1. MALABSORPTION SYNDROME
Dr. M.A. SOFI
MD; FRCP(London); FRCPEdin; FRCSEdin

2. Malabsorption Syndrome:
Malabsorption syndrome refers to a number of disorders in which the intestine can't adequately absorb certain nutrients into the bloodstream. It can impede the absorption of macronutrients (proteins, carbohydrates, and fats), micronutrients (vitamins and minerals), or both.
Clinical features
Malabsorption, from whatever cause, is accompanied by:
Weight loss and fatigue:
Loss of weight in adults or stunting of growth in children and tiredness, lethargy and fatigue.
Children may have similar symptoms accompanied by failure to thrive with growth failure (falling through the centile charts for height and weight).

3. Malabsorption Syndrome:
Diarrhea:
Diarrhea frequently is watery, reflecting the osmotic load received by the intestine.
Bacterial action producing hydroxy fatty acids from undigested fat further worsening the diarrhea.
Flatulence and abdominal distention
Bacterial fermentation of unabsorbed food releases gaseous products, such as hydrogen and methane, causing flatulence.
Steatorrhea: is the result of fat malabsorption.
The hallmark of steatorrhea is the passage of pale, bulky, and malodorous stools.
Such stools often float on top of the toilet water and are difficult to flush. Also, patients find floating oil droplets in the toilet following defecation.

4. Anemia can be either microcytic or macrocytic
Malabsorption
Anemia
Anemia can be either microcytic or macrocytic
Iron deficiency anemia often is a manifestation of celiac disease.
Ileal involvement in Crohn disease or ileal resection can cause megaloblastic anemia due to vitamin B-12 deficiency.
Edema
Hypoalbuminemia from chronic protein malabsorption or from loss of protein into the intestinal lumen causes peripheral edema.
Extensive obstruction of the lymphatics, can cause protein loss.
Severe protein depletion, ascites may develop.

5. Malabsorption
Bleeding disorders:
Bleeding usually is a consequence of vitamin K malabsorption and subsequent hypoprothrombinemia.
Ecchymoses usually manifests, although, occasionally, melena and hematuria occur.
Metabolic defects of bones:
Vitamin D deficiency can cause bone disorders, such as osteopenia or osteomalacia.
Bone pain and pathologic fractures may be observed.
Malabsorption of calcium can lead to secondary hyperparathyroidism.

6. Malabsorption
Vitamin malabsorption can cause:
Generalized motor weakness (pantothenic acid, vitamin D)
Peripheral neuropathy (thiamine)
Loss for vibration and position (cobalamin),
Night blindness (vitamin A)
Seizures (biotin).
Neurologic manifestations:
Hypocalcemia & hypomagnesemia, can lead to tetany, manifesting as the Trousseau sign and the Chvostek sign.

7. Malabsorption: Causes
In clinical practice the term malabsorption mal-digestion has come to denote derangements in both processes.
Three steps are required for normal nutrient absorption:
Luminal and brush border processing
Absorption into the intestinal mucosa
Transport into the circulation
Malabsorption can result from defects in each of these three phases . Furthermore, one or more mechanisms may exist concurrently.

8. Malabsorption syndrome: Causes
Mucosal causes
Coeliac disease usually presents in childhood but can present later. It is due to allergy to gluten in the diet that results in subtotal villous atrophy.
Cows' milk intolerance.
Soya milk intolerance.
Fructose intolerance and malabsorption: Simultaneous consumption of glucose reduces fructose malabsorption.

9. Malabsorption syndrome: Causes
Whipple bac infec on intestine serious neurlogic infestation
Infection:
Giardiasis
Whipple's disease
Intestinal tuberculosis
Tropical sprue
Traveller's diarrhoea
Diphyllobothriasis
(tapeworm B12 deficiency)
Ancylostomiasis (hookworm)
Strongyloidiasis (nematode)
In patients with an IBD and malabsorption, an immune deficiency, including HIV enteropathy, should be considered.
Intestinal lymphangiectasia and other causes of lymphatic obstruction include lymphoma, tuberculosis and cardiac disease.
Meagaloblastic anemia – tape warm

10. Malabsorption syndrome: Causes
Surgical causes of mal-absortoption
Intraluminal causes
Pancreatic insufficiency:
Cystic fibrosis
Chronic pancreatitis
Carcinoma of pancreas
Zollinger-Ellison syndrome
Defective secretions of bile salts, due to cholestatic jaundice or disease of the terminal ileum.
Drugs.
Structural causes
Intestinal hurry:
Post-gastrectomy
Post-vagotomy
Gastrojejunostomy
The blind loop syndrome
Fistulae.
Diverticulae and strictures.
Crohn's disease.
Short bowel syndrome.
Eosinophilic gastroenteropathy.
Mesenteric arterial insufficiency.
Zollinger-Ellison syndrome
Stimulits in stomach .. Hydrochoic acis .. Tymor of betal cells in pancreas called : .. Massive ulceration in stomach if iany d ulcer not treated with PPI think pf this

11. Malabsorption
Clinical features
Laboratory findings
Calories
Weight loss with normal appetite
Fat
Pale and voluminous stool, diarrhea without flatulence, steatorrhoea
Stool fat >7 g/day
Protein
Edema, muscle atrophy, amenorrhea
Hypoalbuminemia, hypoproteinemia
Carbohydrates
Watery diarrhea, flatulence, acidic stool pH, milk intolerance, stool osmotic gap
Increased breath hydrogen
Vitamin B12
Anemia, subacute combined degeneration of the spinal cord (early symptoms are paresthesias and ataxia associated with loss of vibration and position sense)
Macrocytic anemia, vitamin B12 decreased, abnormal Schilling test, serum methylmalonic acid and homocysteine increased

12. Malabsorption Clinical features Laboratory findings Folic acid Anemia
Macrocytic anemia, serum and RBC folate decreased, serum homocysteine increased
Vitamin B, general
Cheilosis, painless glossitis, acrodermatitis, angular stomatitis
Iron
Microcytic anemia, glossitis, pagophagia
Serum iron and ferritin decreased, total iron binding capacity increased
Calcium and vitamin D
Paresthesia, tetany, pathologic fractures due to osteomalacia, positive Chvostek and Trousseau signs
Hypocalcemia, serum alkaline phosphatase increased, abnormal bone densitometry
Vitamin A
Follicular hyperkeratosis, night blindness
Serum retinol decreased
Vitamin K
Hematoma, bleeding disorders
Prolonged prothrombin time, vitamin K-dependent coagulation factors decreased

13. Acrodermatitis enteropathica
Cheilosis
Follicular Keratosis
Glossitis

14. Physical signs
General physical examination
Patients may have orthostatic hypotension.
Patients may complain of fatigue.
Signs of weight loss, muscle wasting, or both may be present.
***Patients may have signs of loss of subcutaneous fat.
Abdominal examination
The abdomen may be distended, and bowel sounds may be hyperactive.
Ascites may be present in severe hypoproteinemia.

15. Neurologic examination
Physical signs
Dermatologic manifestations
Pale skin - anemia.
Ecchymoses due to vitamin K deficiency.
Dermatitis herpetiformis
erythema nodosum, and pyoderma gangrenosum may be present.
Pellagra, - skin like zipera .. B6
Dirrhea
Demintia
Dermatits
alopecia, or seborrheic dermatitis may be present.
Neurologic examination
Motor weakness, peripheral neuropathy- B12 or B1
, or ataxia- sub acute or neuropathy may be present.
The Chvostek sign or the Trousseau sign may be evident
Cheilosis, glossitis, or aphthous ulcers of the mouth

16. Laboratory Studies:
Electrolytes and chemistries:
Malabsorption can involve electrolyte imbalances, such as:
Hypokalemia
Hypocalcemia
Hypomagnesemia
Metabolic acidosis.
Protein malabsorption
hypoproteinemia
hypoalbuminemia.
Fat malabsorption can lead to low serum levels of triglycerides, cholesterol, and alpha- and beta-carotene. – jauncice feature
Hyopcartnemia jaundes is ddx
Erythrocyte sedimentation rate is elevated in:
Crohn disease
Whipple disease.

17. Laboratory Studies:
Flocculation of the barium occurs in the gut lumen.
Small bowel dilatation and diverticulosis in scleroderma.
Regional enteritis of the small intestine can lead to stricture, ulceration, and fistula formation.
Imaging Studies:
Small bowel barium studies
An abnormal small bowel pattern from barium studies may reveal the nature of malabsorption.
The mucosa pattern in celiac disease often becomes obliterated or coarsened.

18. Differential diagnosis:
Hematologic tests:
A CBC count may reveal microcytic/macrocytic anemia due to iron/B-12 or folate malabsorption.
Serum iron, vitamin B-12, and folate concentrations may help establish a diagnosis.
Prothrombin time may be prolonged – due to malabsorption of vitamin K, a fat-soluble vitamin.
Acrodermatitis Enteropathica
Cystic Fibrosis
Hartnup Disease
Intestinal Lymphangiectasia
Whipple Disease
Zollinger-Ellison Syndrome

19. Laboratory Studies:
Serology:
No serologic tests are specific for malabsorption.
Serum antigliadin and antiendomysial antibodies can be used to help diagnose celiac sprue.
Serum IgA can be used to rule out IgA deficiency.
Determination of fecal chymotrypsin and elastase (2 proteases produced by the pancreas) can be used to try to distinguish between pancreatic causes and intestinal causes of malabsorption.

20. Sprue.
Celiac disease
Scalloped duodenal folds seen on endoscopy in a patient with celiac disease
Radiograph from a small-bowel series in a patient with celiac disease shows jejunization of the ileal fold pattern; this is characteristic of celiac disease.

21. Small bowel follow through study showing multiple concentric strictures shown by the red arrows.
Flocculation and segmentation of barium with mild dilatation of the bowel in a small bowel series in a child with celiac disease.

22. Other Tests Tests of fat malabsorption
Many disease processes result in fat malabsorption.
Quantitative measurement of fat absorption, a 72-hour fecal fat collection is often performed.
Patients will consume a normal amount ( g/d) of fat before and during the collection.
Based on this intake, fecal fat excretion in healthy person should be less than 7 g/d.
Serum retinyl palmitate to identify severe cases of fat malabsorption may be useful relative to the 72-hour fecal fat test.
Imp will come in examitation- 4 :
Test for fat
Fecal fat test
More than 7 – ismalabsotbtion offat – stiturial
D-xyclose
Monoscharied no nedd for oher enzyme
Test intergryt of mucosa if damage
70 in urine .. If no in urine is’t absprm
Falure of absorbtion of muscosal diseas = celiac , resection .. Any disease affecting the mucosa
Hydrogen breath tst .. For ,alabsrob of carbs
Have umpnoraml normal flora so act with carb prodce upon normal flora so produce hydrogen
Exxcessive exceretion of hydrogen
.. Because fermentation
Bile salt ..
Antro-hepatic circulation bile return
If malabsorbiton .. If comjcated ..
Bile salt +Radio-active glycine substace

23. Laboratory Studies D-xylose test
D-xylose test is used to document the integrity of the intestinal mucosa.
In normal individuals, 25 g oral dose of D-xylose will be absorbed and excreted in the urine 4.5 g in 5 hours.
If the absorption of D-xylose is impaired due to either a luminal factor (e.g., bacterial overgrowth) or a reduced or damaged mucosal surface area (e.g., surgical resection, celiac disease), urinary excretion is lower than normal.
Cases of pancreatic insufficiency usually result in normal urinary excretion because the absorption of D-xylose is still intact.

24. Other tests: Tests of carbohydrate absorption:
A simple sensitive test for carbohydrate malabsorption is the hydrogen breath test, in which patients are given an oral solution of lactose.
In cases of lactase deficiency, colonic flora digest the unabsorbed lactose, resulting in an elevated hydrogen content in the expired air.
Bacterial overgrowth or rapid transit also can cause an early rise in breath hydrogen, necessitating the use of glucose instead of lactose to make a diagnosis. However, 18% of patients are hydrogen non-excretors, causing a false-negative test result.

25. Other tests: Test of bile salt absorption:
Bile salt breath test can determine the integrity of bile salt metabolism.
The patient is given oral conjugated bile salt, such as glycine cholic acid with the glycine radiolabeled in the carbon position.
The bile salt is de-conjugated and subsequently metabolized by bacteria, leading to a radioactively labeled elevated breath carbon dioxide level if interrupted enterohepatic circulation, such as bacterial overgrowth, ileal resection, or disease, is present.

26. Other tests:
Wireless capsule endoscopy : This allows visualization of the entire small bowel and much more detailed evaluation of small bowel mucosal disease than barium studies. Its role may include evaluating suspected small bowel disease (such as Crohn's disease) associated with malabsorption.
Because of the risk of retention, wireless capsule endoscopy should generally be avoided in patients with known or suspected small bowel strictures.

27. Other tests: ***** upper endoscopy with small bowel mucosal biopsy
Establishing a definitive diagnosis of malabsorption of the mucosal phase often can be achieved by histologic examination of biopsied mucosal specimens obtained during routine upper endoscopy
Examples of conditions that can be* diagnosed this way include:
Celiac sprue
Giardiasis, (parasite)
Crohn’s disease
Whipple disease
Amyloidosis,
Abetalipoproteinemia
Lymphoma.

28. Principles of management:
Identification and treatment of the underlying disease
Treatment of the diarrhea that often accompanies these disorders
Identification and correction of nutritional deficits.
There are three major principles underlying the management of patients with malabsorption and maldigestion, and appropriate care of such patients in the majority of cases necessitates that each of these three are addressed.

29. Principles of management:
Because symptoms may be absent or mimic other diseases, a routine battery of blood tests is often helpful as an initial step
Several invasive and noninvasive tests are available to establish the cause of malabsorption. Further testing may not be necessary in patients who have gross steatorrhoea.
Summary and recommendations:
Malabsorption depend upon the cause and severity of the disease
The etiology can often be obtained from a detailed patient history, which can also exclude other causes of symptoms.
Deficiencies of specific nutrients and vitamins may also identify the underlying cause and its duration

30. THANK
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