Malabsorption syndrome

Dr. Randula Samarasinghe

 Malabsorption constitutes the

pathological interference with the
normal physiological sequence
ofdigestion(intraluminal process),
absorption (mucosal process) and
transport (postmucosal events) of
nutrients.

 The small intestine is the main site of nutrient digestion and

absorption in gastro intestinal tract
The nutrients usually absorbed are
- fat
- carbohydrates
- protiens
- vitamins
Malabsorption syndrome may result from failure to absorb one or
more nutrients from the GI tract and this depends on the nature
and extent of the pathological process affecting the GI tract

Pathophysiology
Problems of digestion
can be due to intraluminal or brush
border enzyme deficiancy
eg - lactase deficiency causing
lactose intolarance
- Lipase deficency ( chronic
pancreatitis) causing fat
malabsorption

 Can be due to bile acid deficiency

which decreases the micelle forming
capacity in the small intestine that
results in fat malabsorption

 Causes of bile acid deficiency

- reducesSynthesis eg- Cirrhosis

- reduced Biliary secretion eg- Primary biliary
cirrhosis , obstructive jaundice
- reduced conjugated bile acids eg- Bacterial
overgrowth
- reduced ileal Reabsorption eg-Crohn's disease
A defect at any point in the physiological
enterohepatic circulation of bile acid and a defect in
production will lead to its deficiency

 Can be due to reduced function of

small intestinal enzymes
eg - alteration of small intestinal pH
( reduced ) due to increased gastric
acid secretion in Zollinger Ellison
syndrome
Due to reduced intestinal transit time
eg - post gastrectomy,

 Problems of absorption due defects

of the absorptive mucosa
- Reduced length of small intestine
eg Surgical resection
- Reduced surface area of the villi
eg villous atrophy in celiac
disease

 Disorders of absorption constitute a

broad spectrum of conditions with
multiple etiologies and varied clinical
manifestations.

Clinical features
Diarrhea is the most common
symptomatic complaint and often it
is watery
Steatorrhea - the result of fat
malabsorption.
Weight loss and fatigue

 Most, but not all, of these clinical

conditions are associated with
steatorrhea, an increase in stool fat
excretion of >6% of dietary fat
intake. Some disorders of absorption
are not associated with steatorrhea

 Flatulence and abdominal distention Bacterial

fermentation of unabsorbed food substances
releases gaseous products
Oedema ,ascitis -Hypoalbuminemia from chronic
protein malabsorption
Anemia microcytic or macrocytic or mixed
picture
Bleeding disorders -vitamin K malabsorption

 osteomalacia - Vitamin D deficiency

Bone pain and pathologic fractures

Secondary hyperparathyroidism from hypocalcemia

tetany due to hypocalcemia and or hypomagnesemia
Vitamin malabsorption - generalized motor weakness
(pantothenic acid, vitamin D), peripheral neuropathy
(thiamine), loss of vibration and position sense
(cobalamin), night blindness (vitamin A), seizures (biotin)

Physical examination

orthostatic hypotension.
weight loss
muscle wasting
loss of subcutaneous fat
Ascites
Pallor
Ecchymoses
Motor weakness, peripheral neuropathy, ataxia
Tetani may be elicited
Cheilosis, glossitis, or aphthous ulcers of the mouth
Peripheral edema

Causes
Causes are mainly due to disease
entities affecting
- Small intestine
- Hepatobilliary system cirrhosis
- Pancreas chronic pancreatitis

 Disease of the small intestine can

either affect part or the entire
intestine

Disorders in the small intestine

causing malabsorption

Coeliac disease
Dermatitis herpetiformis
Tropical sprue
Bacterial overgrowth
Intestinal resection
Whipples disease
Radiation enteritis
Parasitic infestation eg- Giardia
intestinalis

Investigations

FBC - microcytic anemia ,macrocytic anemia

Serum iron, vitamin B-12 and red cell folate levels
Prothrombin time may be prolonged
Electrolytes
hypoproteinemia and hypoalbuminemia.
low serum levels of triglycerides, cholesterol
ESR - Crohn and Whipple disease.
Serology -Serum antigliadin and antiendomysial antibodies
can be used to help diagnose celiac sprue.
Serum IgA - to rule out IgA deficiency.
Determination of fecal elastase and chymotrypsin (2
proteases produced by the pancreas) to distinguish between
pancreatic and intestinal of malabsorption.

Imaging
Small bowel barium studies - obliterated or
coarsened mucosal pattern in celiac disease,Small
bowel dilatation and diverticulosis in scleroderma,
stricture, ulceration, and fistula formation in crohns
CT scan of the abdomen- pancreatic calcification or
atrophy in chronic pancreatitis, Enlarged lymph
nodes are seen in Whipple disease and lymphoma.
Endoscopic retrograde cholangiopancreatogram
(ERCP): This study helps document malabsorption
due to pancreatic or biliary-related disorders.
Plain abdominal x-ray film: Pancreatic calcifications
are indicative of chronic pancreatitis.

Other tests
Feacal fat estimation fecal fat
excretion in healthy individuals
should be less than 7 g/d.
D-xylose test
Tests of carbohydrate absorption

 Tests of carbohydrate absorption hydrogen breath test

Test of bile salt absorption -bile salt
breath test
The 3-stage Schilling

histology
Depending on the cause, the
histologic features of malabsorption
vary. A frequently encountered
histologic finding is villous atrophy,
which is seen in celiac disease,
tropical sprue, viral gastroenteritis,
bacterial overgrowth, inflammatory
bowel disease, immunodeficiency
syndromes, lymphoma, and radiation
enteritis.

treatment
Two main objectives
1. the correction of nutritional deficiencies
2. when possible, the treatment of causative diseases.

Nutritional support
Supplementing various minerals
Caloric and protein replacement
Medium-chain triglycerides can be used as fat substitutes
because they do not require micelle formation for absorption
and their route of transport is portal rather than lymphatic.
parenteral nutrition may become necessary.

Thank you