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For further information, see CMDT Part 15-27: Malabsorption

Key Features

  • Malabsorptive condition following removal of significant portions of the small intestine

  • Causes

    • Crohn disease

    • Mesenteric infarction

    • Radiation enteritis

    • Volvulus

    • Tumor resection

    • Trauma

  • Type and degree of malabsorption depend on length and site of resection and degree of adaptation of remaining bowel

Clinical Findings

  • Terminal ileal resection

    • Watery diarrhea

    • Malabsorption of bile salts and vitamin B12

    • Low serum vitamin B12 levels

    • Steatorrhea and malabsorption of fat-soluble vitamins

    • Cholesterol gallstones

    • Calcium oxalate kidney stones

  • Extensive (> 40–50%) small bowel resection: short bowel syndrome, characterized by weight loss and diarrhea due to nutrient, water, and electrolyte malabsorption

Diagnosis

  • Clinical diagnosis based on presence of diarrhea and malabsorption with prior bowel resection

Treatment

Terminal ileal resection

  • Vitamin B12 injections subcutaneously or intramuscularly monthly

  • If watery diarrhea, bile salt-binding resins with meals (cholestyramine, 2–4 g/day orally, colestipol tablets 1–2 g orally once or twice daily, or colesevelam, 625 mg, 1–3 tablets orally twice daily)

  • Cholestyramine or colestipol doses can be slowly increased (cholestyramine maximum 24 mg/day; colestipol tablets 16 g/day), but the higher doses are associated with increased side effects of nausea, bloating, and constipation

  • Calcium supplements to bind oxalate

Extensive small bowel resection

  • If the colon is preserved, 100 cm of proximal jejunum may be sufficient to maintain adequate oral nutrition with a low-fat, high–complex-carbohydrate diet

  • If the colon has been removed, at least 200 cm of proximal jejunum is typically required to maintain oral nutrition

  • Parenteral vitamin supplementation

  • Monitor levels of zinc, selenium, and magnesium

  • Antidiarrheal agents (eg, loperamide, 2–4 mg three times daily orally)

  • Octreotide

  • Proton pump inhibitor to reduce acid hypersecretion

  • Total parenteral nutrition (TPN) required if < 100–200 cm of proximal jejunum intact

  • TPN has an estimated annual mortality rate of 2–5% resulting from TPN-induced liver disease, sepsis, loss of venous access

  • Teduglutide

    • Stimulates small bowel growth and absorption

    • Has resulted in a reduced need for parenteral nutrition

  • Small intestinal transplantation, chiefly for patients in whom severe problems develop from TPN

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