1. Clinical Approach to Mal digestion & Malabsorption APS

2. OVERVIEW Defect either in –DIGESTION OR –ABSORPTION

3. Malabsorption Defect in maldigestion/malabsorption can be Macronutrient –Carbohydrate –Fat –Protein Micronutrient –Vitamins –Trace elements

4. Clinical manifestations Depends on which component is affected Fat Protein Carbohydrate Vitamins Trace elements

5. Defect in Fat malabsorption Symptoms Passage of large, bulky, foul smelling, floating stool which tends to stick to bottom of pan. Signs Patient looks emaciated & under weight Causes of Fat maldigestion /absorption:- Ch.pancreatitis.Defective metabolism of Bile acidsLoss of jejunum mucosa

6. Defect in Protein malabsorption Patients look –Wasted –Oedema –Muscle atrophy

7. Carbohydrate malabsorption Features are –Watery diarrhoea –Abdominal distension –Borborygmi –Flatulence 1-2 hours after ingestion of food

8. CBC Stool exam for excretion of Fat>6 gm /day LFT for Proteins Dxylose test for Carbohydrate absorption Vit level estimation Pancreas evaluation

9. Malabsorption of Vitamins Fat soluble Vitamins –Def of Vit A Xeroopthalmia Night Bilndness Corneal ulceration & Loss of vision Bitot’s spot Toad skin

10. Bitot’s spot

11. Corneal opacity

12. Xeroopthalmia Vit A def

13. Skin manifestation of Vit A def

14. VITAMIN “D” defeciency –Rickets –Osteomalacia

15. Rickets

16. Vit D def-Rickets

17. Rickets

19. Vit K Defeciency Occurs in association with malabsorption of fat –Manifests as bleeding disorders Due to poor synthesis of Clotting factors like factor 2, 7,9 & 10 Clinically manifesting as mucosalbleed Easy bruising & intracranial bleed

20. Vitamin B12 defeciency Defect in stomach –Lack of Intrinsic factotrs –Gastrectomy due to carcinoma stomach ) –Atrophy of gastric mucosa due to pernicious anemia. Defect in terminal ileum –Loss of absorptive surface due to disease of terminal ileume. –Chrohn’s disease, –Resection of terminal ileum –Fish tapeworm infestation

24. Protein malnutrion

25. Coeliac disease

26. Celiac disease Results in the inability to properly digest a protein known as gluten. Gluten is found in certain grains: wheat, rye, barley and oats. An individual will have an immunological reaction to gluten, causing irritation and damage to the lining of the small intestine. T his damage will cause the small intestine to be unable to fully absorb specific nutrients.

27. Cause of COELIAC DISEASE Not known. The disease is inherited; An individual that has a family member with celiac disease has an up to twenty percent chance of having the disease as well. Disease can appear spontaneously after a severe strain to the body such as physical injury, infection, pregnancy or surgery.

28. Common symptoms of Coeliac disease Bloating, irregular bouts of diarrhea, and abdominal pain. These symptoms mimic other diseases such as parasite infections, anemia, gastric ulcers and irritable bowel syndrome.

29. Diagnosis of Coeliac disease Blood tests -Antibodies are elevated –anti-gliadin, –anti-endomysium, and –anti-tissue transglutaminase Biopsy of Jejunum mucosa –Atrophy of mucosa

30. Treatment of Coeliac Disease No cure for celiac disease, the damage can be controlled and the intestine will heal itself. To have gluten free diet. Once gluten is eliminated the small intestine villi will heal and proper digestion will resume.

31. Lactose intolerance Lactase deficiency; Milk intolerance; Disaccharidase deficiency; Dairy product intolerance

32. Lactose intolerance Lactose intolerance is very common in adults. It is rarely dangerous In Caucasians, lactose intolerance often develops in children older than age 5. In African Americans, the problem can occur as early as age 2.

33. Lactose is a type of sugar found in milk and other dairy products. Lactose intolerance develops when the small intestine does not make enough of an enzyme called lactase. The body needs this enzyme to digest lactose.

34. Other causes of lactose intolerance Bowelsurgery Infections in the small intestine from viruses, bacteria, or parasites (most often seen in children, but can also occur in adults) Intestinal diseases such as celiac sprueceliac sprue

35. Lactose intolrance Symptoms Symptoms often occur 30 minutes to 2 hours after having milk products. Large doses of milk products may cause worse symptoms. Abdominal bloating Abdominal cramps Diarrhea Gas Nausea

36. Signs and tests Other intestinal problems, such as irritable bowel syndrome, may cause the same symptoms as lactose intolerance.irritable bowel syndrome Tests to help diagnose lactose intolerance include: Lactose-hydrogen breath test Lactose tolerance test Stool pH

37. Treatment of Lactose intolrance Treatment Cutting down or removing milk products from your diet usually eases symptoms.

38. Treatment of LI Milk products may be easier to digest include: Buttermilk and cheeses (have less lactose than milk) Fermented milk products, such as yogurt Goat's milk Ice cream, milkshakes, and aged or hard cheeses Lactose-free milk and milk products Lactase-treated cow's milk for older children and adults Soy formulas for infants younger than 2 years Soy or rice milk for toddlers