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Introduction. Malabsorption. Malabsorption Syndrome. Diminished intestinal absorption of one or more dietary nutrients Not an adequate final diagnosis Most are associated with steatorrhea Increase in stool fat excretion of >6% dietary fat intake. Approach to the Patient. Malabsorption.

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introduction

Introduction

Malabsorption

malabsorption syndrome
Malabsorption Syndrome
  • Diminished intestinal absorption of one or more dietary nutrients
  • Not an adequate final diagnosis
  • Most are associated with steatorrhea
    • Increase in stool fat excretion of >6% dietary fat intake
history symptoms and initial preliminary observation
History, Symptoms and Initial Preliminary Observation
  • Extensive small-intestinal resection for mesenteric ischemia
    • Short bowel syndrome
  • Steatorrhea with chronic alcohol intake and chronic pancreatitis
    • Pancreatic exocrine dysfunction
active transport of site specific dietary nutrient absorption
Active Transport of Site-specific Dietary Nutrient Absorption
  • Throughout SI (Proximal>Distal)
    • Glucose, amino acids, lipids
  • Proximal SI (esp. duodenum)
    • Calcium
    • Iron
    • Folate
  • Ileum
    • Cobalamin
    • Bile acids
adaptation
Adaptation
  • Morphologic and functional
  • Due to segmental resection
  • Secondary to the presence of luminal nutrients and hormonal stimuli
  • Critical for survival
steatorrhea
Steatorrhea
  • Quantitative stool fat determination (72 hours)
    • Gold standard
  • Qualitative Sudan III stain
    • Does not establish degree of fat malabsorption
    • For preliminary screening studies
  • Blood, breath, and isotropic test
    • Do not directly measure fat absorption
    • Excellent sensitivity only with obvious steatorrhea
    • Not survived transition from research laboratory to commercial application
laboratory testing
Laboratory Testing
  • Vitamin D malabsorption
    • Evidence of metabolic bone disease
    • Elevated serum ALP
    • Reduced serum calcium
  • Vitamin K malabsorption
    • Elevated prothrombin time
    • Without liver disease
    • No intake of anti-coagulants
laboratory testing1
Laboratory testing
  • Cobalamin/Folate malabsorption
    • Macrocytic anemia
  • Iron malabsorption
    • Iron deficiency anemia
    • No occult bleeding from GIT
    • Non-menstruating female
    • Exclusion of celiac sprue
      • Iron is absorbed in the proximal SI
diagnosis of malabsorption
Diagnosis of Malabsorption
  • Effect of prolonged (>24h) fasting on stool output
    • Osmotic diarrhea
      • Decrease in stool output: Presumptive evidence that diarrhea is related to malabsorption
    • Secretory diarrhea
      • Persistence of stool output: Not due to nutrient deficiency
stool osmotic gap
Stool Osmotic Gap

Useful in differentiating secretory from osmotic diarrhea

  • Normal: 290-300 mosmol/kg H20
  • Significant osmotic gap
    • Suggests the presence of anions other than Na and K are present in the stool, presumably the cause of diarrhea
  • Diff >50: osmotic gap present, dietary nutrient is not absorbed
  • Diff <25: dietary nutrient is not responsible for the diarrhea

2 x (stool [Na+] + [stool K+]) ≤ stool osmolality

schilling test
Schilling Test
  • Pernicious Anemia
    • Atrophy of gastric parietal cells lead to absence of gastric acid and intrinsic factor secretion
  • Chronic Pancreatitis
    • Deficiency of pancreatic proteases to split the cobalamin-R binder complex
  • Achlorydia
    • Absence of another factor secreted with acid that is responsible for splitting cobalamin from the proteins in food
  • Bacterial Overgrowth syndromes
    • Bacterial utilization of cobalamin
  • Ileal dysfunction
    • Impaired cobalamin – intrinsic factor uptake
biopsy of small intestinal mucosa
Biopsy of Small-Intestinal Mucosa
  • Essential in the evaluation of a patient with documented steatorrhea or chronic diarrhea
  • Preferred method to obtain histologic material of proximal small-intestinal mucosa
  • Indications:
    • Evaluation of a patient either with documented or suspected steatorrhea or with chronic diarrhea
    • Diffuse or focal abnormalities of the small intestine defined on a small-intestinal series