BY Dr. Naglaa Ibrahim Azab Assistant professor of medical biochemistry CHO METABOLISM BY Dr. Naglaa Ibrahim Azab Assistant professor of medical biochemistry

CHO IN DIET Mostly Small amounts Monosaccharides Polysaccharides disaccharides

Polysaccharides Starch Glycogen Cellulose

Disaccharides Sucrose Lactose Maltose

Monosaccharides Glucose Fructose

CHO DIGESTION

Starch Dextrins sucrose Lactose Isomaltose Maltose Fructose Galactose In the mouth Salivary amylase Dextrins In the intestine sucrose Lactose Isomaltose Maltose Lactase Sucrase Maltase Isomaltase Fructose Galactose Glucose Glucose

NO. ……….. Why? No digestive enzymes for CHO in the stomach What about the stomach? Is there digestion of CHO in the stomach??? NO. ……….. Why? No digestive enzymes for CHO in the stomach & the gastric HCL can not digest CHO

the gastric HCL It is destroyed by What about the salivary amylase? Why does not it digests CHO in the stomach??? It is destroyed by the gastric HCL

Does digestion of cellulose occur??? CHO in diet: Starch, glycogen, cellulose, sucrose, maltose, lactose, glucose, fructose & fructose Does digestion of cellulose occur??? NO. ……….. Why? Because salivary amylase (α- amylase acts only on α-1,4 glucosidic linkage found in starch and glycogen but not in cellulose in which the linkage is β -1,4 glucosidic linkage

So, what about glycogen??? salivary amylase acts on α-1,4 glucosidic linkage found in glycogen giving…………..

End products of CHO digestion Glucose Pentose Galactose Mannose Fructose

CHO ABSORPTION

Occurs in duodenum and upper jejunum Glucose uptake by the intestinal cells not need insulin What if it needs insulin???

Mechanisms of absorption of CHO Facilitated transport Simple diffusion Facilitated transport Active transport

Intestinal mucosal cell Simple diffusion Intestinal lumen Intestinal mucosal cell Fructose and pentoses . . . . . . . . . . . . . . . . . . . No need for energy

. . . . . . . . . . . . . . . . . . . Facilitated diffusion Intestinal mucosal cell Intestinal lumen . . . . . . . . . . . . . . . . . . . Glucose, Fructose and galactose Glucose transporter -5 which is Na independant No need for energy

Active transport Intestinal lumen Intestinal mucosal cell Glucose, galactose Glucose, galactose . . . . Na Glucose transporter -1 Na . . . . . . . . . . . . . . . . Na Na Na /K pump (Na/K ATPase) K K

Fate of absorbed sugars Intestinal mucosal cell Portal blood Liver Systemic circulation Monosaccharides Glucose Fructose Galactose Glucose Glucose Fructose Galactose

Fate of absorbed glucose 1- Oxidation Major pathways Minor pathways Glycolysis Krebs cycle ATP(Energy) HMP shunt NADPH+H Ribose 5- P Uronic acid pathway Glucuronic acid

Fate of absorbed glucose 2- Storage Glycogenesis Lipogenesis Glycogen Triglycerides

Fate of absorbed glucose 3- Conversion to other substances Amino-acids Amino-sugars Fructose Galactose In semen Lactose of milk( in the lactating mammary gland

Disorders of CHO digestion Sucrase deficiency Lactose intolerance Only congenital (Occurs at infancy and may (recover at old age Congenital or Acquired Deficient intestinal sucrase  sucrose not digested  accumulation of sucrose in the intestine  fermented by the intestinal bacteria  acids and gases Deficient intestinal lactase  lactose not digested  accumulation of lactose in the intestine  fermented by the intestinal bacteria  acids and gases Cause and pathogenesis The same Abdominal distension Abdominal cramps Diarrhea Acid stool Manifestations -Sucrose free diet Lactose free milk No milk or milk products Treatment

CASE (1)

A young man entered the physician office complaining of intestinal gases and diarrhea. He had signs of dehydration . The patient temperature was normal. He said that this occurred after a birthday party in which he had participated in icecream eating contest . The patient reported prior episodes of similar nature following ingestion of a significant amount of dairy products . The clinical picture is probably due to deficiency in : A - Salivary α- amylase. B - Isomaltase. C - Pancreatic α- amylase. D - Sucrase. E – Lactase.

Comment lactose, a prominent component of milk and most other dairy products. Undigested lactose -------------------> acids + gases

ANSWER : E – Lactase.

Lactose intolerance .

Definition .

The inability to digest lactose (the main sugar in milk) Due to deficiency of the intestinal enzyme lactase giving rise to gastrointestinal symptoms.

Lactase deficiency is not the same as lactose intolerance. Persons with milder deficiencies of lactase often have no symptoms after the ingestion of milk. For unclear reasons, even persons with moderate deficiencies of lactase may not have symptoms. A diagnosis of lactase deficiency is made when the amount of lactase in the intestine is reduced, but a diagnosis of lactose intolerance is made only when the reduced amount of lactase causes symptoms.

Causes

1-Congenital lactase deficiency because of a congenital absence (absent from birth) of lactase due to a mutation in the gene that is responsible for producing lactase. This is a very rare cause of lactase deficiency, and the symptoms of this type of lactase deficiency begin shortly after birth. 2-Primary lactose intolerance The most common cause of lactase deficiency is a decrease in the amount of lactase that occurs after childhood and persists into adulthood, referred to as adult-type hypolactasia. This decrease in lactase is genetically programmed, and the prevalence of this type of lactase deficiency in different ethnic groups is highly variable. 3-Secondary lactose intolerance This type of deficiency is due to diseases that destroy the lining of the small intestine along with the lactase. An example of such a disease is celiac sprue.

Biochemical background .

Small intestinal Lactase Normally Disaccharides cannot be absorbed through the wall of the small intestine into the bloodstream Lactose Small intestinal Lactase Glucose + Galactose Absorbed

In lactose intolerance Small intestinal Lactase Glucose + Galactose Colon

In colon Lactose Glucose + Galactose Colonic bacteria secreting lactase Glucose + Galactose Used and some splitted by these bacteria(fermentation) CO2 gas+ Hydrogen gas + acids as lactic acid Most of the hydrogen is used up in the colon by other bacteria A small proportion is expelled increased flatulence (passing gas) Some is absorbed from the colon and into the body expelled by the lungs in the breath changed into methane gas by another type of colonic bacterium present in some people. These people will excrete only methane or both hydrogen and methane gas in their breath and flatus.

In colon The copious amounts of gas (a mixture of hydrogen, carbon dioxide, and methane), may cause a range of abdominal symptoms, including stomach cramps, nausea, bloating, acid reflux and flatulence. Not all of the lactose that reaches the colon is split and used by colonic bacteria. The unsplit lactose in the colon and its fermentation products draws water into the colon (by osmosis). This leads to loose, diarrheal stools.

The severity of the symptoms of lactose intolerance varies greatly from person to person as the severity depends on: 1- The amounts of lactose in diet; the more lactose in the diet, the more likely and severe the symptoms. 2- The severity of lactase deficiency, that is, they may have mild, moderate, or severe reduction in the amounts of lactase in their intestines. Thus, small amounts of lactose will cause major symptoms in severely lactase deficient people but only mild or no symptoms in mildly lactase deficient people. 3- The different responses of people to the same amount of lactose reaching the colon. Whereas some may have mild or no symptoms, others may have moderate symptoms. The reason for this is not clear but may relate to differences in their intestinal bacteria.

Diagnosis

1-Elimination diet -- A diet that eliminates milk and milk products, continued long enough to clearly evaluate whether or not symptoms are better --Elimination of all milk products should eliminate symptoms completely if lactose intolerance alone is the cause of the symptoms

2-Milk challenge A person fasts overnight and then drinks a glass of milk in the morning. Nothing further is eaten or drunk for 3-5 hours. If a person is lactose intolerant, the milk should produce symptoms within several hours of ingestion. If there are no symptoms or symptoms are substantially milder than the usual symptoms, it is unlikely that lactose intolerance is the cause of the symptoms. Milk used must be fat-free to eliminate the possibility that fat in the milk is the cause of symptoms. It is not possible to eliminate the possibility that symptoms are due to milk allergy, however, this usually is not confusing since allergy to milk is rare and primarily occurs in infants and young children. (If milk allergy is a consideration, pure lactose can be used instead of milk.)

3-Breath test The hydrogen breath test is the most convenient and reliable test for lactase deficiency and lactose intolerance. For the breath test, pure lactose, usually 25 grams , is ingested with water after an overnight fast. Samples of breath are collected every 10 or 15 minutes for 3-5 hours after ingestion of the lactose, and the samples are analyzed for hydrogen and/or methane. If hydrogen and/or methane are found in the breath, it means that the person is lactase deficient. The amount of hydrogen or methane excreted in the breath is roughly proportional to the degree of lactase deficiency, that is, the larger the amount of hydrogen and/or methane produced, the greater the deficiency. The amount of hydrogen and/or methane in the breath, however, is not proportional to the severity of the symptoms. In other words, a person who produces little hydrogen and/or methane may have more severe symptoms than a person who produces a large amount hydrogen and/or methane.

4-Blood glucose test Lactose is ingested (usually 0.75 to 1.5 gm of lactose per kg of body weight) after an overnight fast, and serial blood samples are drawn and analyzed for glucose. If the level of blood glucose rises more than 25 mg/100ml, it means that the lactose has been split in the intestine and the resulting glucose has been absorbed into the blood. This implies that lactase levels are normal Not often used due to false positive tests, that is, an abnormal test in people who have normal lactase levels and no lactose intolerance. .

5- stool acidity test Is a test for lactase deficiency in infants and young children. For the stool acidity test, the infant or child is given a small amount of lactose orally. Several consecutive stool samples then are tested for acidity. With a deficiency of lactase, unabsorbed lactose enters the colon and is split into glucose and galactose. Some of the glucose and galactose is broken down by the bacteria into acids, for example, lactic acid. Lactic acid turns the stool acidic. Therefore, a lactase deficient infant or child will develop an acidic stool following the test dose of lactose. The stool acidity test is not done frequently due to superiority of breath testing has led to modifications in the equipment for collecting breath samples that makes it easier to do breath testing in young children and even infants

6-Intestinal biopsy: For measurement of lactase levels in the lining. The analysis of lactase levels in the biopsy requires specialized procedures that are not often available, and, as a result, lactase levels are not often measured except for research purposes.

Treatment

1- Dietary changes Reducing the amount of lactose in the diet . Lactose free milk formulas are used for infants with lactose intolerance Though yoghurt contains large amounts of lactose, it often is well-tolerated by lactose intolerant people. This may be so because the bacteria used to make yoghurt contain lactase, and the lactase is able to split some of the lactose during storage of the yoghurt as well as after the yogurt is eaten (in the stomach and intestine). Yoghurt also has been shown to empty more slowly from the stomach than an equivalent amount of milk. This allows more time for intestinal lactase to split the lactose in yoghurt, and, at least theoretically, would result in less lactose reaching the colon. Supermarkets may carry milk that has had the lactose already split by the addition of lactase. Substitutes for milk also are available, including soy and rice milk. Acidophilus-containing milk is not beneficial since it contains as much lactose as regular milk, and acidophilus bacteria do not split lactose.

For individuals who are intolerant to even small amounts of lactose, the dietary restrictions become more severe. Any purchased product containing milk must be avoided. It is especially important to eliminate prepared foods containing milk purchased from the supermarket and dishes from restaurants that have sauces. 2- Lactase enzyme Caplets or tablets of lactase are available to take with milk-containing foods. 3- Adaptation Some people find that by slowly increasing the amount of milk or milk-containing products in their diets they are able to tolerate larger amounts of lactose without developing symptoms. This adaptation to increasing amounts of milk is not due to increases in lactase in the intestine. Adaptation probably results from alterations in the bacteria in the colon. Increasing amounts of lactose entering the colon change the colonic environment, for example, by increasing the acidity of the colon. These changes may alter the way in which the colonic bacteria handle lactose. For example, the bacteria may produce less gas. There also may be a reduction in the secretion of water and, therefore, less diarrhea. 4- Calcium and vitamin D supplements

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