MALABSORPTION

SYNDROME
Prof. Saleh M. Al-Amri
Consultant, Gastroenterology Unit
College of Medicine & K.K.U.H.
King Saud University

MALABSORPTION SYNDROME
This occurs when the normal digestion and absorption
.of food is interrupted
:PATHOPHYSIOLOGICAL (MECHANISM)
:Is divided intoA) Intraluminal stage
Impaired hydrolysis and solubilization of nutrients
. in the small intestine

:Impaired fat absorption) 1

i) Pancreatic lipase is necessary for triglyceride
hydrolysis in duodenum.
Pancreatic enzyme deficiency leads to fat malabsorption.
ii) Inactivation of pancreatic lipase by low gastric luminal
pH fat malabsorption.
iii) Interruption of enterohepatic circulation of bile salt
impaired micelle formation fat malabsorption.
Absorption of fat soluble vitamins may be impaired as well.

:Impaired carbohydrate absorption) 2

Most diseases that causes carbohydrate
malabsorption
do so by affecting intestinal stage.

But amylase catalyse hydrolysis of starch to

. oligosaccharides

:Impaired protein absorption) 3

Hydrolysis of polypeptides occurs mainly in small

intestine by action of pancreatic enzyme trypsin,
chymotrypsin

Deficiency of pancreatic proteases impaired

.
protein absorption
: Diseases like
Chronic pancreatitis
Cystic fibrosis
Ca. pancreatic resection
Protein malnutrition

B) Intestinal stage
.Abnormalities of small intestinal mucosa) 1
Lactase deficiency
e.g. Congenital or acquired
.Result malabsorption of lactose
Acquired:- i) Coeliac disease
ii) Crohns disease
iii) Infective enteritis

:Impaired epithelial cell transport) 2

Many diseases cause loss of intestinal surface
area
.malabsorption of many nutrients
e.g.

i)

Coeliac disease

ii) Tropical spure

iii) Extensive surgical resection
iv) Drugs

:C) Lymphatic transport

Lymphatic obstruction fat malabsorption

e.g. i) Intestinal lymphangiectasia

iii) Tuberculous enteritis
iv) Intestinal lymphoma

D) Decreased availability of ingested nutrients and

cofactors for absorption.
i) Vitamin B12 malabsorption if intrinsic factor is
.deficient. e.g. gastrectomy, antiparietal cell Ab
.ii) Bacterial overgrowth can bind B12
iii) Patient infected with fist tapeworm B12
.
deficiency

CLINICAL MANIFESTATIONS
:History
Diarrhea/steatorrhoea
Weight loss
Symptoms of anaemia
Diarrhoea bulky, floating, malodorous stool
.
difficult to flush
Weight loss may be profound, usually associated
.
with anorexia
Anaemia B12, iron, folate malabsorption.
Patient may complain of dizziness, dyspnoea and

:Important part of history

Recent travel - giardiasis
Drug abuse/multiple blood transfusions or ethanol
abuse
surgical resection
small bowel
gastric

Malabsorption + chronic lung disease = cystic fibrosis

Fever + weight loss = TB, lymphoma.

:O/E
.Normal
Pallor

- muscle wasting

Sign of vitamin deficiency

glossitis B deficiency
ecchymoses
parasthesia
tetany

:Investigations
:General
CBC

Blood film
.Ca

B12, folate
Iron study
LFT, PT, PTT

:Investigations
:Specific
:Tests of fat absorption
Quantitative fecal fat
Patient should be on daily diet containing 80-100
.
grams of fat
.Fecal fat estimated on 72 H collection
.grams or more of fat/day is abnormal 6
May be due to: - Pancreatic
Small intestinal
Hepatobiliary disease

:14C-Triolein Test
Is triglyceride which is hydrolysed by pancreatic
.
lipase
absorption of metabolism 14CO2
lung

:Tests for pancreatic function

:Bentiromide test) 1
Chymotrypsin
PABA + pepside
PABA absorbed and conjugated in liver
urine excretion
Schilling test) 2

3) Pancreatic stimulation test

Secretin stimulation
4) Radiographic techniques:
- Plain abdominal X-ray
- U/S abdomen
- ERCP
- CT abdomen

Carbohydrate absorption test

Hydrogen breath test) 1
Hydrogen excretion in
bacterial overgrowth
small intestinal malabsorption

Carbohydrate absorption test

D-xylose test) 2
carbon sugar excreted unchanged in urine-5
grams given 25
Urine collected for 5 hours
Normally 25% is excreted
In patients with fat malabsorption, this test
differentiates pancreatic from small intestinal
.
malabsorpton
D-xylose is normal in pancreatic disease
Serum level of D-xylose at 1-2 hours after ingestion
.
can be measured

Test for bacterial overgrowth:

1)
2)
3)

Intestinal aspiration and culture

Breath test
C-D xylose breath test

1)

Radiography of small intestine:

Barium swallow and follow-through to
see
- Blind loop
- Stricture
- J. diverticular

2)

Intestinal mucosal biopsy:

- using crossby capsule
- endoscopy
Coeliac disease:
- Villous atrophy
Tropical spure:
- short villi and increased lymphocyte

Selection of tests in evaluation malabsorption

Quantitaive fecal fat
Normal

Abnormal
D-xylose test

Abnormal

Normal

C-D-xylose test 14

Abd. Radiograph
Bentiromide test
.CT-abd

Normal

Abnormal

Small intestinal
Bx

Jej culture
Tetracyclin
Then repeat breath test

Classification of Malabsorption
Syndrome

Inadequate digestion:

A.

Postgastrectomy steatorrhea.
Exocrine Pancreatic insufficiency.
Reduced bile salt concentration in
intestine:
I.) Liver Disease
II.) Cholestasis
III.) Bacterial over growth
IV.) Interruption of enterohepatic circulation of
bile salt.

B.

Inadequate absorptive surface:

Resection
Diseased intestine

C.

Lymphatic obstruction.
e.g Lymphoma

D.

Primary mucosal defects.

Crohns disease
Coeliac disease
Tropical Sprue
Disaccharide Deficiency
Lymphoma
TB

Malabsorption due to bacteral over

growth of small bowel
Normal small intestine is bacterial sterile due to:
Acid
Int. peristalsis (major)
Immunoglobulin
Cause of bacterial growth.
e.g.
Small intestinal diverticuli
Blind loop
Strictures
DM/ Scleroderma

Pathophysiology
1)

Bacterial over growth: Metabolize bile salt

resulting in deconjugation of bile salt

Bile Salt
Impaired intraluminal micelle formation

Malabsorption of fat.

Intestinal mucosa is damaged by

Bacterial invasion
Toxin
Metabolic products
Damage villi may cause total villous atrophy.
2)

Clinically:
Steatorrhea
Anaemia
B12 def.
Reversed of symptom after antibiotic
treatment.
Diagnosis:
Breath test
Cxylose test
Culture of aspiration (definitive)
Treatment: Antibiotic
Tetracyclin
Ciproflexacin
Metronidazole
Amoxil

Intestinal Lymphoma
Primary
2nd
Affect male = 50 Y.
Feature of malabsorption
Biopsy resemble coeliac sprue
Abdominal pain
Fever
Incomplete respond to gluten free diet.
Absent features of generalized lymphoma.

Malabsorption may be due to:

Diffuse small intestinal mucosa disease.
Obstruction of lymphatic channels
Stenosis bacterial overgrowth.
Fever
Diagnosis:
History/Endoscopic Biopsy CT scan of abdomen
Laparotomy
Some form secretion - heavy chain
Ig A.

Complication:
Perforation
Bleeding
Intestinal obstruction

Treatment:
Chemotherapy
Surgery