Malabsorption

Summary Share this: http://prezi.com/rse33mngff82/malabsorption/ And one more thing... No specific evaluation No specific testing No specific management History Chronic pancreatitis Intestinal resection Cystic fibrosis On Orlistat (Alli) Family history Symptoms Diagnosis Management Malabsorption & Maldigestion Malabsorption -Impaired transport of nutrients across the small intestinal lining -Congenital or aquired Maldigestion - Impaired digestion of nutrients in intestinal lumen or in brush border Classic global malabsorption: -diarrhea with pale, greasy, voluminous, foul-smelling stools & weight loss despite adequate food intake. -most are NOT classic Most are mild & nonspecific mimic IBS anorexia, flatulance, abdominal distension, borborigmi assymptomatic signs of specific micronutrient deficiency iron deficiency or osteoporosis with celiac B12 deficiency with pernicious anemia Look to fat to Dx global malabsorption Most complex absorption & most sensitive to interference Most likely to cause weight loss Qualitative fecal fat 72 hour quantitative fecal fat if normal on 100 gram fat/day diet Normal is < 6 grams per day up to 125 grams fat intake daily If Increased fecal fat TTG IgA & total IgA for celiac Fecal elastase testing for pancreatic insufficiency 4.3 grams of fat in a slice of bacon =23 1/4 slices of bacon OR Butter 81 g fat in 100 g Each stick is 113 grams, or 91 grams fat Imaging US used elsewhere SBFT, CT, MR enterography Looking for bowel wall thickening (Crohns) or dilation jejeunal loops (Celiac) Endoscopy (at least 4 duodenal biopsies) Colonoscopy with intubation of TI Testing for carbohydrate malabsorption D-xylose test measures absorptive capacity proximal small intestine, passive 25 gram xylose when NPO from midnight 5 hour urine collection Normal with pancreas insufficiency, abnormal with proximal mucosal disease False results with renal disease, impaired gastric emptying, bacterial overgrowth Lactose Tolerance Test 50 grams lactose after NPO from MN Blood glucose at 0, 60, 120 minutes Increase glucose < 20 mg/dl diagnositic, >40 normal False results with diabetes, bacterial overgrowth, abnormal gastric emptying Patricia Raymond MD FACG Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School Gastroenterology Associates a division of Gastrointestinal & Liver Specialists of Tidewater pllc Correct underlying pathology if possible Limit caffeine to 1 serving per day Reduce highly sugared beverages (soft drinks, juices) May dilute with water at 1:1 ratio Consider oral rehydration solution Bile salt depletion: oral bile salts Dietician consult Nutient supplimentation: need5-10 x DV Use polar versions of fat soluble vitamins if steatorrhea Hectorol or calciediol instead of D2 or D3 TPGS (d-alpha-tocopheryl PEG 1000 succinate)instead of vitamin E Intentional: Surgical malabsorption: post gastric bypass Annual panel should include: Iron saturation, copper, zinc, vitamin A & D CMP, CBC, B12, folate, magnesium Carbohydrate maldigestion: Trials of lactulose, alpha galactosidase (Beano), Prelief Trial of low FODMAP diet Dietary diary Consider fructose intolerance 50% cannot absorb 25 g, daily intake ranges 11-54 g daily; role of HFCS Not just beans:Breaks down polysaccharides and oligosaccharides Legumes (beans and peanuts) Cruciferous vegetables (cauliflower, broccoli, cabbage, brussels sprouts, among others) MCT oil or oral supplement Oil alone may cause nausea or osmotic diarrhea 10 cc MCT + 8 oz nonfat milk + 1 pkt powdered instant breakfast Major site of MCT absorption is the colon Pancreatic enzymes Target: 30K IU lipase per meal 15K IU per snack One IU= 2-3 USP Add H2 or PPI if gastric acid breakdown (Go with your guts.) Celiac Disease Healthy Individuals 1:133 Symptomatic Subjects 1:40 1st Degree Relative with Celiac 1:22 2nd Degree Relative with Celiac 1:39 Projected number Celiacs in US 2,115,954 Known Celiacs in US 40,000 For each known Celiac, there are 53 undiagnosed patients Testing: TTG IgA & Total IgA Additional tests Schilling test for B12 1.radiolabelled B12, 2.Intrinsic factor, 3.antibiotics prior to IF Check B12 and methylmalonic acid instead SeHCAT test-bile acid malabsorption (selenium homocholic acid taurine) Administer selenium 75 labelled bile acid PO, measure retention with gamma camera at seven days (abnormal < 5 %) Bacterial Overgrowth Gold standard is bacterial count from aspirated intestinal fluid (<100,000 ) Prefer hydrogen breath test with lactulose or other carbohydrate substrate MALoderous MALadaptive MALadies