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Prof. Saleh M. Al-Amri
Consultant, Gastroenterology Unit
College of Medicine & K.K.U.H.
King Saud University

This occurs when the normal digestion and absorption
.of food is interrupted
:Is divided intoA) Intraluminal stage
Impaired hydrolysis and solubilization of nutrients
. in the small intestine

:Impaired fat absorption) 1
i) Pancreatic lipase is necessary for triglyceride
hydrolysis in duodenum.
Pancreatic enzyme deficiency leads to fat malabsorption.
ii) Inactivation of pancreatic lipase by low gastric luminal
pH – fat malabsorption.
iii) Interruption of enterohepatic circulation of bile salt –
impaired micelle formation – fat malabsorption.
Absorption of fat soluble vitamins may be impaired as well.

:Impaired carbohydrate absorption) 2 Most diseases that causes carbohydrate malabsorption do so by affecting intestinal stage. oligosaccharides . But amylase catalyse hydrolysis of starch to .

:Impaired protein absorption) 3 . pancreatic resection Protein malnutrition - . chymotrypsin Deficiency of pancreatic proteases – impaired . Hydrolysis of polypeptides occurs mainly in small intestine by action of pancreatic enzyme trypsin. protein absorption : Diseases like Chronic pancreatitis Cystic fibrosis Ca.

Congenital or acquired .Abnormalities of small intestinal mucosa) 1 Lactase deficiency e.Result – malabsorption of lactose Acquired:.g.i) Coeliac disease ii) Crohn’s disease iii) Infective enteritis .B) Intestinal stage .

malabsorption of many nutrients e.:Impaired epithelial cell transport) 2 Many diseases cause loss of intestinal surface area . i) Coeliac disease ii) Tropical spure iii) Extensive surgical resection iv) Drugs - .g.

:C) Lymphatic transport Lymphatic obstruction – fat malabsorption e.g. i) Intestinal lymphangiectasia iii) Tuberculous enteritis iv) Intestinal lymphoma .

deficiency . i) Vitamin B12 malabsorption if intrinsic factor is . gastrectomy.D) Decreased availability of ingested nutrients and cofactors for absorption.g.ii) Bacterial overgrowth –can bind B12 iii) Patient infected with fist tapeworm – B12 . antiparietal cell Ab . e.deficient.

difficult to flush Weight loss – may be profound.CLINICAL MANIFESTATIONS :History Diarrhea/steatorrhoea Weight loss Symptoms of anaemia Diarrhoea – bulky. folate malabsorption. usually associated . dyspnoea and . floating. with anorexia Anaemia – B12. malodorous stool – . Patient may complain of dizziness. iron.

lymphoma.:Important part of history Recent travel . .giardiasis Drug abuse/multiple blood transfusions or ethanol abuse  surgical resection small bowel gastric - Malabsorption + chronic lung disease = cystic fibrosis Fever + weight loss = TB.

:O/E .muscle wasting Sign of vitamin deficiency glossitis – B deficiency ecchymoses parasthesia tetany .Normal Pallor .

PT.Ca - B12. PTT - . folate Iron study LFT.:Investigations :General CBC - Blood film .

:Investigations :Specific :Tests of fat absorption Quantitative fecal fat Patient should be on daily diet containing 80-100 .Pancreatic Small intestinal Hepatobiliary disease - .grams or more of fat/day is abnormal 6 May be due to: .Fecal fat estimated on 72 H collection . grams of fat .

:14C-Triolein Test Is triglyceride which is hydrolysed by pancreatic . lipase  absorption of metabolism ↑ 14CO2 lung .

:Tests for pancreatic function :Bentiromide test) 1 Chymotrypsin PABA + pepside PABA  absorbed and conjugated in liver  urine excretion Schilling test) 2 .

ERCP .Plain abdominal X-ray .3) Pancreatic stimulation test Secretin stimulation – 4) Radiographic techniques: .CT abdomen .U/S abdomen .

Carbohydrate absorption test Hydrogen breath test) 1 Hydrogen excretion ↑ in bacterial overgrowth small intestinal malabsorption .

Carbohydrate absorption test D-xylose test) 2 carbon sugar  excreted unchanged in urine-5 grams given 25 Urine collected for 5 hours Normally 25% is excreted In patients with fat malabsorption. malabsorpton D-xylose is normal in pancreatic disease Serum level of D-xylose at 1-2 hours after ingestion . this test differentiates pancreatic from small intestinal . can be measured .

Test for bacterial overgrowth: 1) 2) 3) Intestinal aspiration and culture Breath test C-D xylose breath test .

Blind loop .1) Radiography of small intestine: Barium swallow and follow-through – to see .Stricture .J. diverticular .

endoscopy Coeliac disease: .using crossby capsule .short villi and increased lymphocyte .2) Intestinal mucosal biopsy: .Villous atrophy Tropical spure: .

Radiograph Bentiromide test .Selection of tests in evaluation malabsorption Quantitaive fecal fat Normal Abnormal D-xylose test Abnormal Normal C-D-xylose test 14 Abd.CT-abd Normal Abnormal Small intestinal Bx • Jej culture • Tetracyclin •Then repeat breath test .

Reduced bile salt concentration in intestine: I.) Interruption of enterohepatic circulation of bile salt.) Liver Disease II. • • • Postgastrectomy steatorrhea. Exocrine Pancreatic insufficiency. .Classification of Malabsorption Syndrome Inadequate digestion: A.) Cholestasis III.) Bacterial over growth IV.

g Lymphoma D.B. Crohn’s disease • Coeliac disease • Tropical Sprue • Disaccharide Deficiency • Lymphoma • TB • . e. Inadequate absorptive surface: Resection • Diseased intestine • C. Primary mucosal defects. Lymphatic obstruction.

g. peristalsis (major)  Immunoglobulin Cause of bacterial growth.  Small intestinal diverticuli  Blind loop  Strictures  DM/ Scleroderma  . e.Malabsorption due to bacteral over growth of small bowel Normal small intestine is bacterial sterile due to: Acid  Int.

Pathophysiology 1) Bacterial over growth: Metabolize bile salt resulting in deconjugation of bile salt   Bile Salt  Impaired intraluminal micelle formation  Malabsorption of fat. 2) . Intestinal mucosa is damaged by  Bacterial invasion  Toxin  Metabolic products  Damage villi  may cause total villous atrophy.

Reversed of symptom after antibiotic treatment. Diagnosis:  Breath test  Cxylose test  Culture of aspiration (definitive) Treatment: Antibiotic  Tetracyclin  Ciproflexacin  Metronidazole  Amoxil .Clinically:  Steatorrhea  Anaemia  B12 def.

Absent features of generalized lymphoma. .  Feature of malabsorption  Biopsy resemble coeliac sprue  Abdominal pain  Fever Incomplete respond to gluten free diet.Intestinal Lymphoma  Primary 2nd Affect male = 50 Y.

Malabsorption may be due to:  Diffuse small intestinal mucosa disease. .  Fever Diagnosis:  History/Endoscopic Biopsy  CT scan of abdomen  Laparotomy Some form secretion  .  Obstruction of lymphatic channels  Stenosis  bacterial overgrowth.heavy chain Ig A.

Complication:  Perforation  Bleeding  Intestinal obstruction Treatment:  Chemotherapy  Surgery .