MALABSORPTION SYNDROME

Hassan Mohammad Al-Shehri

2051040085

To Department of Pathology KFU

Dr. Tariq Hashm

2007-11-26

To other students of KFU 4th year please DO NOT COPY AND PASTE my
assignment. However, you may take general points if you wish and start from there.

Again please do not take the exact content and give it to doctor under your name. cuz

0
I’ll give it to doctor and if u do the same we well take both of us.

If you are not 4th year student at KFU you may do what ever you want with it.

1
 Malabsorption Syndrome

Malabsorption: is inadequate assimilation of dietary substances due to defects in digestion,

absorption, or transport. Malabsorption affects macronutrients (e.g., proteins, carbohydrates, fats) or
micronutrients (e.g., vitamins, minerals), causing excessive fecal excretion and producing nutritional
deficiencies and GI symptoms.

Malabsorption Syndrome: a group of symptoms resulting from disorders in the intestines' ability to
absorb nutrients from foods eaten. It may lead to loss of appetite, weight loss, swollen abdomen,
muscle cramps, bone pain, and fat in the feces. Anemia, weakness, and tiredness can occur because
iron, folic acid, and vitamin B12 are not absorbed in right amounts. Among the many conditions
causing this syndrome are stomach or small bowel surgery, celiac disease, tropical sprue, cystic
fibrosis, Whipple's disease, and intestinal lymphangiectasia, a disease involving the grouping of the
lymph ducts in the intestines.

Pathophysiology:

Digestion and absorption occur in three phases: (1) intraluminal hydrolysis of fats, proteins, and
carbohydrates by enzymes (bile salts enhance the solubilization of fat in this phase) (2) digestion by
brush border enzymes and uptake of end-products; (3) lymphatic transport of nutrients. Malabsorption
occurs when any of these phases is impaired.

Causes:

A) Incomplete digestive process, which may be due to:

- Damage or dysfunction of the pancreas
- Reduction or absence of bile salts to emulsify fats for absorption; this can occur in billiary
obstruction, liver disease or extensive resection of the small bowel
- Excessive transit time, impairing optimal absorption; this can occur in disorders of metabolic rates,
inflammatory bowel disease and even prolonged and excessive stress
B) Faulty absorption of nutrients due to:
- Damage to the absorptive surfaces, as in inflammatory bowel disease and coeliac disease
- Impaired enzyme activity e.g. in lactose intolerance
- Resection of the absorptive surfaces e.g. in inflammatory bowel disease.

The Major Malabsorption Syndromes:

(1) Exocrine Pancreatic Insufficiency (EPI):
It’s the inability to properly digest food due to a lack of digestive enzymes made by the pancreas. EPI
is found in patient afflicted with cystic fibrosis. It is caused by a progressive loss of the pancreatic
cells that make digestive enzymes. Chronic pancreatitis is the most common cause of EPI in humans.
Treatment
Often this is treated with Pancreatic Enzyme Products (PEPs), such as pancrelipase, that are used to
breakdown fats (lipases), proteins (proteases) and carbohydrates (amylases) into units that can be
digested by those with EPI.
(2)Biliary Obstruction:
2
Biliary obstruction refers to the blockage of any duct that carries bile from the liver to the gallbladder
or from the gallbladder to the small intestine. Biliary obstruction separated into:
(I) Intrahepatic
Intrahepatic cholestasis generally occurs at the level of the hepatocyte or biliary canalicular
membrane. Causes include hepatocellular disease (e.g., viral hepatitis, drug-induced hepatitis), drug-
induced cholestasis, biliary cirrhosis, and alcoholic liver disease.
(II) Extrahepatic
Extrahepatic obstruction to the flow of bile may occur within the ducts or secondary to external
compression. Overall, gallstones are the most common cause of biliary obstruction.

(3)Lactose Intolerance:

A disorder characterize by the inability to digest milk sugar (lactose) because of an enzyme lactase
deficiency.

There are three major types of lactose intolerance:

1. Primary lactose intolerance: Environmentally induced by weaning in non dairy consuming
societies. Where industrialized and commercial dairy is uncommon, milk consumption beyond
infancy is not common.
2. Secondary lactose intolerance: Environmentally induced, resulting from certain gastrointestinal
diseases, including exposure to intestinal parasites such as giardia.
3. Congenital lactase deficiency: A genetic disorder which prevents enzymatic production of lactase.
Present at birth, and diagnosed in early infancy.

Symptoms and Signs:

The effects of unabsorbed substances include diarrhea, steatorrhea, abdominal bloating, and gas.
Other symptoms result from nutritional deficiencies. Patients often lose weight despite adequate food
intake.
Chronic diarrhea is the most common symptom. Steatorrhea is the hallmark of malabsorption.
Steatorrhea produces foul-smelling, pale, bulky, and greasy stools.
Severe vitamin and mineral deficiencies occur in advanced malabsorption symptoms are related to the
specific nutrient deficiency.

Treatment:
The diet must be adjusted to restrict such foods as milk, cheese, butter, and any other products
containing milk.

3
(4)Coeliac Disease (Non-Tropical Sprue, Coeliac Sprue):

It’s an autoimmune disorder of the small bowel that occurs in genetically predisposed people of all
ages. Coeliac disease is caused by a reaction to gluten (protein found in wheat).
Upon exposure to gluten, the enzyme tissue transglutaminase modifies the protein, and the immune
system cross-reacts with the bowel tissue, causing an inflammatory reaction. That leads to flattening
of the lining of the small intestine, which interferes with the absorption of nutrients.

Symptoms and Signs:

Classic symptoms of coeliac disease include diarrhea, weight loss (or stunted growth in children), and
fatigue.
Children between 9 and 24 months tend to present with bowel symptoms and growth problems shortly
after first exposure to gluten-containing products. Older children may have more malabsorption-
related problems and psychosocial problems, while adults generally have malabsorptive problems.
Many adults with subtle disease only have fatigue or anemia.

Worth note Tropical Sprue has similar symptoms but it differs in the cause which is unknown.
It has been suggested that it is caused by bacterial, viral, amoebal, or parasitic infection.
Tropical sprue is largely limited to within about 30 degrees north and south of the equator.
Therefore, if one resides outside of that geographical region, recent travel to the region is a key factor
in diagnosing this disease.
Treatment
The only effective treatment is a lifelong gluten-free diet.
Treatment for Tropical sprue: Once diagnosed, tropical sprue can be treated by a course of the
antibiotic tetracycline and vitamins B12 and folic acid for at least 6 months.

(5)Idiopathic Inflammatory Bowel Disease:

Crohn’s disease and ulcerative colitis are chronic relapsing disorders of unknown origin. These
diseases share many common features and are collectively known as idiopathic inflammatory bowel
disease

(I)Ulcerative Colitis (Colitis Ulcerosa, UC):

Ulcerative colitis (UC) is an ulceroinflammatory disease affecting the colon but limited to the mucosa
and submucosa except in the most severe cases. UC begins in the rectum and extends proximally in a
continuous fashion, sometimes involving the entire colon.
Ulcerative colitis is an intermittent disease, with periods of exacerbated symptoms, and periods that
are relatively symptom-free.

Symptoms and Signs:

Patients usually present with diarrhea mixed with blood and mucus, of gradual onset. They also may
have signs of weight loss, and blood on rectal examination. The disease is usually accompanied with
different degrees of abdominal pain, from mild discomfort to severely painful cramps.
Ulcerative colitis is a systemic disease that affects many parts of the body. Sometimes the extra-
intestinal manifestations of the disease are the initial signs, such as painful, arthritic knees in a
teenager. It is, however, unlikely that the disease will be correctly diagnosed until the onset of the
intestinal manifestations.

4
Treatment
Physicians first direct treatment to inducing a remission which involves relief of symptoms and
mucosal healing of the lining of the colon and then longer term treatment to maintain the remission.

(II)Crohn's Disease (Regional Enteritis, CD):

It is one of a group of diseases called inflammatory bowel disease. The disease can affect any area
from the mouth to the anus; as a result, the symptoms of Crohn's disease vary between affected
individuals (often affects the ileum).
Although the cause of Crohn's disease is not known, it is believed to be an autoimmune disease that is
genetically linked.

There are three major classes of Crohn’s disease:

1. Ileocolic Crohn's: Disease, which affects both the ileum and the large intestine, accounts for 50%
of cases
2. Crohn's Ileitis: Affecting the ileum only, accounts for 30% of cases, and
3. Crohn's Colitis: Affecting the large intestine, accounts for the remaining 20% of cases

Symptoms and Signs:

Abdominal pain may be the initial symptom of Crohn's disease. It is often accompanied by diarrhea,
which may or may not be bloody. Flatus and bloating may also add to the intestinal discomfort.

Treatment:
Treatment is only needed for people exhibiting symptoms. The therapeutic approach to Crohn's
disease is sequential: to treat acute disease and then to maintain remission.
Once remission is induced, the goal of treatment becomes maintaining remission and avoiding flares.
Surgery may be required for complications such as obstructions, fistulas and/or abscesses, or if the
disease does not respond to drugs within a reasonable time.

Comparison between Crohn’s disease and Ulcerative colitis:

Feature Crohn’s Ulcerative Colitis

Involves terminal ileum Commonly Seldom

Involves colon Usually Always

Endoscopy Linear and serpiginous Continuous ulcer

(snake-like) ulcers

Depth of inflammation May be transmural, deep into Shallow, mucosal

tissues

Fistulae Commonly Seldom

Surgical cure Often returns following Usually cured by removal of colon,

removal of affected part can be followed by pouchitis

(Inflammation of the ileal pouch)

Smoking Higher risk for smokers Lower risk for smokers

5
Cancer risk Lower Higher

(6)Small Bowel Resection:

Small bowel resection may be recommended for the following:

• A block in the intestine due to scar tissue or deformities
• Bleeding, infection, or ulcers due to inflammation of the small intestine (e.g. Crohn's disease)
• Injuries
• Cancer
• Precancerous polyps
• Benign tumors
List of Common Malabsorped Elements and their Symptoms:

Malabsorbed Nutrient Symptom

Iron Anemia (hypochromic, microcytic)

Vitamin B12, folate Anemia (macrocytic)

Vitamins K and C Bleeding, bruising, petechiae

Ca, Mg Carpopedal spasm

Protein Edema

Vitamins B2 and B12, Glossitis

folate, iron

Vitamin A Night blindness

K, Mg, Ca, vitamin D

Vitamins B1, B6, B12

Peripheral neuropathy

6
READ CARFULLY!
To other students of KFU 4th year please DO NOT COPY AND PASTE my
assignment. How ever, you may take general points if you wish and start from there.
If you are not 4th year student at KFU you may do what ever you want with it.