2. Malabsorption
Disorders in which there is disruption of digestion
and nutrient absorption

3. Clinical manifestations
Steatorrhea (bulky, light colored stools)
Diarrhea
TG’s
Fats, CHO, Water
Weight loss; muscle wasting Fats, Proteins, CHO
Anemia
Iron, B12, folate
Paresthesias, tetany, Calcium, Vit D
Bone pain pathological fractures, deformities Calc
Bleeding tendencies Vitamin K
Edema Proteins

4. Laboratory findings
Increase in fecal fats
Decreased albumin and proteins
Decreased Ca, Iron, B12, red cell folate
Prolonged prothrombin time
Abnormal D-Xylose absorption
Decreased Vitamin A, carotene levels

5. Normal digestion
Intraluminal phase: Nutrients are hydrolyzed
and solubilized
fats: monoglycerides and fatty acid
proteins: di- and tri-peptides, amino acids
CHO: di- and mono-saccharides

6. Defects in intra-luminal phase
Decreased pancreatic enzymes
Chronic pancreatitis, cystic fibrosis, Z-E syndrome
Insufficient bile salts
Biliary obstruction
Resection and /or diseases of terminal ileum
Bacterial overgrowth
Produce significant steatorrhea. Protein and CHO
digestion is affected less

7. Mucosal phase
Sufficient surface area of intestinal epithelium
Brush border enzymes

8. Defects in mucosal phase
Deficiency of brush border enzymes
Lactase
Short bowel syndrome
Malabsorption of all nutrients; fats, CHO, and
proteins

9. Absorptive phase
Majority of nutrients are directly absorbed from
epithelial cells into blood stream
Chylomicrons and lipoproteins are absorbed through
lymphatics; lymphatic obstruction can impair their
absorption
Leads to steatorrhea and protein losing enteropathy

10. Labs
Routine blood tests in
malabsorption
Microcytic anemia (iron deficiency)
Macrocytic anemia(folate or B12 deficiency)
Increased prothrombin time (vit. K def)
Hypoalbunemia
Hypocalcemia and Vit. D def
Deficiencies of zinc, phosphate, and magnesium

11. Case presentation
Ms. Sakina is 22years of age and came to her
physician with complaints of weakness, easy
fatiguability and body aches and pains.
She passes 2-3 loosely formed, pale and bulky stools
per day, and has abdominal bloating for the last six
months.
She has a reasonable appetite; has no food fads; and
belongs to middle socioeconomic class.

12. No past H/O abdominal complaints.
No associated fever or constitutional symptoms.
No H/O abdominal surgery or radiation therapy.
One elder sister has related symptoms.

13. Differential diagnosis
What is the possible cause?
Malabsorption
Intra-luminal phase defects?
Mucosal phase defects?
Absorptive phase defects?

14. Physical findings
Ms. Sakina was found to be pale. Her BMI was 19.6.
She neither had edema nor any skin bruises. She had
bone tenderness and a positive Chvostek’s sign.
The abdomen was distended, soft, non tender, with
no organomegaly; it was hyper-resonant on
percussion.
Can you make a diagnosis now?

15. Lab findings
Hb
TLC, DLC, PLT
75gm/l
normal
Retics count
1.2%
Red cell morphology microcytic, hypo chromic
PTT
4sec prolonged
Serum albumin
Serum calcium
38gm/l
8.8mg/dl

16. What is this history, physical examination, and lab
data suggestive of?
Malabsorption due to ?
Further lab tests are needed to find a possible
cause

17. Establishing the cause
Small intestinal biopsy
Normal histology with well formed
villous pattern almost excludes diffuse
small intestinal mucosal disease
Biopsy is usually abnormal in
Celiac
disease
Tropical sprue
Whipple’s disease

20. Establishing the cause
Small intestinal radiography is usually diagnostic
in diseases with a gross anatomical abnormality as
jejunal diverticulosis precipitating bacterial
overgrowth, diffuse Crohn’s disease, and lymphoma.
Hydrogen breath test
Pancreatic imaging
Plain X-rays, USG, CT scan, and ERCP

22. Usual causes of generalized
malabsorption
Post infectious malabsorption / tropical sprue
Celiac disease (Non-tropical sprue)
Bacterial overgrowth
Diverticulosis, blind loops, hypo motile states
Short gut syndrome
Immunodeficiency
Pancreatic diseases

23. Ms. Sakina had a normal Plain X-ray of abdomen.
Her abdominal USG was also normal.
 A small bowel enema was done and it did not reveal
any abnormality.
Hydrogen breath test after 50 gm lactose was also
unremarkable.

24. Duodenal biopsy from D2 revealed a blunting and
shortening of villous pattern and infiltration of lamina
propria with plasma cells and lymphocytes.
Antibodies against gliadin, reticulin, and
endomysium were present.
Diagnosis?
COELIAC DISEASE

25. Ms. Sakina was treated with a short course of steroids
and was advised strict gluten free diet. Her symptoms
improved dramatically and steroids were withdrawn,
after tapering, in six weeks
Four months later, the duodenal biopsy was found to
be normal.

26. Alternative scenarios
If the abdominal USG shows calcification in the
region of pancreas and D-xylose test is abnormal?
Ms. Sakina has a past H/O Hodgkin’s Lymphoma and
H/O abdominal radiation?
Duodenal biopsy shows villous atrophy but antibody
screen is negative

27. Alternative scenarios
Small bowel enema shows jejunal diverticulosis and
hydrogen breath test is positive?
Small bowel enema is normal but hydrogen breath
test is positive?
Ms. Sakina has normal lab tests, USG abdomen, and
Barium followthrough?

28. Take home message
In a case of chronic diarrhea first establish the
presence of malabsorption and if present the
work up the cause of malabsorption

29. Thank you