Malabsorption of Nutrients

Learning Objectives

At the end of this lecture on malabsorption, students should be

able to:
1. Identify the major pathophysiological mechanisms
responsible for generalized malabsorption and malabsorption of
specific nutrients.
2. Explain malabsorption of specific nutrients.
3. Explain genetic metabolic defects
4. Foods to eliminate in genectic defects
5. Dietary management of malnutrition for specific age.

Gastrointestinal Tract
A series of organs connected in series to the outside
world whose function is:
1. Efficient uptake from a mixed intake of sufficient
amounts of fuel (hexoses, amino acids, fatty acids) and
essential chemicals (I.e., those that cannot be synthesized).
2. Exclusion other, potentially harmful, organic and
inorganic compounds and infectious agents.
This process is not normally perfect, however
malabsorption
is the clinical state in which digestion/absorption are impaired
sufficiently to lead to clinical symptoms.

Examples of Malabsorption
Mucosal Maldigestion: Disaccharide
Lactase deficiency

Mucosal Maldigestion/Malabsorption:
Generalized malabsorption
Celiac sprue
Bacterial overgrowth

Lactose Intolerance
Lactase: enterocyte brush-border
disaccharidase found in nursing mammals.
Lactose intolerance is the inability to digest and
absorb lactose (sugar found in milk) causing
gastrointestinal symptoms.
Lactase splits lactose in milk to the
monosaccharides glucose and galactose for
absorption.
Normally little of the enzyme is made by villus
enterocytes after weaning
Exceptions are groups of humans who exhibit unusual
persistence of lactase throughout adulthood

Symptoms occur upon ingestion of lactose by

lactase-deficient individuals.

Food for Lactose intolerance

Eating low-lactose dairy products including aged
cheeses (such as Cheddar and Swiss), yogurt, or
lactose-reduced or lactose-free milk Chinese cabbage,
broccoli, collards and fortified foods) or take a calcium
supplement. Speaking with your health care provider on
the right choice of birth control pills helps to reduce
lactose from being consumed. Following all these
conditions will help to reduce discomfort while
consuming a low- lactose diet will provide this essential
nutrient in the body.

WEAK BONES IN CHILDREN

* Adequate Intake (AI)

CALCIUM SUPPLEMENTCONT
In aging adults, particularly among postmenopausal women,
bone breakdown exceeds formation, resulting in bone loss
that increases the risk of osteoporosis over time.
Table 1: Recommended Dietary Allowances (RDAs) for Calcium [1]
Age

Male

Female

Pregnant

Lactating

06 months*

200 mg

200 mg

712 months*

260 mg

260 mg

13 years

700 mg

700 mg

48 years

1,000 mg

1,000 mg

913 years

1,300 mg

1,300 mg

1418 years

1,300 mg

1,300 mg

1,300 mg

1,300 mg

1950 years

1,000 mg

1,000 mg

1,000 mg

1,000 mg

5170 years

1,000 mg

1,200 mg

71+ years

1,200 mg

1,200 mg

Clinical Clues to Nutrient Malabsorption

Weight loss, fatigue, out of gas
Intake of excess calories without weight gain
Diarrhea:
bulky, oily stools (fat)
liquid stools (carbohydrates)
Excess flatus
Evidence of vitamin/mineral deficiencies

glossitis, cheilosis (iron/B vitamins)

acrodermatitis (zinc)

dry skin and hair (essential fatty acids)

anemia
microcytic - iron deficiency
macrocytic - folate/B-12 deficiency

osteopenia/osteoporosis Vit D/calcium

night blindness
Vitamin A

easy bruising
Vitamin K

Steatorrhea

Angular Cheilosis
Deficiencies:
Vitamin B-12
Iron
Folate
B vitamins

Glossitis
Deficiencies of:
Vitamin B-12
Iron
Folate
Niacin

Red tongue with burning sensation

B-12 deficiency with hypersegmented PMNs

Zinc Deficiency
Acrodermatitis

Acrodermatitis

Loss of hair, skin rash and diarrhea due to zinc deficiency

TREATMENT FOR CALCIUM

MALABSORPTION

Malabsorption due to
Luminal Maldigestion of Fat:
Differential Diagnosis
Pancreatic insufficiency:

Chronic pancreatitis

Bile salt deficiency:

Loss of terminal ileum:

loss of bile salts in stool
insufficient bile salts

Bacterial overgrowth:

Deconjugation and loss

of bile acids

Gastric hypersecretion:

Acid inactivation of
pancreatic enzymes

Examples of Malabsorption
Luminal Maldigestion: Fat
Chronic pancreatitis

Mucosal Maldigestion: Disaccharide

Lactase deficiency
Any malabsorbed carbohydrate

Mucosal Maldigestion/Malabsorption:
Generalized malabsorption
Celiac sprue
Bacterial overgrowth

Lactase-Deficient Patient with low activity enzyme

other individuals may also downregulate genes, etc.

Protein stained

Lactase activity stained

To understand flatus, one must understand

the bacterial inhabitants of the gut.

Adapted from Mariana Ruiz Villarreal (LadyofHats), Wikimedia Commons

Mechanism of Lactose-Induced Diarrhea

and Flatus
Lactase-sufficient
people absorb
>80% of lactose
Lactase-deficient
people absorb
<50% of lactose
6-20 grams malabsorbed
lactose = flatus
(1 g = 44 ml H2)
>20 grams malabsorbed
lactose = flatus+diarrhea

Glucose
Galactose

Lactose

Small
bowel

Lactose
SCFA

CO2+H2

FLATUS

lactose
glucose
galactose

Colon

OSMOTIC DIARRHEA

Examples of Malabsorption
Mucosal Maldigestion: Disaccharide
Lactase deficiency

Mucosal Maldigestion/Malabsorption:
Generalized malabsorption
Celiac sprue
Bacterial overgrowth

Pathophysiology of coeliac
disease
A digestive disease that damages the lining of the
small intestine and interferes with absorption of
nutrients from food, injuries to the small intestine can
also reduce the amount of lactase available to process
lactose properly.
Gliadin content of the food leads to diffuse lesions
of the upper small interstinal mucosa. Short flat
villi, deepened crypts. (Prof. Dnes Molnr,2009)

Celiac Sprue I
Immune-mediated destruction of enterocytes (cells that
absorbs nutrients) in response to ingestion of the protein
gluten found in wheat and certain other grains. A fraction
termed gliadin contains the immunogenic material
Small intestinal villi are damaged or destroyed - "flat gut"
appearance.
Mature digesting and transporting enterocytes are virtually
absent.

Celiac Sprue - II
Patchy disease - usually affects proximal intestine
more than distal intestine .
Mucosal digestion and absorption are both
severely impaired.
Characteristic antibodies used in diagnosis: IgA
antibodies to tissue transglutaminase or gliadin.
(New England Journal of Medicine 357:1731, 2007)

Stereomicroscopic view of
small bowel biopsies:
Normal (below)
Celiac sprue (right)

Small Bowel Biopsies

Normal
Celiac Sprue
Villi and mature enterocytes destroyed
Deep crypts (arrows)
Inflammation

Clinical Manifestations of
Sprue
Weight loss, often with increased appetite
Bulky, oily stools steatorrhea - fat malabsorption
Flatus/frothy stools carbohydrate malabsorption
Anemia deficiencies of

iron, folate

Osteopenic bone disease Vitamin D and calcium

malabsorption
Edema/hypoproteinemia protein deficiency and
malnutrition
Cheilosis and glossitis B vitamin deficiencies

Malabsorbed Nutrients in Celiac Sprue

The degree of malabsorption depends on the severity and
extent of the disease: how much of the small bowel is affected
and how severely?

Iron
Fat
Fat-soluble vitamins
Carbohydrate
Protein
Water-soluble vitamins
Other minerals
(Bile acids - rarely)

DIET FOR CELIAC DISEASE

READ
THE
LABELS
REMOVE
GLUTEN FROM
YOUR DIET SUCH
AS WHEAT,RYE
&BARLEY

BUY GLUTEN
FREE
PRODUCTS

FOODS ALLOWED IN GLUTEN FREE DIET

Many healthy and delicious foods are naturally gluten-free:
Beans, seeds, nuts in their natural, unprocessed form.
Fresh eggs
Fresh meats, fish and poultry (not breaded, batter-coated or
marinated)
Fruits and vegetables
Most dairy products
It's important to make sure that they are not processed or
mixed with gluten-containing grains, additives or preservatives.
Many grains and starches can be part of a gluten-free diet:
Amaranth
Arrowroot
Buckwheat
Corn and cornmeal
Flax
Gluten-free flours (rice, soy, corn, potato, bean)

Bacterial Overgrowth-I
Definition: overgrowth of bacteria in small
bowel due to anatomic or motility factors.
Clinical consequences:
Deconjugation of bile acids by bacterial enzymes
Loss of deconjugated bile acids in stool
Decreased bile acid pool - not enough for lipid
digestion/absorption

Damage to enterocytes by bacteria

Bacterial Overgrowth-II
Clinical consequences:
Intraluminal consumption of nutrients by
bacteria (competition)
Carbohydrates, amino acids
Vitamin B-12, iron

Damage to small bowel enterocytes

causing a sprue-like histologic appearance
Mild to severe generalized malabsorption

Tests of Malabsorption:
what types are available?
Screening tests
Quantitate nutrient malabsorption
Specific diagnostic tests

Tests of Malabsorption
Screening tests simple, cheap, fast
Stool smear with fat stain
CBC for evidence of anemia
Cholesterol/carotene blood levels
Stool osmotic gap for carbohydrates
Weight loss/clinical clues

Tests of Malabsorption
Quantitate nutrient malabsorption:
messy, take time, accurate and
quantitative
72-hour fecal fat
D-xylose excretion (monosaccharide)
Schillings test for B-12 absorption (no
longer available)
Breath hydrogen test (carbohydrate)

Hydrogen Breath Test for

Carbohydrate Malabsorption
Principle:
malabsorbed sugar passes into colon
bacteria produce hydrogen gas
H2 diffuses into blood and is excreted by lungs

Practice:
Administer 25-50 grams of glucose or other sugar
orally
Measure hydrogen in exhaled breath at 2-4 hours

Variants:
Other sugars can be employed to test for specific
disaccharidase or transporter defects
lactase deficiency
glucose-galactose malabsorption

Additional Source Information

for more information see: http://open.umich.edu/wiki/CitationPolicy

Mariana Ruiz Villarreal (LadyofHats), Wikimedia Commons,
http://commons.wikimedia.org/wiki/File:Diagram_of_swine_influenza_symptoms_EN.svg

METABOLIC DISORDER
Metabolic disorders are genetic diseases that interfere
with the body's ability to process specific substances.
Often, the body is missing an enzyme that is needed to
process a certain type of amino acid. As a result, these
acids can build up in the body causing health problems.
OR
Impaired formation of a product normally produced by
deficient enzyme.
PHENYLKETNURIA (PKA)
GALACTOSEMIA

Phenylketonuria (PKU)
PKU is a complete absence or deficiency in phenylalanine
hydroxylase (PAH), an enzyme involved in metabolizing or
converting the amino acid phenylalanine into tyrosine,
another amino acid. PAH deficiency results in high levels of
blood phenylalanine and an accumulation of
phenylketones in the urine.
Partial deficiency of the enzyme results in
hyperphenylalaninemia. In this condition, the child has
elevated blood phenylalanine, although it is not quite as
high as when there is a complete absence of PAH.
Unless it is recognized and treated soon after birth, PKU
will cause brain damage.

DIET FOR PERSONS WITH PHENYLKETONURIA-PKU

For the most severe form of PKU, high-protein foods are
removed from the diet, since majority of protein contains
phenylalanine.Foods such as meat,chicken,fish,eggs,nuts,
cheese, legumes, milk and this means that all concentrated
sources of protein must be eliminated or restricted from the
diet in order to limit the amount of phenylalanine. The
sweetener aspartame, present in many diet foods and soft
drinks, must also be avoided, as aspartame contains
phenylalanine.
Consume fruits and vegetables , small amounts of cereals
and crackers. The PKU diet is too low in protein for normal
health, so children and adults with PKU also need to
consume special protein drinks formulated without
phenylalanine.

IF YOU HAVE PKA STAY AWAY

FOOD DIET FOR PERSONS WITH PKU

GALACTOSEMIA
Galactosemia (galactose in the blood) is a hereditary
disorder of carbohydrate metabolism caused by a
deficiency of the enzyme galactose-1-phosphate
uridyltransferase (GALT);characterized by vomiting,
diarrhea, jaundice, poor weight gain, and malnutrition
during early infancy. Mental retardation, cataracts, and
cirrhosis of the liver are sometimes seen in this condition.
Clinically, the diagnosis is usually established on the
basis of an abnormal galactose tolerance curve and the
presence of galactose in the urine.

DO YOU KNOW WHAT TO DO IF GALACTOSEMIA AFFECTS

YOUR FAMILY??????
KHGF

FOODS TO AVOID IF YOU SUSPECT GALACTOSEMIA

Nonfat Milk
Milk
Nonfat Dry Milk
REMOVAL OF LACTOSE
Buttermilk
AND GALACTOSE
Cream
FROM YOUR DIET
Milk Chocolate
Cheese
REPLACE WITH SOY
Buttermilk Solids
OR LACTOSE FREE
Nonfat Dry Milk Solids
FORMULA
Milk Derivatives
Dried Cheese
Dry milk
Yogurt

FOODS YOU CAN CONSUME IF YOU ARE

GALACTOSEMIC
They are meats, eggs, legumes, fruits, vegetables, grains,
breads, soy milk, fats, and sweets that do not contain
galactose or lactose.

PEM MOVING FULL SPEED AHEAD -EXISTING

IN THE 21ST CENTURY

Malnutritional Disorders

Introduction
Malnutrition means more than feeling hungry or not
having enough food to eat. It is a condition that
develops when the body does not get the proper
amount of protein, calories, vitamins and other
nutrients it needs to maintain healthy tissues and
organ function. It occurs in children who are either
undernourished or over nourished. Children who are
over nourished may become over weight or obese
and those who are under nourished are more likely
to have severe long term consequences.

Definition
Malnutrition includes: under nutrition and
over nutrition.
- Under nutrition: is a consequence of
consuming little energy and other
essential nutrients or using or excreting
them more.
Malnutrition: is a term referring to poor or
inadequate nutrition.

Prevalence of
malnutrition
Malnutrition remains of the worlds highest
priority health issues not only because its effects
are so widespread and long lasting, but also
because it can be eradicated.
More than 35% of all preschool age children in
developing countries are under weight.
The unicef report found that 146 million children
under five years in the developing world are
suffering from insufficient food intake, repeated
infections diseases, muscle wasting and vitamin
deficiencies.

Consequences of malnutrition
(long term effects)
1. Slowed growth & delayed
development
2. Difficulty in school
3. High rates in illnesses
4. social stress

Protein energy malnutrition

1- Marasmus
Definition:
It is a clinical syndrome and a form of under nutrition characterized
by failure to gain weight due to inadequate caloric intake.

Incidence:
commonly in infants between the age of 6mo. - 2years (Infantile
atrophy).

Etiology

1- Dietary errors
2 Infection :Acute or chronic as T.B, otitis media pyelo
nephritis
3- Gastroenteritis: (acute or chronic )
4- parasitic inf estuations as: Ascaris, ankylostoma ,giardia
5-Congenital anomalies as: Cardiac (P.D.A,V.S.D,F4) ,Renal
(renal agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis ,
cleftlip or palat
6-Metabolic diseases.: Galactosemia, Fructose intolerance,
Idiopathic hypocalcaemia
7- Prematurety
8- Some cases of mental retardation
9- Low socio economic status
10-Endocrine causes ( DM.hyperthyroidism )

Assessment of Marasmic
Child/Infant
failure a to thrive ,loss of weight (weight < 60%of expected)
loss of subcutaneous fat : measured at many parts of the body
according to the degress:1 st degree : s.c fat in the abd. wall
2 nd degree : s.c fat in the abd. wall and limbs
3 rd degree : s.c fat in the abd. wall and limbs and face

Assessment of Marasmic
Child/Infant
(Cont.)
Muscle wasting ( thin muscles and prominence of bony surfaces )
G.I.T disturbances as anorexia in advanced cases, hungry,
constipation or diarrhea or starvation diarrhea
liability to infection
Hypovolemia
Weak feeble pulse, subnormal temp, pulse rate
Senile face and pallor

Treatment
1- Prevention :

proper diet ( balanced nutritional diet )

encourage breast feeding up to weaning
proper weaning
proper vaccination as measles , T.B. whooping cough
Education regarding the cheap sources of balanced
diet, family planning.
Proper follow up of the growth rate
Early treatment of defects or associated diseases

Treatment (Cont.)

2 Curative treatment:-

A- Proper dietary management:

Adequate balanced feeding. teaching about nutritional
needs.preparation of diet, technique of administration of
food

If there is vomiting or anorexia, give IV fluids or naso

gastric tube feeding.

Gradual increase the amount and concentration of

formula (total calories is120-200cal kg d)
B Treatment of the cause
C- Emergency treatment for complications
D Blood transfusion
E Vitamins and minerals supplementation

Kwashiorkor
Definition
It is a clinical syndrome and a form
of malnutrition characterized by slow
rate of growth due to deficient of protein
intake, high CHO diet and vitamins &
minerals deficiency (adequate supply
of calories).
Incidence
Commonly in toddlers between the
age 1-3years, following or with weaning

WHAT TO LOOK FOR

1- Essential features
(cardinal manifestation):

Growth retardation :Weight is diminished (60-80%) of

expected

Edema :

It is due to hypo proteinemia. It is

starts in the feet and lower parts of the
legs) then becomes generalized
edema . The cheeks become bulky,
pale, waxy in appearance (doll-likecheeks)

1- Essential features
- Diminished muscle fat ratio:
Generalized (muscle wasting) with
subcutaneous fat
- Fatty liver :
It is detected by liver biopsy

- Mental changes :
The infant has apathy never smile, looks
sad his cry is weak

2-Early features
(usual manifestation)

Hair changes : The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.

G.I.T Manifestations: Anorexia ,vomiting in severe cases, diarrhea due to k

3-Occasional or variable features

- Vitamins and minerals defection and vit.D , A,C
minerals as iron, zinc, Mg,
Hepatomegaly.
Skin changes (dermatitis in areas due to pigmentation
,napkin dermatitis, petechiae over the abdomen,
fissures,ulceration
Poor resistance and liability to infections

Complication of
kwashiorkor

1. Secondary infection ,fungal and

bacterial infection
2. Hemorrhagic tendency, purpura
3. Gastroenteritis
4. Hypoglycemia
5. Hypothermia
6. Heart failure due to anemia and
infection.

Prepared By

Dr. Sahar Farouk

Lecturer Of Pediatric Nursing