LACTOSE INTOLERANCE

Section D-2 Group 3 Edora, Jela Tongol, Timothy Torralba, Marie Nina Tuddao, Abigail Tumuiging, Jessward Tupaz, Maria Ana Ugalino, Robby Marc

Outline
Case Introduction Definition of Lactose Intolerance and Lactase Food Sources of Lactose Normal Digestion and Utilization of Lactose Definition and Differentiation of Lactose and Lactase Deficiency - Robby Marc Ugalino -Timothy Tongol - Timothy Tongol - Timothy Tongol - TimothyTongol

Distinct Clinical Syndromes of Lactase Deficiency

Characteristic Clinical Manifestations of Lactose Intolerance Laboratory Tests/Procedures to Diagnose Lactose Intolerance Therapy & Treatment for Lactose Intolerance Case Discussion and Application

- Jessward Tumuiging
- JesswardTumuiging - Robby Marc Ugalino - Robby Marc Ugalino - Robby Marc Ugalino

Case Introduction
SALIENT FEATURES 54 y/o, female Chief complaint: Abdominal distension & bloating after meals Associated w/: flatulence Episodic diarrhea (30mins-4hours after meals) Mild suprapubic cramping & urgency before BM relieved by defecating (-) Nausea/Vomiting (-) Skin rash Past Medical History: (-) DM (-) Prev GI surgery (-) History of foreign travel (-) Radiation exposure (+) Osteoporosis-15months ago - dietary calcium intake (3cups of milk/day) Physical examination: -Unremarkable Stool examination: - (-) for occult blood Flexible sigmoidoscopy - normal

Lab Tests:
Hemoglobin = 15 g/dL (normal = 14-16 d/dL)

Hematocrit = 46% (normal = 44-50%)

Serum albumin = 4.5 g/dL (normal = 3.8-4.8g/dL) Serum cholesterol = 210 mg/dL (normal = <200 mg/dL) Serum beta-carotene = 35.7 ug/dL (normal = 20-60 ug/dL) Stool ova and parasites = (-) negative giardia and amoeba Fecal leukocytes = (-) negative Thyroid stimulating hormone (TSH) = 1ulU/ml (normal = 0.6-4.6 ulU/ml)

Lactose
Lactose (galactosyl-P- 1,4-glucose) in the milk of mammals (including humans) is the major dietary source of galactose. Lactose is hydrolyzed in the intestine by lactase. Galactose produced by hydrolysis of dietary lactose is mostly in the form of the @-somer.

Lactase
Lactase is the enzyme needed to digest Lactose in the intestine, with the absence of Lactase, the Lactose cannot be digested and absorb in the body. And if Lactose cant be digested Lactose Intolerance could happen to a person

Food Sources of Lactose

Milk, Milk Products bread and other baked goods waffles, pancakes, biscuits, cookies, and mixes to make them processed breakfast foods such as doughnuts, frozen waffles and pancakes, toaster pastries, and sweet rolls processed breakfast cereals potato chips, corn chips, and other processed snacks margarine salad dressings

Digestion of Lactose

Lactose
Stomach
Small Intestines (Brush border of Proximal Jejunum)

Beta-Glycosidase Complex

Beta-Glycosidase Complex
Lactase
Cleaves via Beta 1,4 Glycosidic bond

Glucosyl Ceramidase
Split Glucose and Galactose from Ceramides

Lactose to Glucose and Galactose

Active Secondary Simporter

Glucose and Galacose + SGLT1

Absorption in the intestinal epithelium

GLUT5

Glucose and Galactose + GLUT 2

Exit to the blood capillaries

Lactose Intolerance

Lactose
Stomach (Small Intestine)

Absence of Glycosidase Complex

Goes down to large intestine

Normal flora ferment the lactose to lactate

Producing gases and flatulence

Attracts water to large intestine causing osmotic Diarrhea and bloating

Differences of Lactose Intolerance and Lactase Deficiency

Lactose Intolerance Is usually a disease of adults and is most often associated with an inadequate amount of an enzyme lactase in the small intestines, which is essential to digest lactose. Without enough lactase, there is lactose intolerance Lactase Deficiency Not enough of an enzyme called lactase in the small intestine to digest lactose .

Lactoferrin
also known as lactotransferrin Found in milk, saliva, tears, and nasal secretion Human Colostrum has the highest concentration Component of Immune system (antimicrobial) Provide antibacterial activity to infant

3 Distinct Clinical Syndromes of Lactase Deficiency:

Congenital Very rare inborn error of metabolism Autosomal recessive pattern Alactasia Primary, adult lactase deficiency or hypolactasia Most common type Begins to fall after weaning Almost completely lost by late adolescence Secondary Disease or damage to the small intestine villous structure or its function e.g. Celiac disease, Cystic Fibrosis, Short gut syndrome (small bowel resection), Parasitic infection, - Gardia, Zollinger Ellison Syndrome, Whipples disease

Clinical Manifestations of Lactose Intolerance:

Meteorism Borborygmi Flatulence Abdominal pain/Colicky pains Dyspepsia Bloating/Fullness Nausea Diarrhea

Diagnostic Tests

Breath Hydrogen Test

After an overnight fast, patient exhales through a breath analyzer Water solution of 50 grams of lactose (32 oz of milk) is then ingested End-expiratory samples are taken at 30-minute intervals and compared with zero-time level

Hydrogen breath >20 ppm above zero-time level Hypolactasia

Oral Lactose Tolerance Test

Ethanol (300 mg/kg) is administered 15 minutes before oral lactose
40 minutes after lactose ingestion, blood sample is taken Blood galactose level of <0.3mmol/L (5mg/dL) Hypolactasia

Lactose-Ethanol Load Test

Ingestion of 50g lactose

Serum glucose is measured in fasting state, then every 30 minutes thereafter 2 hours following lactose ingestion
Blood glucose rise of less than 1.1 mmol/L (20mg/dL) Hypolactasia Blood glucose rise greater than 1.7 mmol/L (30 mg/dL) lactose persistence Blood glucose incremental rise of 1.1 - 1.7 mmol/L inconclusive

Quantitation of Small Bowel Lactase Activity

Tissue sample obtained from distal duodenum by endoscopy or jejuna biopsy Most accurate, but also most invasive method Seldom used clinically to make the diagnosis of lactase deficiency

Therapy
Amount of lactose that can be toleratedvaries from person to persons Complete lactose restriction to confirm all symptoms are indeed related to the Lactose Intolerance Dietary management
Avoiding lactose-containing products Alternative products Lactase supplementation Division into several meal

SALIENT FEATURES 54 y/o, female Chief complaint: Abdominal distension & bloating after meals Associated w/: flatulence Episodic diarrhea (30mins-4hours after meals) Mild suprapubic cramping & urgency before BM relieved by defecating (-) Nausea/Vomiting (-) Skin rash Past Medical History: (-) DM (-) Prev GI surgery (-) History of foreign travel (-) Radiation exposure (+) Osteoporosis-15months ago - dietary calcium intake (3cups of milk/day) Physical examination: -Unremarkable Stool examination: - (-) for occult blood Flexible sigmoidoscopy - normal

Lab Tests:
Hemoglobin = 15 g/dL (normal = 14-16 d/dL)
Hematocrit = 46% (normal = 44-50%) Serum albumin = 4.5 g/dL (normal = 3.8-4.8g/dL) Serum cholesterol = 210 mg/dL (normal = <200 mg/dL) Serum beta-carotene = 35.7 ug/dL (normal = 20-60 ug/dL) Stool ova and parasites = (-) negative giardia and amoeba Fecal leukocytes = (-) negative Thyroid stimulating hormone (TSH) = 1ulU/ml (normal = 0.6-4.6 ulU/ml)

Sources:
Laboratory Manual and Conference Guide Lecture Guide in Biochemistry, vol. 1 Harpers Illustrated Biochemistry 28th ed Biochemistry 5th ed, Stryer Biochemistry 4th ed, Lehninger Lippincott Biochemistry 3rd ed Medical Biochemistry: Human Metabolism in Health and Disease, 2009 http://medical-dictionary.thefreedictionary.com/lactase+deficiency http://www.nlm.nih.gov/medlineplus/ency/article/000276.htm http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance http://en.wikipedia.org/wiki/Nausea http://en.wikipedia.org/wiki/Dyspepsia http://en.wikipedia.org/wiki/Diarrhea http://en.wikipedia.org/wiki/Colic http://en.wikipedia.org/wiki/Bloating