The Cause, Effect And Treatment Of Malabsorption Syndrome

Malabsorption syndromes are a group of conditions in which the intestines are not able to absorb one or more of the essential nutrients (such as minerals vitamins, proteins, fats, carbohydrates, etc)[1].  The individual may develop a range of symptoms and signs arsing from this condition.  The malabsorption may be general or specific[2].

            There may be several causes and factors that can lead to the development and progression of malabsorption syndrome.  The proteins, carbohydrates, fats and vitamins are absorbed though the mucosa of the small intestines.  The actual process of digestion begins in the mouth and is continued through the oesophagus and the stomach.  Once the food reaches the small intestines, it is partly digested in the form of a bolus and is absorbed by the mucosa of the small intestines[3].  The entire process of digestion has three phases namely the luminal phase, mucosal phase and the removal phase.  In the luminal phase, the nutrients present in the partly digested food is hydrolysed and made more soluble using enzymes and substances emitted by the liver and the pancreas.  In the mucosal phase, the epithelial cells present in the mucosa of the small intestines absorb some of these nutrients and process them to be dispatched to other parts of the body.  In the removal phase, the nutrients enter blood or the lymph to be sent to various parts of the body.  Malabsorption syndrome implies that a defect or a disturbance (From congenital or acquired reasons) develops in any of these three phases[4].  A defect may develop in digestive process resulting in the failure of the body to digest the food.

The digestive enzymes may not be produced or certain congenital or acquired structural defects may affect the structures of the digestive system (such as the liver, gall bladder, pancreases, etc).  Besides, several infectious diseases and inflammatory conditions in the body can also bring about malabsorption.  There may also be disorders in the transportation in the intestinal mucosa that would affect in the absorption of the nutrients and lead to malabsorption syndrome[5].

Some of the conditions in which malabsorption syndrome can develop include pancreatic disorders (such as pancreatitis, Shwachman-Diamond syndrome, chronic alcoholism, cystic fibrosis and carcinoma of pancreas), bile deficiency (such as removal of the terminal ileum, blockage of the entero-hepatic circulation, etc), uncoordinated emptying of the contents of the stomach (such as in gastrectomy and gastroenterostomy), generalised mucosal disorders (such as celiac disease, tropical sprue, lyumphoma, radiation enteritis, giardiasis, Abetalipoproteinemia, agammaglobulinemia, radiation enteritis, ulcerative jejunitis, short bowel syndrome, bacterial overgrowth, Whipple’s disease, etc), malabsorption of certain substance (such as lactase deficiency), impaired fat absorption (such as gastrinoma and colipase deficiency), abnormal micelle formation (such as chronic liver disease, bacterial overgrowth, cholestatic disease of the liver, Crohn’s disease and ileal removal), unknown mechanisms (such as in adrenal insufficiency, hyperthyroidism and carcinoid syndrome), etc[6],[7].

When the individual undergoes surgery involving removal of the stomach and the jejunum, the biliary and the pancreatic secretions are released into the small intestines away from the normal site of entry (that is the jejunum).  The fats may not be broken down properly.  Besides, the micelle formation may also become abnormal (as the bile salts production or supply to the lumen are reduced) leading to malabsorption of fats.  The food may pass through the jejunum at a very fast rate leading to malabsorption[8].

In several disorders affecting the pancreas, lipase secretion may be reduced leading to malabsorption of fats.  In certain disorders of the small intestines, the enzymes responsible for digestion may be absent or substances that help in the transportation of nutrients and intermediary substances may be deficient.  The nutrients may not be absorbed into the small intestines as the mucosa may be damaged, involved with certain systemic disease or surgically treated.  The specific nutrient not absorbed depends on the portion of the intestine that has been involved[9].

There may be several risk factors for the development of malabsorption syndrome including a family history of malabsorption, administration of certain medications (such as laxatives), surgery performed on the stomach and the intestines, alcoholism, etc[10].  Individuals who have visited tropical areas are also at a higher risk of developing malabsorption due to the development of protozoan infections of the small intestines[11].

Individuals with malabsorption can develop a number of symptoms and signs.  The symptoms and signs that may develop depend on the specific type of malabsorption syndrome existing.  Some of the common symptoms that may develop include anaemia (due to deficiency of vitamin B12, folic acid or iron required to produce RBC’s), diarrhoea, steatorrhoea (presence of fat in the stools), abdominal cramps, bloating, excessive gas production, abdominal distension, abdominal discomfort, foul-smelling stools, etc.  The individual may also develop several generalised symptoms such as skin rashes, itching, muscle wasting, oedema, growth retardation, tiredness, loss of body weight, problems in healing of the wounds, breathlessness, etc.

The individual may develop fat, carbohydrate, protein, vitamin and/or mineral deficiency.  If the protein absorption is low, fluids tend to accumulate in various parts of the body leading to oedema.  In carbohydrate and fat malabsorption, diarrhoea, abdominal cramps, weight loss, growth retardation and excessive production of gas occurs.  In malabsorption of electrolytes, diarrhoea, shock, dehydration and cardiac abnormality develops.  In iron malabsorption, anaemia, angular chelitis, weakness, breathlessness, and tiredness develop.  In calcium and vitamin D malabsorption, bone pain, fractures, tetany, defects in nerve signal conduction, etc, develop.  In vitamin B-complex deficiency, anaemia, angular chelitis, glossitis, chelitis, beri beri, skin problems, etc may develop.  In vitamin A deficiency, night blindness develops and in vitamin K deficiency ecchymosis can occur.  Individuals with vitamin E malabsorption may develop paraesthesia and ataxia[12].  In spite of the individual consuming normal amount of nutrients in the diet, a deficiency may exist and the individual may tend to loss body weight.  Some individuals may develop vague symptoms.

The diagnosis of malabsorption syndrome is made based on the history, symptoms, signs, physical examination, blood tests, urine tests, stool examination, imaging tests, biochemical tests, endoscope studies, breath tests, biopsy of the small intestines, D-xylose test, Schilling’s test, liver function tests, pancreatic function tests, and other tests.  A detailed medical and family history is taken from the individual.  The medical history is taken to determine past GI surgeries, GI disorders, radiotherapy, etc[13].  A detailed family history is taken to detect the presence of celiac disease, Crohn’s disease, cystic fibrosis, lactase deficiency, etc in the family[14].  A thorough physical examination is performed to determine the physical symptoms present such as the skin rashes, abdominal discomfort, etc[15].

The physician also studies the mental functions as some of the malabsorption conditions may also affect the functioning of the brain.  Stool examination is performed to determine the amount of stools emitted every day, microbiology, fat content, etc.  Presence of D-xylose usually suggests malabsorption[16].  Blood tests are utilised to determine the levels of certain substances in the blood.  Various imaging techniques such as X-rays, ultrasound, MRI scans and CT scans are performed to study any abnormality of the organs of the digestive tract[17].  Breath tests are required to determine the presence of microorganisms in the digestive tract[18].  Several specific malabsorption syndromes may require the use of biopsy of certain specific structures to confirm the diagnosis[19].  Schilling’s test may be required to confirm the diagnosis of Vitamin B-12 deficiency[20].

Individuals with malabsorption syndrome should be closely assessed with the type of deficiency that they are suffering from and efforts should be made to replace the substances in the body that are deficient to ensure that vital functions are not affected.  Electrolytes should be replaced immediately as a deficiency could seriously affect the functioning of the heart.  If the individual lacks carbohydrates immediate provision of dextrose through an intravenous line may be necessary.  Some individuals with severe forms of malnutrition may require hospitalisation in order to handle glucose and electrolyte deficiency[21].

After the acute complications are handled, the cause of the malabsorption syndrome should be managed appropriately and a diet chart should be prepared in consultation with a nutritionist[22].  The cause of malabsorption should be addressed properly.  Infectious diseases should be treated by administering the appropriate anti-microbial agents.  Enzymes that are not produced by the body should be replaced.  Substances that the body cannot be metabolised may have to be administered regularly through parental or oral means[23].  Individuals who tend to repeatedly develop abdominal cramps and discomfort may have to be given antispasmodic agents[24].  In some individual vitamin and mineral deficiencies may have to be corrected by administering supplements.  The individual should also consume a nutritious diet containing appropriate quantities of all nutrients.  Some individuals may have to modify their diet to avoid certain substances (such as lactose or gluten), as they may be unable to digest these substances[25].

References:

Lehrer, J. K. (2006), Malabsorption, [Online], Available: http://www.nlm.nih.gov/medlineplus/ency/article/000299.htm, [Accessed: 2007, April 15].

OME – WGO Practice Guideline: Malabsorption, [Online], Available: http://www.omge.org/globalguidelines/guide03/g_data3_en.php, [Accessed: 2007, April 15].

Ramakrishna, B.S., Venkataraman, S. and Mukhopadhya, A. (2006), “Tropical malabsorption” Postgrad Med J, vol. 82, no. 974, December, pp. 779-87. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17148698&dopt=Abstract

Semrad, C.E., and Chang, E. B. (2000), Malabsorption Syndromes. In: Goldman, L. and Bennett, J. C. (eds), Cecil Textbook of Medicine, 21^st ed, W. B. Saunders Company, Philadelphia, pp. 712-722.

Shearman, D. J. C. (1996), Diseases of the alimentary tract and pancreas, In: Edwards, C.R.W., Bouchier, I.A.D. and Haslett, C. (eds), Davidson’s Principles and Practice of Medicine, 17^th ed, Churchill Livingstone, Edinburgh, pp. 447.

The Merck Manual (2003), Malabsoprtion-Introdcution.Retrieved, [Online], Available: http://www.merck.com/mmhe/sec09/ch125/ch125a.html, [Accessed: 2007, April 15].

Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[1] Shearman, D. J. C. (1996), Diseases of the alimentary tract and pancreas, In: Edwards, C.R.W., Bouchier, I.A.D. and Haslett, C. (eds), Davidson’s Principles and Practice of Medicine, 17th ed, Churchill Livingstone, Edinburgh, pp. 447.

[2] Lehrer, J. K. (2006), Malabsorption, [Online], Available: http://www.nlm.nih.gov/medlineplus/ency/article/000299.htm, [Accessed: 2007, April 15].

[3] Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[4] OME – WGO Practice Guideline: Malabsorption, [Online], Available: http://www.omge.org/globalguidelines/guide03/g_data3_en.php, [Accessed: 2007, April 15].

[5] Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[6] Shearman, D. J. C. (1996), Diseases of the alimentary tract and pancreas, In: Edwards, C.R.W., Bouchier, I.A.D. and Haslett, C. (eds), Davidson’s Principles and Practice of Medicine, 17th ed, Churchill Livingstone, Edinburgh, pp. 447.

[7] Semrad, C.E., and Chang, E. B. (2000), Malabsorption Syndromes. In: Goldman, L. and Bennett, J. C. (eds), Cecil Textbook of Medicine, 21st ed, W. B. Saunders Company, Philadelphia, pp. 712-722.

[8] Semrad, C.E., and Chang, E. B. (2000), Malabsorption Syndromes. In: Goldman, L. and Bennett, J. C. (eds), Cecil Textbook of Medicine, 21^st ed, W. B. Saunders Company, Philadelphia, pp. 712-722.

[9] IBID.

[10] Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[11] Ramakrishna, B.S., Venkataraman, S. and Mukhopadhya, A. (2006), “Tropical malabsorption” Postgrad Med J, vol. 82, no. 974, December, pp. 779-87.

[12] Semrad, C.E., and Chang, E. B. (2000), Malabsorption Syndromes. In: Goldman, L. and Bennett, J. C. (eds), Cecil Textbook of Medicine, 21st ed, W. B. Saunders Company, Philadelphia, pp. 712-722.

[13] Semrad, C.E., and Chang, E. B. (2000), Malabsorption Syndromes. In: Goldman, L. and Bennett, J. C. (eds), Cecil Textbook of Medicine, 21st ed, W. B. Saunders Company, Philadelphia, pp. 712-722.

[14] OME – WGO Practice Guideline: Malabsorption, [Online], Available: http://www.omge.org/globalguidelines/guide03/g_data3_en.php, [Accessed: 2007, April 15].

[15] Semrad, C.E., and Chang, E. B. (2000), Malabsorption Syndromes. In: Goldman, L. and Bennett, J. C. (eds), Cecil Textbook of Medicine, 21st ed, W. B. Saunders Company, Philadelphia, pp. 712-722.

[16] Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[17] OME – WGO Practice Guideline: Malabsorption, [Online], Available: http://www.omge.org/globalguidelines/guide03/g_data3_en.php, [Accessed: 2007, April 15].

[18] OME – WGO Practice Guideline: Malabsorption, [Online], Available: http://www.omge.org/globalguidelines/guide03/g_data3_en.php, [Accessed: 2007, April 15].

[19] Shearman, D. J. C. (1996), Diseases of the alimentary tract and pancreas, In: Edwards, C.R.W., Bouchier, I.A.D. and Haslett, C. (eds), Davidson’s Principles and Practice of Medicine, 17th ed, Churchill Livingstone, Edinburgh, pp. 447.

[20] Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[21] Wright, K. D. (1999), Malabsorption Syndrome, [Online], Available: http://healthresources.caremark.com/topic/topic100587120, [Accessed: 2007, April 15].

[22] IBID.

[23] IBID.

[24]IBID.

[25]IBID.