MALABSORPTION AND CELIAC DISEASE
Key Clinical Questions Malabsorption and Celiac Disease
Small Bowel Obstruction Small Bowel Ileus Acute Mesenteric Ischemia
Does this patient have malabsorption?
Is the malabsorption due to celiac disease?
What other diseases need to be considered?
What are the consequences of malabsorption?
How is malabsorption managed?
Does this patient have acute mesenteric ischemia?
How does mesenteric ischemia differ from colonic ischemia?
Is emergent surgery necessary?
Numerous causes lead to malabsorption and maldigestion, ranging from the common to the obscure. Causes of malabsorption and maldigestion include celiac disease, small bowel bacterial overgrowth, Crohn disease with small bowel involvement, chronic pancreatitis, short bowel syndrome, protein losing enteropathy, intestinal lymphangiectasias, amyloid, small bowel lymphoma, eosinophilic gastroenteritis, common variable immunodeficiency, lactose intolerance and other disaccharidase deficiencies, and Zollinger-Ellison syndrome (Table 162-1).
TABLE 162-1Disorders Associated with Malabsorption ||Download (.pdf) TABLE 162-1 Disorders Associated with Malabsorption
|Disorder ||Affected Nutrient(s) ||Mechanism(s) |
|Chronic pancreatitis ||Fat ||Lipase and colipase deficiencies |
| ||Carbohydrate ||Pancreatic amylase deficiency |
| ||Protein ||Protease deficiencies |
|Cystic fibrosis ||Protein ||Impaired protease excretion |
|Zollinger-Ellison syndrome ||Fat, protein ||Digestive enzyme inactivation |
|Cirrhosis ||Fat, fat-soluble vitamins ||Decreased bile salt production |
|Chronic cholestasis ||Fat, fat-soluble vitamins ||Impaired bile salt secretion |
|Bacterial overgrowth ||Fat, fat-soluble vitamins ||Bile salt deconjugation |
| ||Carbohydrate ||Damage to brush border enzymes |
| ||Protein, carbohydrate, vitamin B12 ||Consumption of nutrients by bacteria |
|Lactose intolerance ||Lactose ||Lactase deficiency |
|Celiac disease, tropical sprue, common variable immunodeficiency ||Carbohydrate ||Decreased brush border enzyme activity due to villous damage |
| ||Carbohydrate, protein, fat ||Decreased absorptive surface area |
|Short bowel syndrome ||Fat, carbohydrate, protein, vitamin B12 ||Decreased absorptive surface area |
|Pernicious anemia ||Vitamin B12 ||Impaired production of intrinsic factor |
|Ileal disease (eg, Crohn, lymphoma, amyloid) ||Vitamin B12 ||Decreased absorptive surface |
|Intestinal lymphangiectasia ||Fat, fat-soluble vitamins ||Impaired transport into lymphatics |
Lactose intolerance is a common cause of maldigestion. It is present in 7% to 20% of Caucasian adults, 50% of Hispanics, 65% to 75% of African Americans, and 90% of some East Asian populations. Celiac disease is most commonly seen in whites of northern European ancestry. In a large screening study from the United States, the prevalence of celiac disease in average risk individuals was 1:133. The prevalence was highest in first-degree relatives of a patient with celiac disease (1:22). Other disorders, such as primary intestinal lymphangiectasias, occur so rarely that it is difficult to estimate their true prevalence.
While generally managed as outpatients, patients with severe malnutrition or dehydration may need admission for nutritional support, volume repletion, and to correct electrolyte abnormalities. Significant weight loss (>10%) is ...