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8.9 L
Total absorbed
by intestine
Intestinal Morphology
Stem
cells
Secretory
cells
Carbohydrate
Malabsorption
Starch,
sucrose
and
lactose
comprise
85%
of
ingested
carbs.
Carbohydrate
malabsorption
caused
by
(1)
absolute
or
functional
decreased
mucosal
surface
area,
or,
(2)
decreased
disaccharidases
or
transporters.
Non-absorbed
carbs
increase
osmolality
in
the
lumen
and
water
enters
lumen
to
maintain
isosmotic
state.
Non
absorbed
carbs
are
fermented
by
colonic
bacteria.
Carbohydrate
Malabsorption
Lactase
deciency
is
most
common
cause
of
carb
malabsorption.
Congenital
lactase
is
rare.
Primary
lactase
deciency
has
delayed
onset
and
is
common
in
North
America,
Africa
and
Asia.
Acquired
lactase
deciency
can
occur
after
mucosal
resection,
mucosal
disease
or
in
the
post
infectious
state
following
gastroenteritis.
Fat
Malabsorption
Fat
absorption
requires
competent
pancreas,
liver,
small
bowel
and
lymphatics.
Triglycerides
are
the
major
form
of
dietary
fat.
Pancreatic
lipase
is
the
major
hydrolytic
enzyme
and
breaks
down
TG
into
fatty
acids
and
beta
monoglycerol.
The
pH
optimal
is
8.
It
can
be
inactivated
by
overproduction
of
acid.
Hepatic
derived
conjugated
bile
salts
combine
with
these
constituents
to
form
micelles
which
enter
enterocytes.
TG
are
re-esteried
and
synthesized
into
chylomicrons
which
are
exported
into
lymphatics.
Fat
Malabsorption
Medium
chain
TG
do
not
require
micellar
formation
and
pass
directly
into
portal
blood.
Clinical
features:
Steatorrhea,
weight
loss
and
complications
from
fat
soluble
vitamin
deciencies
A,D,
E
and
K.
Diagnosis:
>
14
g
of
fat
in
a
3
day
stool
collection
on
a
100
g/d
fat
diet.
Need
to
determine
cause
of
fat
malabsorption
Small
bowel
(D-xylose
testing)
Pancreatic
(imaging,
lab,
endoscopic)
Protein
Malabsorption
Dietary
proteins
are
cleaved
initially
by
gastric
pepsin
(active
at
pH
1-3;
inactive
at
pH
>
5).
Pancreatic
trypsin
is
activated
by
duodenal
derived
enterokinase.
Trypsin
further
activates
a
series
of
pancreatic
proteases
which
cleave
proteins
into
peptides
and
AAs.
Brush
border
oligopeptidases
cleave
small
peptides
and
subsequent
OPD
and
free
AAs
are
transported
into
the
enterocyte.
Clinical
Features
Diarrhea,
edema,
ascites,
possible
concomitant
CHO
and
fat
malabsorption.
Low
serum
protein,
albumin
and
Igs
(except
IgE).
Lymphopenia
in
setting
lymphangiectasia.
Diagnosed
by
measuring
absorption
of
marker
alpha-1-antitrypsin.
Mechanisms of Malabsorption
Mechanisms of Malabsorption
Diarrhea
Mechanisms
Decreased
absorption
(Villous
function)
Increased
secretion
(Crypt
function)
Both
Inammatory
vs
Non-Inammatory
Inammatory
diarrhea
(IBD,
invasive
pathogens,
ischemia,
radiation)
Abdominal
pain
Fever
Tenesmus
(urgency
to
defecate)
Small
volume
mucoid
stool
with
variable
amounts
of
blood
and
leukocytes
Secretory
diarrhea
290
-2
(Na
+
K)
=
<
50
Celiac
Disease
Immune
response
to
dietary
gliadins
(wheat,
barley,
rye).
Prevalence
highest
amongst
people
of
European
descent.
Prevalence
of
1:100
in
North
America,
1:56
in
symptomatic
patients,
1:22
in
FDR
of
patients.
Occurs
at
all
ages;
20%
over
60.
95%
HLA
DQ2,
5%HLA
DQ8
however
30
to
40%
of
general
population
are
DQ2
or
DQ8.
Diagnosis
Presence
of
symptoms
congruent
with
the
disease.
These
range
from
classic
malabsorption
to
more
atypical
extraintestinal
signs
and
symptoms.
Atypical
form
is
now
the
most
common
form
of
disease
presentation.
Supportive
serological
studies.
Characteristic
small
intestinal
biopsy
ndings.
There
are
proxy
endoscopic
markers.
Clinical
response
to
gluten
free
diet
(GFD).
Clinical Features
Histology of Celiac
Celiac Disease
Normal villi
Villous atrophy
Dermatitis Herpetiformis
Positive
Negative
Yes
Negative
Positive
Negative
Tx and monitor
Improvement?
Yes
Dx confirmed
No
Evaluate for possible secondary
cause of symptoms
Whipples
Disease
Multisystem
disease.
Diarrhea
Weight
loss
Arthritis
CNS
ndings.
Gram
+ve
Tropheryma
whippelii.
PAS
+ve
macrophages
on
small
bowel
biopsy.
+ve
PCR
reaction.
Treatment
with
long
term
antibiotics