6. Malabsorbsi Dan Intoleransi - Dr. Joko WW

8/17/2019 6. Malabsorbsi Dan Intoleransi - Dr. Joko WW

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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

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6. Malabsorbsi Dan Intoleransi - Dr. Joko WW