frequently necessary.  The patients with SBS are encouraged to eat at least six meals per day to increase the contact with the food and intestine. CLINICAL MANIFESTATIONS Diarrhea. nutrients. vitamins. pectin. steatorrhea Signs of malnutrition and multiple vitamin deficiency ( weight loss.  A diet rich in carbohydrate and low in fat supplemented with soluble fiber. PATHOPHYSIOLOGY Resection of the small intestine affects the absorption of the water. minerals and electrolytes. folate.  Anemia and prolonged prothrombin time may develop. The severity of the disorders depends on the total amount of bowel resected and the total portion of bowel removed. hypocalcaemia) May develop lactase deficiency and bacterial overgrowth Oxalate kidney stones ( increased absorption of oxalate from the colon) DIAGNOSTIC METHODS  Assess serum level of proteins (albumin).

Macrocytic anemia is due to the cobalamine deficiency. Urinary elimination of cobalamine will reflect the cobalamine absorption provided that intrahepatic binding sites for cobalamine are fully occupied. To ensure saturation of hepatic cobalamin binding sites so that all absorbed radio labeled Cobalamin will be excreted in urine. ETIOLOGY: y y y y y One or more diverticula Fistulas and strictures related to chorn¶s disease.  Barium enema shows any blind loops or fistula. . 1 mg cobalamine is administered IM following 1 hr of oral ingestion. they use up the relatively small amount of cobalamine and results in deficiency. A proximal duodenal afferent group following a subtotal gastrectomy and gastrojejunostomy. Schillings test It is performed by administering Co-labeled cobalamine orally and collecting urine for 24 hour. PATHOPHYSIOLOGY The manifestations are due to the increased presence of colonic ± type bacterial flora such as E. Steathorea is due impaired micelle formation because of the presence of increased unconjugated bile acids and reduced conjugated bile acids.  The bacterial overgrowth can be best identified by schillings test and lactase breath test. chronic pancreatitis. This condition is also called as stagnant bowel syndrome or blind loop syndrome. The Schilling test may be abnormal (usually defined as <10 % excretion in 24 hour) in pernicious anemia. As most of the bacteria requir cobalamin for their growth. Intestinal bypass(jejunoilleal) Dilatation at the site of previous intestinal anastamosis. This bacterial proliferation is due to the stasis caused by the impaired peristalsis and changes in the intestinal anatomy. DIAGNOSIS:  Blood studies shows low cobalamine level and elevated serum folate level. steathorea and macrocytic anaemia whose common feature is the proliferation of colonic type bacteria within the small intestine. blind loop syndrome and illeal disease.coli or Bacteroides.D) CLIENT WITH BACTERIAL OVERGROWTH SYNDROME Bacterial overgrowth syndrome consists of a group disorder with diarrhea.

arthralgia and central nervous system and cardiac problems. dosing schedule and the concomitant chemotherapy. Diagnosis: tissue biopsies²the presence of PAS(periodic acid Schiff) reagent positive macrophages containing characteristic small bacilli is suggestive of this diagnosis.  Metranidazole 400 mg 8 hourly or ciprofloxacin 250 mg 12 hourly is an alternative. weight loss. E) CLIENT WITH WHIPPLES DISEASE It is a chronic multi-system disorder which is associated with diarrhea. sigmoid colon and terminal ileum are frequently affected. steatorhea. E) CLIENT WITH RADIATION ENTERITIS Intestinal damage occurs in 10-15% of patients undergoing radiotherapy for abdominal or pelvic malignancy. It is caused by bacteria Tropheryma whipplei. Low grade fever may also present. steatorhea.  Surgical resection of anatomical blind loop. Antibiotics for the bacterial growth. shortening of villi. .Treatment Modalities  Tetracycline 250 mg 6 hourly for seven days is the drug of choice. Colestyramine is used for the absorption of bile salts. Barium follow through examination reveals small bowel stricture. Management: antidiarrhoeals are administered in case of diarrhea. Clinical manifestations: The onset is insidious and characterized by diarrhea. ulcers and fistula. In case of rectal involvement there will be bleeding and tenesmus. vomitting. Management: it includes the prolonged use of antibiotics like Trimethoprim or Sulfamethazole for approximately 1 year. cramping and abdominal pain. weight loss. Clinical manifestations: nausea. Radiation causes acute inflammation. edema and abscess formation. Nutritional supplements are given in case of malabsorption. The risk varies with dose. In later stage patient may develop dementia. arthralgia and central nervous system and cardiac problems. Pathophysiolgy: the rectum. Diagnosis: mainly by sigmoidoscopy and colonoscopy.  Intra-muscular vitamin B12 supplementation is given in chronic cases.

K. small intestine or colon. PATHOPHYSIOLOGY € Disrupting the normal function of epithelial cells ² cells that make up liver.  Later manifestations include GI bleeding and obstruction caused by growth of tumor. CLINICAL MANIFESTATIONS:  The manifestations of GISTs depends on the part of GI tract affected. € Sometimes surgery is needed to remove an intestinal blockage . E. Sunitinib F) CLIENT WITH CYSTIC FIBROSIS Cystic fibrosis (CF) is a genetic disorder that particularly affects the lungs and digestive system.E) CLIENT WITH GASTROINTESTINAL STROMAL TUMORS Gastrointestinal stromal tumors are the most common mesenchymal tumors in the GI tract. pancreas. DIAGNOSIS: Mainly based on the histological examination of the biopsied tissue.  Early symptoms include satiety and bloating. A familial tendany is found in the occurrence of GISTs. and digestive systems € Increased production of mucus. GISTs can involve the stomach. Endoscopic ultrasound is used to determine the extent of tumor. TREATMENT:The main treatment is surgery. € Mucus-thinning medicines to treat intestinal blockages. D. CLINICAL FEATURES € Steatorrhea € Flatulence or foul-smelling flatus € Recurrent abdominal pain € Abdominal distention TREATMENT € Supplements of vitamins A. Chemotherapeutic drugs: Imatiib.

Linton AD. Fauci AS. and failure to thrive. Hinkle LJ. 2004. Assessment of the diagnostic value of duodenal bulb histology in patients with celiac disease. 2008 5. 2. 2010 Apr. Journal of clinical gasteroenterology. 2009 Apr.4th Edition. Newdelhi: Lippincot . Journal of clinical gasteroenterology. Bare BG. Green HR. that affect one or more of the different steps in the intestinal hydrolysis and subsequent transport of nutrients. Pradeep SB.CONCLUSION Malabsorption syndromes encompass numerous clinical entities that result in chronic diarrhea. 2005. Principles of Harrison¶s internal medicine. Introduction to Medical surgical nursing. 3. Thappa BR. Clinical malabsorption can be broken down into several distinct conditions. 8th Edition.11th Edition. London: Mc Graw Hill Publications. Body mass index in celiac disease-beneficial effect of a gluten free diet. Smeltzer SC.Hawks HJ. using multiple biopsy sites. Prasad KK. Lomgo DL. BIBLIOGRAPHY 1. 17th Edition. Cheng J. 4. Text book of medical surgical nursing. Nain CK. Black MJ. both congenital and acquired. Kasper DL.et al.Medical surgical n ursing. 43(4): 307-11 . New Delhi: Saunders Elsevier. Lee AR. Missouri: Saunders Publications. 44(4): 267-71 6.2007. abdominal distention.

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