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Malabsorbsi dan intoleransi
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CONDITIONS OF MALABSORPTION
Malabsorption: is the inability of the digestive system to
absorb one or more of•The major vitamins( B12)•Minerals (iron& calcium)• utrients (carbohydrates!fats& proteins)"
#nterruptions in the comple$ digestive process may occur
any%here in the digestive system and cause decreased
absorption"
iseases of the small intestine are the most common
cause of malabsorption"
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Pathophysiology
The conditions that cause malabsorption can be grouped into the
follo%ing categories:
Mucosal disorders' causing generalied malabsorption
(celiacsprue! regional enteritis! radiation enteritis)"
#nfectious diseases causing generalied malabsorption (small
bo%el bacterial overgro%th)
uminal problems causing malabsorption(pancreatic
insufficiency)
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Pathophysiology
The conditions that cause malabsorption can be grouped into the
follo%ing categories:
Mucosal disorders' causing generalied malabsorption
(celiacsprue! regional enteritis! radiation enteritis)"
#nfectious diseases causing generalied malabsorption (small
bo%el bacterial overgro%th)
uminal problems causing malabsorption(pancreatic
insufficiency)
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Gastrointestinal Tract
A series of organs connected in series to the outsideworld whose function is:
1. Efficient uptake fro a i!ed intake of sufficient
aounts of fuel "he!oses# aino acids# fatt$ acids% andessential cheicals "&.e.# those that cannot 'e s$nthesi(ed%.
2. E!clusion other# potentiall$ harful# organic and
inorganic copounds and infectious agents.
)his process is not norall$ perfect# howe*er
ala'sorption
is the clinical state in which digestion/a'sorption are ipaired
sufficientl$ to lead to clinical s$ptos.
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PANCREAS LIVER JEJUNAL MUCOSA LYMPHATICS BLOOD
1) Digestion 2) MicellarSolubilization
3)BrushBorderDigest,Absorpt
4) Delivery
Triglyceride
Protein
Carbohydrate
Fatty acidsMonoglycerides
Mixed micellewith bile acids
TriglyceridesynthesisChylomicronformation
Chylomicrons
PeptidesAmino Acids
Amino Acids
OligosaccharidesDisaccharides
Monosaccharides
+oral ,igestion and A'sorption
-uinal processes ucosal processes
)hese phases of digestion are re*iewed and defined in the te!t'ook.
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Efciency o Small Bowel Absorption:not perect
Nutrients
› Fat 9!9"# o tri$lyceride
› Starc% &'!9"# dependin$ on type
› (isacc%arides 9)!9
› *rotein 9"!99#
Minerals
› +ron )!,'# dependin$ on body ironstatus
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Intestinal Reserve:excessive capacity is built-in
Se-eral processes.en/ymes are present orsome di$esti-e processes
› *ancreatic and brus%!border oli$osacc%aridases
and proteinases *ancreas secretes an e0cess o en/ymes
Surace area or absorption is in e0cess
1olon sca-en$es malabsorbed carbo%ydrates
as s%ort c%ain atty acids2 products obacterial ermentation
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DIARRHEA
MALABSORPTION
elationship 'etween ,iarrhea
and ala'sorption
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0linical 0lues to +utrient ala'sorption
eight loss# fatigue# out of gas&ntake of e!cess calories without weight gain
,iarrhea: 'ulk$# oil$ stools "fat%
liuid stools "car'oh$drates%
E!cess flatus
E*idence of *itain/ineral deficiencies
glossitis# cheilosis "iron/5 *itains%
acroderatitis "(inc%
dr$ skin and hair "essential fatt$ acids%
aneia icroc$tic iron deficienc$acroc$tic folate/512 deficienc$
osteopenia/osteoporosis 7it ,/calciu
night 'lindness 7itain A
eas$ 'ruising 7itain
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9teatorrhea
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An$ular 1%eilosis
,eficiencies:
7itain 512
&ron
olate
5 *itains
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;lossitis
,eficiencies of:
7itain 512 &ron
olate
+iacin
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3ed ton$ue wit% burnin$ sensation
512 deficienc$ with h$persegented
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=inc ,eficienc$
Acroderatitis
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Acrodermatitis
-oss of hair# skin rash and diarrhea due to (inc deficienc$
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Normal di$estion:a play in acts
4uminal di$estion 5pancreatic
en/ymes6
Mucosal di$estion 5small bowel
brus% border en/ymes6
Mucosal absorption 5small bowel
mucosa2 lymp%atics6
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4uminal (i$estion o Fat
3euires pancreatic lipases
3euires conu$ated bile acids 5salts6rom t%e li-er
No small intestinal back-upavailable
1% i * titi
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1%ronic *ancreatitis:Maniestations
;ei$%t loss
› Malabsorption o at due to loss.inacti-ation opancreatic en/ymes
Bul Fat soluble -itamin de8ciency may occur in lon$!standin$ se-ere cases
Edema.%ypoproteinemia
› (ue to malnutrition wit% decreased %epaticsynt%esis o albumin.serum proteins
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0
20
40
60
80
100
0 20 40 60 80 100
Relationship between PancreaticFunction and Steatorrhea
F e c a l F a t (
g / d a y )
Pancreatic Function (%)
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E0amples o Malabsorption
4uminal Maldi$estion: Fat
› 1%ronic pancreatitis
Mucosal Maldi$estion: (isacc%aride› 4actase de8ciency
› Any malabsorbed carbo%ydrate
Mucosal Maldi$estion.Malabsorption:Generali/ed malabsorption
› 1eliac sprue
› Bacterial o-er$rowt%
8 i
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4actase (e8ciency
4actase: enterocyte brus%!border
disacc%aridase ound in nursin$mammals7
4actase splits lactose in mil< to t%e
monosacc%arides $lucose and $alactose or absorption7
Normally little o t%e en/yme is made by-illus enterocytes ater weanin$› e0ceptions are $roups o %umans w%o e0%ibit
unusual persistence o lactase t%rou$%outadult%ood
› nort%ern Europeans and ot%er =dairyin$=cultures
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Mec%anism o 4actose!+nduced (iarr%ea andFlatus
-actasesufficient
people a'sor' >8?@ of lactose
-actasedeficient
people a'sor' B?@ of lactose
62? gras ala'sor'ed
lactose C flatus
"1 g C 44 l D2%
>2? gras ala'sor'ed
lactose C flatusdiarrhea
9all
'owel
0olon
-actose;lucose;alactose
4actose
0F2D2
90A
lactose
glucose
galactose
-A)G9 F9F)&0 ,&ADEA
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1eliac Sprue + +mmune!mediated destruction o enterocytes in
response to in$estion o t%e protein gluten ound inw%eat and certain ot%er $rains7 A raction termed$liadin contains t%e immuno$enic material
Small intestinal -illi are dama$ed or destroyed ! =fatgut= appearance7
Mature di$estin$ and transportin$ enterocytes are
-irtually absent7
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1eliac Sprue ! ++
*atc%y disease ! usually a>ects pro0imalintestine more t%an distal intestine 5? w%y67
Mucosal di$estion and absorption are bot%
se-erely impaired7
1%aracteristic antibodies used in dia$nosis:+$A antibodies to tissue trans$lutaminase
or $liadin7
Nice re-iew: New En$land @ournal o Medicine":2 ,''
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Normal
9all 5owel 5iopsies
0eliac 9prue
7illi and ature enteroc$tes destro$ed
,eep cr$pts "arrows%
&nflaation
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1linical Maniestations o Sprue
;ei$%t loss2 oten wit% increased appetite
Bul
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0F
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Bacterial D-er$rowt%!+
(e8nition: o-er$rowt% o bacteria insmall bowel due to anatomic or motilityactors7
1linical conseuences:› (econu$ation o bile acids by bacterial
en/ymes 4oss o deconu$ated bile acids in stool
(ecreased bile acid pool ! not enou$% or lipiddi$estion.absorption
› (ama$e to enterocytes by bacteria
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Bacterial D-er$rowt%!++
1linical conseuences:
› +ntraluminal consumption o nutrients by
bacteria 5competition6 1arbo%ydrates2 amino acids
itamin B!,2 iron
› (ama$e to small bowel enterocytes
causin$ a sprue!li
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Approach to )hinking a'out ala'sorption
1. Dow an$ nutrientsJ9ingle nutrient "i.e.# 7itain 512%
9u'set of nutrients "i.e.# fats%
;enerali(ed ala'sorption "i.e.# se*eral nutrients%
2. hat t$pe of nutrientJ
at# car'oh$drate# protein# *itains#
inerals or co'inations
3.
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E!aples: &+)E
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Clinical Maniestations
The hallmar*s are diarrhea or fre+uent! loose! bul*y! foul
smelling stools that have increased fat content &are often
grayish"
,bdominal distention! pain! increased flatus! %ea*ness!%eight loss! &a decreased sense of %ell-being"
The chief result of malabsorption is malnutrition! manifested
by %eight loss and other signs of vitamin and mineral
deficiency (eg! easy bruising! osteoporosis! anemia)"
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Assessment and iagnostic !indings
.tool for +uantitative &+ualitative fat analysis" actose tolerance tests ! -$ylose absorption tests
/ndoscopy %ith biopsy of the mucosa is the best diagnostic
Biopsy of the small intestine is performed to assay enyme
activityor to identify infection or destruction of mucosa" 0ltrasound studies! T scans! & $-ray findings can reveal
pancreatic or intestinal tumors that may be the cause"
, complete blood cellcount is used to detect anemia
ancreatic function tests can assist in the diagnosis of specific
disorders"
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Assessment and iagnostic !indings
.tool for +uantitative &+ualitative fat analysis" actose tolerance tests ! -$ylose absorption tests
/ndoscopy %ith biopsy of the mucosa is the best diagnostic
Biopsy of the small intestine is performed to assay enyme
activityor to identify infection or destruction of mucosa" 0ltrasound studies! T scans! & $-ray findings can reveal
pancreatic or intestinal tumors that may be the cause"
, complete blood cellcount is used to detect anemia
ancreatic function tests can assist in the diagnosis of specific
disorders"
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Medical Management
#ntervention is aimed at avoiding dietary substances that
aggravate malabsorption & at supplementing nutrients
that have been lost"
ommon supplements are %ater-soluble vitamins(eg!
B12! folic acid)! fat-soluble vitamins (ie! ,! ! and 3)!
&minerals (eg!calcium! iron)"
ietary therapy is aimed at reducing gluten inta*e in
patients with celiac sprue"
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4olic acid supplements are prescribed for patients %ith
tropical sprue
,ntibiotics(eg! tetracycline! ampicillin) are sometimes
needed in the treatment of tropical sprue & bacterial
overgro%th syndromes"
,ntidiarrheal agents may be used to decrease intestinal
spasms"
arenteral fluids may be necessary to treat dehydration"
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4olic acid supplements are prescribed for patients %ith
tropical sprue ,ntibiotics(eg! tetracycline! ampicillin) are sometimes
needed in the treatment of tropical sprue & bacterial
overgro%th syndromes"
,ntidiarrheal agents may be used to decrease intestinalspasms"
arenteral fluids may be necessary to treat dehydration"
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+ntoleransi la
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*enyebab %ipola