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1
Malabsorption: etiology,pathogenesis and
evaluation
Peter HR Green
NORMAL ABSORPTION
• Coordination of gastric, small intestinal,pancreatic and biliary function
• Multiple mechanismsFatproteincarbohydratevitamins and minerals
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NORMAL ABSORPTION
• Integrated and coordinated responseinvolving different organs, enzymes,hormones, transport and secretorymechanisms
• Great redundancy
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DIFFERENTIAL SITES OFABSORPTION
• Fat, carbohydrate and protein can beabsorbed along the entire length (22 feet)
• Vitamins and minerals are absorbed atdifferent sites
FatProteinCHO
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ABSORPTIONLUMINAL MUCOSAL REMOVAL
FAT ABSORPTION
• GASTRIC PHASElingual lipase
• INTESTINALluminalmucosallymphatic (delivery)
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FAT ABSORPTION
• Luminal phase chyme pancreatic secretion – lipase, colipase micelle formation – bile salts, lecithin
• Intestinal phase transport, chylomicron formation, secretion
• Transport (lymphatic) phase
FAT MALABSORPTION
• Luminal phase altered motility - chyme pancreatic insufficiency - pancreatic secretion– lipase, colipase micelle formation – bile salts, lecithin
• Intestinal phase transport, chylomicron formation, secretion• Transport (lymphatic) phase
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Functional Lipase ReservePancreas
Functional Lipase Reserve
FAT MALABSORPTION
• Luminal phase altered motility - chyme pancreatic insufficiency –cancer, ductal obstruction,
chronic pancreatitis biliary tract / liver disease – cirrhosis, bile duct cancer
SMALL INTESTINAL BACTERIAL OVERGROWTH
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SMALL INTESTINAL BACTERIALOVERGROWTH
BLIND LOOP SYNDROMEJEJUNAL DIVERTICULOSIS
IMPAIRED MOTILITY(sclerthoderma, celiac disease)
Deconjugation bile salts
Rx antibiotics
FAT MALABSORPTION
• INTESTINAL PHASE mucosal disease – celiac disease, tropicalsprue, Crohn’s disease, radiation,abetaliporoteinemia, chylomicron retentiondisease, giardiasis
• REMOVAL PHASELymphatic obstruction (lymphoma)
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ABSORPTION
LUMINAL MUCOSAL REMOVAL
FAT MALABSORPTION
• CONSEQUENCES-steatorrhea, diarrhea-weight loss-vitamin deficiency K –bleeding, A –night blindness D –bone disease, E –neurological disorders
ALL, OR ONLY ONE!!
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PROTEIN ABSORPTION
• Gastric events – acid, pepsin• Luminal events – pancreatic secretions
trypsin, chymotrypsin secreted asprecursors and activated by brush borderenzymes, then actively transported.
• Rare congenital disorders of transport
PROTEIN ABSORPTION
LUMINAL MUCOSAL REMOVAL
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CARBOHYDRATE ABSORPTION
• Salivary amylase• Pancreatic amylase
- products of digestion maltose, maltotriose, and a -dextrins, some glucose
- glucose actively absorbed- brush border enzymes digest oligosaccharides (lactase, sucrase)- fructose malabsorption
CARBOHYDRATE ABSORPTION
LUMINAL MUCOSAL REMOVAL
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BLIND LOOP SYNDROME
ANTIBIOTICS
POORMIXING
ENZYMES, CHYME
ENZYMES
ZOLLINGER ELLISONSYNDROME
MULTIPLE MECHANISMS OFDIARRHEA AND MALABSORPTION
• Excessive water and acid production• Acidification of duodenal contents,
deconjugation bile salts, inactivation ofenzymes
• Villous atrophy
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Consequences of resection
• Site of resection– distal bowel present– distal bowel absent
• Extent/severity of disease• Residual disease• Adaptation of residual intestine• Age
MALABSORPTION DUE TOINFECTIONS
• Giardiasis• Cryptosporidiasis• Strongyloides• Isospora• Mycobacterium avium
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Upper Endoscopy Strongyloides
Upper Endoscopy
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Upper GI Series
Histology – Strongyloides Stercoralis
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Isospora belli
Mycobacterium avium
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Malabsorption due to ilealdisease/resection
Crohn’s ileitis
MALABSORPTIONBile salts
Vitamin B12
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Gallstones and renal stones
• Gall stones are related to bile saltand phospholipid depletion as aresult of fat malabsorption and bilesalt loss
• Renal stones are related to excessoxalate absorption as a result ofintraluminal soap formation anddepletion of calcium ions
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EVALUATION OFMALABSORPTION
• CONSEQUENCESweight, BMIferritin, folate, B12 (methyl malonic acid,homocysteine)zinc, coppercalcium, vitamin D, PTH
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EVALUATION OFMALABSORPTION
• CAUSEPROXIMAL Vs DISTAL?steatorrhea (pancreas, biliary, intestinal)
Radiology (small intestine, CAT, USG)Breath tests (bacterial overgrowth, lactose, fructose)BiopsyVideo capsule endoscopy
EVALUATION OFMALABSORPTION
• STOOLO&PGIARDIA ANTIGENFECAL FAT – quantitative, qualitativePANCREATIC ELASTASE