1Malabsorption Syndrome

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Chronic inflammatory diarrhea:Inflammatorydiarrhea occurs when there is damage to themucosal lining or brush border, which leads to apassive loss of protein-rich fluids, and adecreased ability to absorb these lost fluids

Malabsorption Syndrome

Malabsorption

Is inadequate assimilation of dietary substancesdue to defects in digestion,absorption, or

transport. Malabsorption affects macronutrients(e.g., proteins, carbohydrates, fats)

or micronutrients (e.g., vitamins, minerals),causing excessive fecal excretion and producingnutritionaldeficiencies and GI symptoms.

Malabsorption Syndrome

A group of symptoms resulting from disordersin the intestines' ability toabsorb nutrients fromfoods eaten. It may lead to loss of appetite,weight loss, swollen abdomen,muscle cramps,

bone pain, and fat in the feces. Anemia,weakness, and tiredness can occur becauseiron,

folic acid, and vitamin B12are not absorbed inright amounts. Among the manyconditionscausing this syndrome are stomach orsmall bowel surgery, celiac disease,tropical sprue, cysticfibrosis, Whipple's disease,

and intestinal lymphangiectasia, a diseaseinvolving the grouping of thelymph ducts in theintestines

Pathophysiology:

Digestion and absorption occur in three phases:(1) intraluminal hydrolysis of fats, proteins,andcarbohydrates by enzymes (bile saltsenhance the solubilization of fat in this phase)

(2) digestion by brush border enzymes anduptake of end-products; (3) lymphatic transportof nutrients. Malabsorptionoccurs when any of

these phases is impaired.

Causes:

A) Incomplete digestive process, which may be due to:

- Damage or dysfunction of the pancreas-Reduction or absence of bile salts to emulsify

fats for absorption; this can occur inbilliaryobstruction, liver disease or extensiveresection of the small bowel- Excessive transittime, impairing optimal absorption; this can

occur in disorders of metabolicrates,inflammatory bowel disease and even

prolonged and excessive stress

B) Faulty absorption of nutrients due to:- Damage to the absorptive surfaces, as in

inflammatory bowel disease and coeliac disease-Impaired enzyme activity e.g. in lactose

intolerance- Resection of the absorptive surfacese.g. in inflammatory bowel disease.

The Major Malabsorption Syndromes:

(1)Exocrine Pancreatic Insufficiency(EPI)

Its the inability to properly digest food due to alack of digestive enzymes made by the pancreas.EPIis found in patient afflicted with cystic

fibrosis. It is caused by a progressive loss of thepancreaticcells that make digestive enzymes.

Chronic pancreatitis is the most common causeof EPI in humans.

TreatmentOften this is treated with Pancreatic Enzyme

Products (PEPs), such as pancrelipase, that areused to breakdown fats (lipases), proteins(proteases) and carbohydrates (amylases) intounits that can bedigested by those with EPI.

(2)Biliary Obstruction:

Biliary obstruction refers to the blockage of anyduct that carries bile from the liver to the

gallbladder or from the gallbladder to the small

intestine. Biliary obstruction separated into:(I) IntrahepaticIntrahepatic cholestasis generally occurs at thelevel of the hepatocyte or biliary

canalicular membrane. Causes includehepatocellular disease (e.g., viral hepatitis, drug-induced hepatitis), drug-induced cholestasis,

biliary cirrhosis, and alcoholic liver disease.
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(II) ExtrahepaticExtrahepatic obstruction to the flow of bile may

occur within the ducts or secondary toexternalcompression. Overall, gallstones are themost common cause of biliary obstruction.

(3)Lactose Intolerance:A disorder characterize by the inability to digestmilk sugar (lactose) because of an enzymelactasedeficiency.

There are three major types of lactose

intolerance:1.

Primary l actose intolerance: Environmentally induced by weaning in non

dairy consumingsocieties. Where industrializedand commercial dairy is uncommon, milk

consumption beyondinfancy is not common.2.Secondary l actose intolerance

: Environmentally induced, resulting from

certain gastrointestinaldiseases, includingexposure to intestinal parasites such as giardia.3.

Congenital lactase def ici ency: A genetic disorder which prevents enzymatic

production of lactase.Present at birth,

and diagnosed in early infancy.

Symptoms and Signs:The effects of unabsorbed substances include

diarrhea, steatorrhea, abdominal bloating, and

gas.Other symptoms result from nutritionaldeficiencies. Patients often lose weight despiteadequate foodintake.Chronic diarrhea is themost common symptom. Steatorrhea is the

hallmark of malabsorption.Steatorrhea producesfoul-smelling, pale, bulky, and greasystools.Severe vitamin and mineral deficienciesoccur in advanced malabsorption symptoms arerelated to thespecific nutrient deficiency.

Treatment:The diet must be adjusted to restrict such foods

as milk, cheese, butter, and any other

productscontaining milk

(4)Coeliac Disease (Non-Tropical Sprue, Coeliac

Sprue)Its anautoimmunedisorder of thesmall bowelthat occurs ingenetically predisposedpeople ofallages. Coeliac disease is caused by a reactiontogluten(protein found inwheat).Upon exposureto gluten, the enzymetissue transglutaminase

modifies the protein, and theimmunesystemcross-reacts with the bowel tissue, causing an

inflammatory reaction.That leads to flattening ofthe lining of the small intestine, whichinterfereswith the absorptionof nutrients.

Symptoms and Signs:

Classic symptoms of coeliac disease includediarrhea, weight loss (or stunted growth inchildren), and fatigue. Children between 9 and24 months tend to present with bowel symptomsand growth problems shortly after first exposureto gluten-containing products. Older children

may have more malabsorption-related problemsand psychosocial problems, while

adults generally have malabsorptive problems.Many adults with subtle disease only have

fatigue or anemia.Worth note Tropical Sprue has similar

symptoms but it differs in the cause which isunknown. It has been suggested that it is caused

by bacterial, viral, amoebal, or parasitic

infection.Tropical sprue is largely limited to within about30 degrees north and south of the equator.

Therefore, if one resides outside of thatgeographical region, recent travel to the region

is a key factor in diagnosing this disease.

TreatmentThe only effective treatment is a lifelong

glutenTreatment for Tropical sprue: Once

diagnosed, tropical sprue can be treated by acourse of the antibiotic tetracycline and vitaminsB12 and folic acid for at least 6 months.

(5)Idiopathic Inflammatory Bowel Disease:Crohns disease and ulcerative colitis arechronic relapsing disorders of unknownorigin. These diseases share many commonfeatures and are collectively known as idiopathicinflammatory bowel disease(I)Ulcerative Colitis (Colitis Ulcerosa, UC)Ulcerative colitis (UC) is an ulceroinflammatory

disease affecting the colon but limited to the

mucosa and submucosa except in the mostsevere cases. UC begins in the rectum andextends proximally in a continuous fashion,sometimes involving the entire colon. Ulcerative

colitis is an intermittent disease, with periods ofexacerbated symptoms, and periods that arerelatively symptom-free.

Symptoms and Signs:
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Patients usually present with diarrhea mixedwith blood and mucus, of gradual onset. They

also may have signs of weight loss, and blood onrectal examination. The disease is usuallyaccompanied with different degrees ofabdominal pain, from mild discomfort to

severely painful cramps. Ulcerative colitis isa systemic disease that affects many parts of the

body. Sometimes the extra-intestinalmanifestations of the disease are the initial signs,such as painful, arthritic knees in teenager. Itis, however, unlikely that the disease will

be correctly diagnosed until the onset of theintestinal manifestations

TreatmentPhysicians first direct treatment to inducing aremission which involves relief of symptoms

and mucosal healing of the lining of the colonand then longer term treatment to maintain theremission.

(II)Crohn's Disease (Regional Enteritis, CD)

It is one of a group of diseases calledinflammatory bowel disease. The disease can

affect any area from the mouth to the anus; as aresult, the symptoms of Crohn's disease vary

between affected individuals (often affects the

ileum).Although the cause of Crohn's disease is

not known, it is believed to be an autoimmunethat is genetically linked.

There are three majorclasses of Crohnsdisease:1. Il eocolic Crohn' sDisease, which affects both the ileum and thelarge intestine, accounts for 50%of cases

2. Crohn's I leitisAffecting the ileum only, accounts for 30% ofcases, and

3. Crohn' s Colitis

Affecting the large intestine, accounts forthe remaining 20% of cases

Symptoms and Signs:Pain may be the initial symptom of Crohn's

disease. It is often accompanied bydiarrhea which may or may not be bloody.Flatusand bloating may also add to the intestinaldiscomfort.

Treatment:

Treatment is only needed for people exhibitingsymptoms. The therapeutic approach to

Crohn'sdisease is sequential: to treatacutedisease and then to maintainremission. Onceremission is induced, the goal of treatment

becomes maintaining remission and avoiding

flares.Surgerymay be required forcomplications such as obstructions, fistulasand/or abscesses, or if the disease does notrespond to drugs within a reasonable time.

Malabsorption is a failure to fully absorb

nutrients from the gastrointestinal tract. There

are many causes including abnormalities of the

gut wall, failure to produce digestive enzymes

and abnormalities of gut flora.

The outcome ismalnutrition. Malnutrition may

also be caused by inadequate diet with or

without malabsorption.

Clinical features

Malabsorption, from whatever cause, may be

accompanied by:

Changes in weight and growth:

Inadequate absorption of calories will

lead to loss of weight in adults or

stunting of growth in children.

Adults will complain of unintentional

weight loss and perhaps tiredness,

lethargy and fatigue.

Children may have similar symptoms

accompanied byfailure to thrivewith

growth failure (falling through the

centile charts for height and weight).

Gastrointestinal symptoms:

Chronic diarrhoeais common.

Chronic diarrhoea may be defined as

the abnormal passage of three or

more loose or liquid stools per day

for more than four weeks and/or a
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daily stool weight greater

than 200 g/day.

Steatorrhoeais often present. There is

excessive fat in the stools and they

become pale, bulky and offensive in

smell. Stools float and are difficult to

flush away. They often leave a greasy

rim around the pan.

Signs of deficiencies may be apparent:

There may benon-anaemic iron

deficiency.

Iron deficiency anaemia

Folate deficiencyorvitamin B12

deficiency.

Bleeding may result from low

vitamin K. Oedema occurs in protein/ calorie

malnutrition.

There may also be clinical features associated

with the particular cause of malabsorption. The

commonest causes in the UK are coeliac disease,

Crohn's disease and chronic pancreatitis.

Causes of malabsorption

Mucosal causes

Coeliac diseaseusually presents in

childhood but can present later. It is due to

allergy to gluten in the diet that results in

subtotal villous atrophy. This considerably

reduces the surface area available for

absorption. A diet strictly free of gluten

will reverse the process. Nowadays, about

1 child in 4 with coeliac disease is

diagnosed by targeted screening rather than

presenting with malabsorption.[1]

Cows' milk intolerance.[2

]

Soya milk intolerance.

Infection:

Immune deficiency. InHIV infection,

malnutrition is nearly as important as

opportunistic infection, especially in

countries with access to HAART.[3]

Giardiasis.

Whipple's disease.

Intestinaltuberculosis.

Tropical sprue.

Traveller's diarrhoea.

Diphyllobothriasis(tapeworm can

cause B12 malabsorption).

Ancylostomiasis(Hook worm).

Strongyloidiasis(nematode).

In patients with an inflammatory bowel

disorder and malabsorption, an immune

deficiency should be considered.[4]

Intestinal lymphectasiaand other causes of

lymphatic obstruction includelymphoma,tuberculosis and cardiac disease.

Intraluminal causes

Pancreatic insufficiency:

Cystic fibrosisusually presents in

children who have respiratory

problems, although the malabsorption

may be the presenting feature.Sweat

testwill be positive.

Chronic pancreatitiscan cause both

inadequacy of enzyme production andbicarbonate secretion.[5] It often

follows attacks ofacute

pancreatitisand years ofalcohol

abuse.Plain abdominal x-raymay

show calcification of the pancreas.

Carcinoma of pancreas.

Zollinger-Ellison syndrome.

Defective secretions of bile salts due

tocholestatic jaundiceor disease of the

terminal ileum.

Drugs.

Structural causes

Intestinal hurry:

Postgastrectomy

Postvagotomy

Gastrojejunostomy
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atient.co.uk/search.asp?searchterm=LYMPHOMA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CYSTIC+FIBROSIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CYSTIC+FIBROSIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SWEAT+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SWEAT+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SWEAT+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SWEAT+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CHRONIC+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CHRONIC+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-5http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-5http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-5http://www.patient.co.uk/search.asp?searchterm=ACUTE+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ACUTE+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ACUTE+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ACUTE+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ALCOHOL+ABUSE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ALCOHOL+ABUSE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ALCOHOL+ABUSE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ALCOHOL+ABUSE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ABDOMINAL+X+RAY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ABDOMINAL+X+RAY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ABDOMINAL+X+RAY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PANCREATIC+CANCER&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PANCREATIC+CANCER&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ZOLLINGER+ELLISON+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ZOLLINGER+ELLISON+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONJUGATED+HYPERBILIRUBINAEMIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONJUGATED+HYPERBILIRUBINAEMIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONJUGATED+HYPERBILIRUBINAEMIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+GASTRECTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+GASTRECTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+GASTRECTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VAGOTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VAGOTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VAGOTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VAGOTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+GASTRECTOMY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONJUGATED+HYPERBILIRUBINAEMIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ZOLLINGER+ELLISON+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PANCREATIC+CANCER&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ABDOMINAL+X+RAY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ALCOHOL+ABUSE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ALCOHOL+ABUSE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ACUTE+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ACUTE+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-5http://www.patient.co.uk/search.asp?searchterm=CHRONIC+PANCREATITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SWEAT+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SWEAT+TEST&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CYSTIC+FIBROSIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=LYMPHOMA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=INTESTINAL+LYMPHECTASIA&collections=PPsearchhttp://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-4http://www.patient.co.uk/search.asp?searchterm=NEMATODES++ROUNDWORMS+&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=STRONGYLOIDIASIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=ANCYLOSTOMIASIS+AND+NECATORIASIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=DIPHYLLOBOTHRIASIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TRAVELLER+S+DIARRHOEA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TROPICAL+SPRUE&collection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5/6

Theblind loop syndromeinvolves

disturbance normal of gut flora with

malabsorption. This can occur after surgery

for peptic ulcer such as Billroth II or Polya

gastrectomy. These operations have rarely

been required since about 1980 with the

modern management ofpeptic ulcer

diseasebut the effects may not be manifest

for many years. Abnormalities of bowel

flora causing malabsorption can occur in

immune deficiencies.[4]

Fistulae.

Diverticulae and strictures.

Crohn's disease.

Amyloidosis.

Short bowel syndrome.[6] Eosinophilic gastroenteropathy.

Mesenteric arterial insufficiency.

Radiation enteritis.

Causes outside the gut

Hyperthyroidism

Hypothyroidism

Addisons' disease

Diabetes mellitus

Hyperparathyroidism

Hypoparathyroidism Carcinoid syndrome

Widespread skin disease (rapid cell

turnover may also affect gut mucosa)

Malnutrition

Collagen diseases

Eating disorders

Factitious diarrhoea due to purgative abuse

In the elderly, causes of malabsorption are as in

the young butpancreatic insufficiencycan occur

without obvious cause and intestinal overgrowthcan occur without anatomical abnormality of the

bowel.[7]

Investigations

The British Society of Gastroenterology have

produced guidelines for the investigation of

chronic diarrhoea.[8

]

Blood tests

FBC

Plasma viscosity

Vitamin B12 level

Red cell folate

Iron status (usuallyferritinbut can be iron

andiron binding capacity)

Clotting screen forvitamin K deficiency

Serum albumin

Calcium (corrected for albumin level)

Anti-endomyseal, anti-reticulin and alpha-

gliadin antibodies (coeliac screen)

Liver function tests

Serum magnesium

Iron deficiency causes a microcytic blood

picture. Folate or vitamin B12 deficiency

causesmegaloblastic anaemiabut the picture

may be mixed.

In those thought to have IBS, the incidence of

undiagnosed coeliac disease is high but it is

important not to over-investigate this group.[

8]

Patients with unexplained iron deficiency merit

screening for coeliac disease.[9

]

Stool

Faecal microbiological assessments may be

indicated.

Sudan stain for fat globules.

Imaging and endoscopy

Barium follow through may show

structural abnormalities. Endoscopy and small bowel biopsy is very

useful.

ERCPmay be needed (biliary tree

assessment).

Enteroscopy may have an increasing role.

Breath hydrogen tests
http://www.patient.co.uk/search.asp?searchterm=BLIND+LOOP+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=BLIND+LOOP+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=BLIND+LOOP+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PEPTIC+INFLAMMATION+AND+ULCER+DISEASE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PEPTIC+INFLAMMATION+AND+ULCER+DISEASE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PEPTIC+INFLAMMATION+AND+ULCER+DISEASE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PEPTIC+INFLAMMATION+AND+ULCER+DISEASE&collections=PPsearchhttp://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-4http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-4http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-4http://www.patient.co.uk/search.asp?searchterm=CROHN+S+DISEASE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CROHN+S+DISEASE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=AMYLOIDOSIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=AMYLOIDOSIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SHORT+GUT+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SHORT+GUT+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-6http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-6http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-6http://www.patient.co.uk/search.asp?searchterm=RADIATION+ENTERITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=RADIATION+ENTERITIS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPERTHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPERTHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPOTHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPOTHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PRIMARY+ADRENAL+INSUFFICIENCY++ADDISON+S+&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PRIMARY+ADRENAL+INSUFFICIENCY++ADDISON+S+&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=DIABETES+MELLITUS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=DIABETES+MELLITUS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPERPARATHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPERPARATHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPOPARATHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=HYPOPARATHYROIDISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CARCINOID+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CARCINOID+SYNDROME&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=EATING+DISORDERS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=EATING+DISORDERS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PANCREATIC+INSUFFICIENCY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PANCREATIC+INSUFFICIENCY&collections=PPsearchhttp://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-7http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-7http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-7http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-8http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-8http://www.patient.co.uk/doctor/Gastrointestinal-Malabsorption.htm#ref-8http://www.patient.co.uk/search.asp?searchterm=RED+CELL+FOLATE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=RED+CELL+FOLATE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SERUM+FERRITIN+LEVEL&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SERUM+FERRITIN+LEVEL&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=SERUM+FERRITIN+LEVEL&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+IRON+BINDING+CAPACITY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+IRON+BINDING+CAPACITY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=TOTAL+IRON+BINDING+CAPACITY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VITAMIN+K+DEFICIENCY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VITAMIN+K+DEFICIENCY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=VITAMIN+K+DEFICIENCY&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=LIVER+FUNCTION+TESTS&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=LIVER+FUNCTION+TESTS&collections=PPsearchhttp://www.patient.co.uk/search.asp?search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6/6

Take samples of end-expired air; give glucose;

take more samples at half-hour intervals. If there

is bacterial overgrowth there is an increase in

exhaled hydrogen 1h after ingestion. This test is

better than tests using radioactive 14C bile salts.

Management

Management depends upon the cause. For

example:

Coeliac disease requires a strictgluten free

diet.

Pancreatic insufficiency requires the oral

administration of enzymes with food. Blockage of the flow of bile requires

surgery.

Crohn's disease usually responds to

steroids.

Blind loop syndromes may require further

surgery.

Where bile salts are not reabsorbed, it may

be necessary to give resins to bind

them.[10]

If there is folate deficiency and possibly

B12 deficiency too, it is imperative to give

an injection of vitamin B12 before starting

folate supplementation. Otherwise there is

a risk of precipitatingsubacute combined

degenerationof the cord.

Complications

Complications are related to the underlying

disease.

Lassitude is common. Children will have

stunted growth.

Untreated coeliac disease may result in

small bowel adenocarcinoma or

lymphoma.

Infertilityis common, especially in coeliac

disease.

Anaemia may occur.

Rickets,osteoporosisorosteomalaciamay

occur.

Historical note

Before it was superseded by endoscopy, smallbowel biopsy was performed with the Crosby

capsule: This is swallowed on the end of a tube,

and is monitored by x-ray screening until it

reaches the jejunum. It is fired by suction, and a

biopsy is caught in its jaws. It is then pulled

back up.
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1Malabsorption Syndrome

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