Malabsorption syndrome

MARTIN SHIKUPA
Definition
Malabsorption syndrome is a state arising
from abnormality in absorption of food
nutrients across the gastrointestinal tract.

Impairment can be of single or multiple

nutrients depending on the abnormality.

This may lead to malnutrition and variety of

anaemias.
Classification
Can be classified clinically into three basic
categories:
1. Selective, as seen in lactose malabsorption.

2. Partial, as observed in Beta-lipoproteinemia.

3. Total as in coeliac disease.

Causes
Generally, intestinal malabsorption can be due
to:
Mucosal damage (enteropathy)
Congenital or acquired reduction in absorptive
surface
Defects of specific hydrolysis
Defects of ion transport
Pancreatic insufficiency
Impaired enterohepatic circulation
Causes
Due to infective agents
Intestinal tuberculosis, Tropical sprue
HIV related, traveller’s diarrhoea & parasites.
Due to structural defects
Blind loops, inflammatory bowel diseases
commonly in Crohn’s Disease, intestinal hurry
from post-gastrectomy, post-vagotomy, gastro-
jejunostomy.
Fistulae, diverticulae, strictures & lymphoma
Causes cont.
Due to mucosal abnormality
Coeliac disease, cow’s milk or soya milk
intolerance, fructose malabsorption.
Due to digestive failure
Pancreatic insufficiencies: cystic fibrosis,
chronic pancreatitis, carcinoma of pancreas,
zollinger-Ellison syndrome.
Bile salt malabsorption: terminal ileal disease,
obstructive jaundice, bacterial overgrowth.
Causes cont…
Due to enzyme deficiencies
Lactase deficiency inducing lactose
intolerance, sucrose intolerance, intestinal
disaccharidase deficiency, intestinal
enteropeptidase deficiency.
Due to other systemic diseases affecting GIT:
Hypothyroidism and hyperthyroidism,
Addison's disease, hyperparathyroidism &
hypoparathyroidism, carcinoma syndrome and
malnutrition, Abeta-lipoproteinemia.
Pathophysiology
The main purpose of the gastrointestinal
tract is to digest and absorb nutrients,
micronutrients, water and electrolytes.
Digestion involves both mechanical and
enzymatic breakdown of food.
Mechanical processes include chewing,
gastric churning, and the to and fro mixing
in the small intestine.
Pathophysiology cont.
Enzymatic hydrolysis is initiated by
intraluminal processes requiring gastric,
pancreatic, and biliary secretions.
The final products of digestion are absorbed
through the intestinal epithelial cells.
Malabsorption constitutes the pathological
interference with the normal physiology
sequence of digestion (intraluminal process),
Pathophysiology cont…
absorption(mucosal process),and
transport(postmucosal events) of nutrients.
Intestinal malabsorption can be due to:
mucosal damage, congenital or acquired
reduction in absorptive surface, defects of
specific hydrolysis, defects of ion transport,
pancreatic insufficiency and impaired
enterohepatic circulation.
Clinical features
Diarrhoea, often steatorrhoea: watery,
bulky, frequent stools are the clinical
hallmark of overt malabsorption. It is due to
impaired water, carbohydrate and
electrolyte absorption or irritation from
unabsorbed fatty acid. Latter also results in
bloating, flatulence and abdominal
discomfort.
Weight loss, growth retardation, failure to
thrive, delayed puberty in children.
Clinical features cont.
Swelling from loss of protein.
Muscle cramp from decreased vitamin D,
calcium absorption. Also lead to
osteomalacia and osteoporosis.
Bleeding tendencies from vitamin K and
other coagulation factor deficiencies.
Low serum tryptophan and clinical
depression, as can happen with fructose
malabsorption.
Diagnosis
Routine blood tests review anaemia, high ESR
or low albumin. Low cholesterol or triglyceride
may give clue toward fat malabsorption as low
calcium and phosphate toward osteomalacia
from low vitamin D.
Serological studies.
Stool microscopy – show protozoa like giardia,
ova, cysts. Faecal fat study – to diagnose
stetorrhoea.
Diagnosis cont…
Barium follow through, ct abdomen, magnetic
resonance cholangiopancreatography.
Glucose hydrogen breath test for bacterial
overgrowth
Bile salt breath test to determine bile salt
malabsorption.
Schilling test to establish cause of vitamin 12
deficiency.
Lactose H2 breath test for lactose intolerance.
Management
Treatment is directed largely towards
management of underlying cause.
Replacement of nutrients, electrolytes and
fluids may be necessary. In severe deficiency,
hospital admission for parenteral
administration. People whose absorptive
surface are severely limited from disease or
surgery may need long term total parenteral
nutrition. Pancreatic enzymes are
supplemented orally in insufficiencies.
Management cont.
Dietary modification is important in some conditions.
Life-long avoidance of particular food or food
constituent may be needed in coeliac disease or lactose
intolerance.
Bacterial overgrowth usually respond well to course of
antibiotic.
Use of cholestyramine to bind bile acid will help
reducing diarrhoea in bile acid malabsorption.
 CROHN’S DISEASE;
REGIONAL ENTERITIS; ILEITIS;
GRANULOMATOUS
ILEOCOLITIS.
Definition
Is a form of inflammatory bowel disease,
which involves chronic inflammation of the
GIT. The condition can also occur anywhere
from the mouth to the anus.
Causes
The exact cause is idiopathic, but linked to the
overactive immune response resulting in chronic
inflammation.
Types of Crohn’s disease include the following:
 ileocolitis,
 Gastroduodenal,
 Jejunoileitis
 Crohn’s (granulomatous) colitis.
Epidemiology
Disease occurs at any age, but it usually occurs in
people between ages 15-35.
Risk factors include;
 family history of Crohn’s disease
 Jewish ancestry
 smoking
Clinical picture
Depend on part of GIT affected. Symptoms range from
mild to severe, and can come and go with periods of
flare-ups.
The main symptoms are;
 Crampy abdominal (belly area) pain.
 Fever.
 Fatigue.
 Persistent, watery diarrhoea.
Clinical picture cont.
Other symptoms include;
 abdominal fullness and gas, clotting problems,
constipation, GIT bleeding, joint pain, loss of appetite,
tenesmus, rectal bleeding and bloody stools, skin rash,
swollen gums, unintentional weight loss.
Diagnosis
A physical examination may reveal an abdominal mass
or tenderness, skin rash, swollen joints, or mouth
ulcers.
Barium studies, endoscopy e.g. colonoscopy,
sigmoidoscopy.
Small bowel x-ray series.
FBC – ESR raised.
Treatment
Corticosteroids e.g. predinisolone.
Antibiotics for fistulae and abscesses.
Bowel resection followed by anastomosis.
Eating a healthy amount of calories, vitamins and
proteins is important to avoid malnutrition and weight
loss.
Nil orally.
Possible complications
Abscess, bowel obstructions, fistulas – bladder,
vaginal,skin.
Impaired growth & sexual development in children.
Inflammation of the joints.
Nutritional deficiencies – vit B12 deficiency.
Pyoderma gangrenosum.
Nursing care for crohn’s disease.
Aims

To treat the cause and alleviate symptoms.
Position

Position of comfort.
Room/rest

Well ventilated & quite to promote rest

Control visitors to facilitate rest and avoid cross infection.
Nursing care for crohn’s disease cont.
Do all related procedures at once to avoid disturbing
the patient.
Provide adequate rest & comfort to decrease stress &
to make the person feel some control.
Observations
Frequency of diarrhoea to determine fluid loss & in
turn degree of dehydration.
Indicate amount of diarrhoea & colour
Intake of fluids & output of urine.
Monitor for skin integrity
Monitor vital signs.
Psychological care
Explain the disease process, the course & chronic
nature, the need for follow up care, the symptoms of
recurrence.
Help the patient identify successful coping
mechanisms and to focus on personal strengths.
Deviational therapy e.g. reading magazine.
Hygiene
Change linen whenever soiled keep linen dry.
Bathing of the patient.
Oral care etc.
 Nutrition
Development of a well balanced nutrition plan.
Increase intake of tolerated foods & fluids to improve
nutritional status.
Provide foods with non-fat, non-residue & avoid milk
or milk products if patient has lactose intolerance.
NGT if unable to swallow, also to keep nil orally to rest
the intestines.
 Advise
Assignment