1. Dr. WM Simmonds Internal Medicine (Gastroenterology) 15 August 2011
Wanabsorpsie
Dr. WM Simmonds
Internal Medicine
(Gastroenterology)
15 August 2011

2. Wanabsorpsie
Abnormale absorpsie van enkele of veelvuldige nutriente in die gastro-intestinale sisteem.
3 komponente nodig vir optimale absorpsie
Intraluminaal WANVERTERING
Galsuur of pankreas ensiem gebrek
Mukosale WANABSORPSIE
Abnormale mukosa or onvoldoende funksionele derm lengte (‘Brush border surface area’) bv. Dunderm reseksie.
Post-mukosale limfdreinering obstruksie

3. Malabsorption Syndrome
Pallor/Anaemia
Night blindness (Vit A)
Osteoporosis with
pathological fractures
Muscle wasting
Muscle weakness
Tetany (Low Calcium)
Hypopigmentation/
Pellagra(Niacin)
Ascites (Low Albumin)
Dehydration (Diarrhoea)
Ecchymoses (Vit K
factor deficiency)
Steatorrhoea
Increased fecal fat
Oedema (Low Albumin)
Peripheral neuropathy
(B12 def)
Glossitis, stomatitis
Apthous ulcers (Iron & B
Vitamin deficiency)
Pathological
Weight loss

4. Oorsake van Wanabsorpsie
Due to infective agents
Intestinal tuberculosis
HIV related malabsorption
Tropical sprue
Parasites e.g. Giardia lamblia.
Due to structural defects
Inflammatory bowel diseases - Crohn's Disease
Fistulae, diverticulae and strictures,
Infiltrative conditions - amyloidosis
Short bowel syndrome
Due to mucosal abnormality
Celiac disease
Cows' milk intolerance
Soya milk intolerance
Fructose malabsorption
Due to enzyme deficiencies
Lactase deficiency
Sucrose intolerance
Intestinal disaccharidase deficiency
Intestinal enteropeptidase deficiency
Due to digestive failure
Pancreatic insufficiencies:
Cystic fibrosis
Chronic pancreatitis
Pancreas carcinoma
Zollinger-Ellison syndrome
Bile salt malabsorption
Terminal ileal disease
Obstructive jaundice
Liver cirrhosis
Bacterial overgrowth
Primary bile acid diarrhea

5. Celiac siekte Gluten sensitiewe enteropatie
Algemeen in Europieërs (1:300)
Seldsaam in swart mense
HLA DQ2 en DQ8
Kan op enige ouderdom presenteer
Gewoonlik - moegheid, gewigsverlies en anemie in ‘n jong/middeljarige dame.

6. Celiac siekte

7. Celiac siekte Word geasossieer met: Diagnose: Tipe I diabetes
Tiroid siekte
Addison se siekte (Autoimmuun)
Diagnose:
Anti-endomesiale antiliggame
anti-tTG (weefsel transglutaminase)
Dun derm mukosale biopsie
Vermeerderde intraepiteliale limfosiete
Kript hiperplasia
Villus atrofie

8. Celiac siekte Terapie/behandeling
Streng Gluten vrye dieet. Dietkundige belangrik.
Supplemente (FeSo4, Vitamiene)
Behandel osteoporose
Ander geasossierde autoimmuun toestande moet uitgeskakel word.
Goeie opvolg
Klieniese beeld
Antiligame

9. Kroniese Pankreatitis

10. Kroniese pankreatitis Definisie
Onomkeerbare pankreatiese skade
Histologiese or radiologiese bewys van kroniese inflammasie en fibrose
Verlies aan eksokrine (asinere selle) en endokriene (eiland selle) pankreas weefsel.

11. Kroniese pankreatitis Oorsake (TIGAR-O)
Alcohol and Gallstones most common causes in developed countries (70%)
Kroniese pankreatitis Oorsake (TIGAR-O)
Toxic/Metabolic
Alcohol
Smoking
Hypercalcaemia
Hyperlipidaemia
Idiopathic
Early onset
Late onset
Tropical
Genetic
Autosomal dominant
Hereditary pancreatitis (PRSS1 mutations)
Autosomal recessive or modifier genes
CFTR mutations
SPINK1 mutations
Others
Autoimmune
Autoimmune pancreatitis
IgG4 related systemic disease
Recurrent
Post Necrotic
Chronic alcoholism
Diabetes Mellitus
Radiotherapy
Obstructive
Benign pancreatic duct obstruction
Gallstones
Stricture
Pancreas divisum
Malignant stricture
Ampullary of duodenal carcinoma
Pancreatic adenocarcinoma

12. Galstene

13. Kroniese pancreatitis Patofisiologie (Alcohol)
Cytokine release
stimulate stellate
cells to form collagen
(fibrosis) and increase
cell - mediated
inflammation
Chronic
Pancreatitis

14. Jaster, Molecular Cancer. 2004 3:26 doi:10.1186/1476-4598-3-2

15. Kroniese pankreatitis Kliniese einskappe

16. Kroniese pankreatitis Kliniese einskappe

17. Kroniese pankreatitis Kliniese einskappe

18. Kroniese pankreatitis Kliniese einskappe

19. Kroniese pankreatitis Kliniese einskappe
Ander:
Moegheid, etc
Gewigsverlies agv. wanabsorpsie
Pain geassosieered met hoe proteien and vet iname

20. Kroniese pankreatitis Abdominale pyn
Most common clinical problem
Decreases appetite and limits food
consumption - weight loss and malnutrition
Dramatic reduction in quality of life
Character:
Epigastric, often with radiation to the back.
Boring, deep, and penetrating and is often
Associated with nausea and vomiting.
Relieved by sitting forward or leaning forward, the
knee-chest position
Worsens after a meal and often is nocturnal.
Possible causes:
Acute inflammation/noxious stimuli
Increased intra-pancreatic pressure and ischaemia
Neuropathic (Alterations in nociceptive nerves)
Other

21. Kroniese pankreatitis Steatorrhoea
Exocrine insufficiency.
Passage of bulky, floating, foul-smelling stools or may even note the passage of frank oil droplets.
Occurs when pancreatic lipase secretion is reduced to less than 10% of the maximum output.
A feature of far-advanced chronic pancreatitis or complete blockage of the pancreatic duct.

22. Kroniese pankreatitis Diabetes Mellitus
Endocrine insufficiency
Half of patients with chronic
pancreatitis who develop
diabetes will require insulin.
Insulin-producing beta cells and glucagon-producing alpha cells are injured.
Increased risk of prolonged and severe hypoglycemia with over vigorous insulin treatment due to the lack of a compensatory release of glucagon.

23. Kroniese pankreatitis Diagnose(1)
Kliniese eienskappe (Abdominale pyn, Steatorrhoea, Diabetes Mellitus)
Pankreas funksie toetse
Direk
Direct hormonal stimulation tests are believed to be the most sensitive function test for chronic pancreatitis. Bicarbonate estimation after Secretin administration. (ERCP) – invasive, not routinely done.
Indirek
Serum Trypsinogen
Pancreatic Enzymes in Stool eg chymotrypsin or elastase
Fecal Fat Excretion/Steatocrit

24. Kroniese pankreatitis Diagnose(2)
Beelding
Abdominale x-straal with pankreas kalsifikasies
CT Scan/MRI
Ultrasound (Conventional/EUS)
ERCP/MRCP
Ander
IgG4, ESR, RF, Calcium, Triglyceride levels

29. Kroniese pankreatitis Behandeling
No curative therapy available
Behandel die oorsaak.
Stop rook. Stop alkohol.
Abdominale pyn
Analgesia
Anti-oxidante
Vermindering van intra-pankreatiese druk en onderdrukking van pankreas uitskeiding
Non-enteriese bedekte ensiem vervanging
PPI
Endoskopiese behandeling
Chirurgie
Steatorrhoea
Verminder vet in diet (<20g/dag)
Pankreatiese ensiem vervanging (bv. Pancrelipase - CreonTM)
Suur onderdrukking met ‘n PPI (Verhoog duodenale pH for optimale lipase activiteit.
Diabetes Mellitus
Insulin therapie (NB. Risiko hoer vir hypoglukemie)
Ander
Supplemente, “fat soluble” vitamiene (A, D, E, K)

30. Kroniese pankreatitis Komplikasies
Pseudokiste
Bloeding
Pseudoaneurisme
Milt thrombose met varices wat bloei
Obstruksie (Gemene galbuis, duodenale)
Pankreas Fistel
Na Pseudokist
Externe (chirurgie)
Interne (Askites, pleurale effisie)
Kanker
Risk highest with hereditary pancreatitis
and smoking
Pancreatic adenocarcinoma – CA19-9
Dysmotiliteit
Gastroparese and antroduodenale dysmotiliteit
perigastric inflammation
hormonal changes associated with chronic pancreatitis (e.g. CCK)
side effect of narcotic analgesics.

31. Dankie.