Malabsorption

Malabsorption
Defective absorption of fats, fat-soluble
and other vitamins, proteins,
carbohydrates, electrolytes and minerals,
and water
Most common clinical presentation is
CHRONIC DIARRHEA
Hallmark: Steatorrhea
Cause excessive fecal excretion and
produce nutritional deficiencies and GI
symptoms

Malabsorption occurs when

any of these digestive
1. INTRALUMINAL DIGESTION
functions
is impaired:
Proteins, carbohydrates and fats are broken-down into
assimilable forms.
2. TERMINAL DIGESTION
Hydrolysis of carbohydrates and peptides in the brush border
of the small intestinal mucosa
3. TRANSEPITHELIAL TRANSPORT
Nutrients, fluid & electrolytes are transported across the
epithelium of the small intestine for delivery to the intestinal
vasculature
Absorbed fatty acids triglycerides + cholesterol
chylomicrons intestinal lymphatic system

COMMON CAUSES OF MALABSORPTION

Mechanism

Specific Disease

Maldigestion

Chronic pancreatitis, cystic

fibrosis, pancreatic carcinoma

Bile Salt deficiency

Cirrhosis, cholestasis, bacterial

overgrowth, impaired ileal
reabsorption, bile salt binders

Inadequate Absorptive surface

Massive intestinal resection,

gastrocolic fistula, jejunoileal
bypass

Lymphatic obstruction

Lymphoma, Whipples disease,

intestinal lymphangiectasia

Vascular disease

Constrictive pericarditis, rightsided heart failure, mesenteric

arterial or venous insufficiency

Mucosal disease

Infection (esp.Giardia, Whipples

disease, tropical sprue),
Inflammatory diseases , radiation
enteritis, eosinophilic enteritis,
ulcerative jejunitis, mastocytosis,
biochemical abnormalities

Possible causative disease entities of

the patient
WHIPPLES
PATIENT

GIARDIASIS

DISEASE
Diarrhea
steatorrhea

TROPICAL SPRUE

Diarrhea
-loose, mushy &mucoid
stools
- 3-5x a day for the
past month
-Temporary relief with
Metronidazole
Blood-streaked stools
Rectal tenderness

Diarrhea

Chronic diarrhea
steatorrhea

crampy hypogastric
pain

abdominal pain

abdominal pain

Low grade fever

Fever is rare

fever

fever

Pale palpebral
conjunctiva

bloating, belching,
flatus, nausea and
vomiting last >1 week

weight loss, migratory

large-joint arthropathy,
and as well as
ophthalmologic and CNS
symptoms

weight loss & nutritional

deficiencies including
folate & cobalamin

spent a year in
Bangladesh for
missionary work

G. Lamblia
By ingestion of
contaminated food or
water, poor fecal
hygiene, sexual contact

Infection by T. Whipplei

Uncertain etiology,
however, recent
travellers from
endemic areas such
as southern India,
the Philippines, and

-last >1 week

Blood or mucus in stool

is rare

Tropical Sprue

Epidemiology
affects 510% of the population in some tropical areas.

Etiology
- the etiology and pathogenesis of tropical sprue are uncertain:
1. Its occurrence is not evenly distributed in all tropical
areas; rather, it is found in specific locations, including southern
India, the Philippines, and several Caribbean islands (e.g., Puerto
Rico, Haiti), but is rarely observed in Africa, Jamaica, or Southeast
Asia.
2. An occasional individual will not develop symptoms of
tropical sprue until long after having left an endemic area.
3. Multiple microorganisms have been identified on jejunal
aspirate with relatively little consistency among studies.
4. The incidence of tropical sprue appears to have decreased
substantially during the past two decades.
5. The role of folic acid deficiency in the pathogenesis of
tropical sprue requires clarification.

Work-Ups

CBC
Tests formal nutrition
Perform a 24- to 72-hour stool test for fat. Total stool fat less than
6-7 g/d excludes steatorrhea; therefore, consider chronic diarrhea
The diagnosis of tropical sprue is best made by the presence of an
abnormal small-intestinal mucosal biopsy in an individual with
chronic diarrhea and evidence of malabsorption who is either
residing or has recently lived in a tropical country.
The small-intestinal biopsy in tropical sprue does not have
pathognomonic features but resembles, and can often be
indistinguishable from, that seen in celiac sprue
The biopsy in tropical sprue will have less villous architectural
alteration and more mononuclear cell infiltrate in the lamina
propria.
In contrast to celiac sprue, the histologic features of tropical sprue
are present with a similar degree of severity throughout the small
intestine, and a gluten-free diet does not result in either clinical or
histologic improvement in tropical sprue.

Treatment
Broad-spectrum antibiotics and folic acid are
most often curative, especially if the patient
leaves the tropical area and does not return.
Tetracycline should be used for up to 6 months
and may be associated with improvement
within 12 weeks.
Folic acid alone will induce a hematologic
remission as well as improvement in appetite,
weight gain, and some morphologic changes in
small intestinal biopsy. Because of the presence
of marked folate deficiency, folic acid is most
often given together with antibiotics.