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Malabsorption

1 hour overview of malabsorption for medical residents and nurses, 01/2012
by

Patricia Raymond

on 27 February 2014

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Transcript of Malabsorption

Summary
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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
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