Nutrition in Malabsorption Syndrome1

NUTRITION IN NUTRITION IN MALABSORPTION MALABSORPTION SYNDROMESYNDROME

Boerhan HidayatDepartment of Child Health

Medical Faculty-Airlangga UniversityDr.Soetomo General Hospital

Surabaya

What is “Malabsorption”?

The integrated processes of digestion and absorption have 3 phases:

• Luminal phase- dietary carbohydrates, proteins and fats are hydrolysed and solubilized largely by pancreatic and biliary secretions

•Mucosal phase - final hydrolysis and uptake by epithelial cells prior to cellular export

•Transport phase - absorbed nutrients enter vascular or lymphatic circulation

Disturbances of these processes lead to “malabsorption”

Some causes of malabsorption

Luminal Mucosa Transport Inadequate mixing Mucosal damage Lymphatic disease e.g. post-gastric or disease e.g. lymphangiectasia

surgery e.g. resection coeliac disease

Enzyme deficiency Crohn’s disease e.g. pancreatic disease infections

Bile salt deficiency e.g. cholestasis deconjugation excessive loss

Common luminal causes

• Post-gastric surgery • Chronic pancreatitis

• Bile salt deficiency -chronic liver disease - contaminated

bowel syndrome - ileal disease

(Crohn’s/resection)

Common Intestinal Symptoms Intestinal gas and flatulence Constipation Diarrhea Steatorrhea Gastrointestinal strictures and

obstruction

Normal Function GI

Absorption Most nutrients absorbed in jejunum Small amounts of nutrients absorbed

in ileum Bile salts & B12 absorbed in terminal

ileum Residual water absorbed in colon

Principles of Nutritional Care Dietary modifications

To alleviate symptoms Correct nutritional deficiencies Address primary problem Must be individualized

SteatorrheaDietary Modification

Increase kcal to meet needs, especially protein and carbohydrate

Control fat levelGive only level toleratedUse MCT oil to meet kcal needs with caution

Vitamin and mineral supplementsUse fat-soluble vitamins; add extra Ca, Mg, Zn, Fe

SteatorrheaMCT Oil

8 to 10 carbons long Bile not needed for absorption Delivered to liver via blood 8.3 kcal/g

1 T = 116 kcal Expensive Increases osmolality of tube

feedings

Celiac DiseaseGluten-Sensitive Enteropathy Adverse reaction to gluten—

gliadin fraction Intestinal mucosa damaged

—Malabsorption of nutrients—Iron deficiency—Osteomalacia—Growth failure—Projectile vomiting

Celiac Disease−Cause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

Celiac Disease−Pathophysiology

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenisis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)


Celiac Disease−Medical and Nutritional Management


Celiac DiseaseGluten-Sensitive Enteropathy

TreatmentRemove gluten from the diet:

—Wheat —Rye—Buckwheat—Barley

Tropical Sprue

Cause unknown; imitates celiac disease Results in atrophy and inflammation of villi Sx: diarrhea, anorexia, abdominal distention Rx: tetracycline, folate 5 mg/d, B12 IM

Intestinal Brush Border Enzyme Deficiencies Lactose intolerance Causes: genetic or secondary deficiency of milk

sugar enzyme, lactase—Blacks, Asians, Native Americans—Aging: damage to GI tract

Dx: lactose tolerance test or breath hydrogen test

Rx: avoid large amounts of lactose(milk protein allergy requires milk-free diet);

take lactase enzyme; processed dairy sometimes OK

Inflammatory Bowel Disease

Crohn’s disease or ulcerative colitis Both involve damage to the intestine Crohn’s: may damage either small or

large intestineDisease progression varies

Ulcerative colitis: begins at rectum and progresses up the large intestine

Inflammatory Bowel Disease−Cause


Inflammatory Bowel Disease−Pathophysiology


Inflammatory Bowel Disease−Medical and Nutritional Management


Inflammatory Bowel Diseases

Rx:Diet depends on patient’s statusNutrition assessmentSelect route of feedingFiber is beneficial except during

flareups.

Disorders of the Large Intestine

1. Irritable bowel syndrome—Common syndrome involving altered intestinal motility, increased sensitivity

of the GI tract, and increased awareness and responsiveness of the viscera to internal and external stimuli

—Alternating constipation and diarrhea, abdominal pain, and bloating

Disorders of the Large Intestine —cont’d2. Diverticular disease

—Herniations of the colon, chronic diverticulosis, acute

diverticulitis—Diverticulosis

High-fiber diet: fruits, vegetables, whole grains (2 tsp bran daily)

—DiverticulitisLow-residue or elemental diet Possibly low-fat diet

Disorders of the Large Intestine —cont’d

3. Colon cancer and polyps—Colon cancer is the second most

common cancer among US adults—Polyps are considered precursors of colon cancer.

Short Bowel Syndrome Follows removal of more than two

thirds of small intestine Causes weight loss; diarrhea;

decreased transit time; malabsorption; dehydration; loss of electrolytes; hypokalemia

Short Bowel Syndrome —cont’d Removal of ileocecal valve causes

more complications. Fat malabsorption frequent

SteatorrheaSaponify calcium, zinc, and magnesiumRemove ileum and lose B12 and bile salt absorption

Short Bowel Syndrome —cont’d

Length of remaining small intestine Loss of ileum, especially distal one third Loss of ileocecal valve Loss of colon Disease in remaining segments(s) of

gastrointestinal tract Radiation enteritis Coexisting malnutrition Older age surgery

Factors Affecting Severity of Malabsorption, Number Factors Affecting Severity of Malabsorption, Number of Complications, and Dependence on Parenteral of Complications, and Dependence on Parenteral NutritionNutrition

Short Bowel SyndromeNutritional Care Step 1

Parenteral only for most patients Step 2

Gradually introduce enteral nutrition.

Glutamine is an important nutrient for the gut.

Narcotic drugs for pain cause GI problems and should be evaluated.

Short Bowel Syndrome Eventually the remaining bowel

increases absorptive surface, and problems decrease.

Nutrition support is designed to meet each patient’s needs.

Other Bowel Diseases Irritable bowel syndrome

Alternating diarrhea and constipation Rx:

High-fiber diet: be careful with wheat bran

Elimination of stimulantsEvaluate for food allergies or

intolerances

Blind Loop Syndrome Bacterial overgrowth from stasis in

intestine, obstruction, radiation enteritis, fistula, or surgical repair

Treatment (Rx):Appropriate needs for malabsorptionAntibiotics for bacterial overgrowth

Diet Modification of Fiber in Diets

Restricted-fiber diet 5 to 10 g/day High-fiber diet 25 to 35 g/day Minimal-residue diet or elemental

formulas

Causes of Constipation— Gastrointestinal

Diseases of the upper gastrointestinal tract—Celiac disease—Duodenal ulcer

Diseases of the large bowel resulting in: —Failure of propulsion along the colon

(colonic inertia)—Failure of passage though anorectal

structures (outlet obstruction) Irritable bowel syndrome Anal fissures or hemorrhoids Laxative abuse

Causes of Constipation—Systemic

Side effect of medication Metabolic endocrine abnormalities, such as

hypothyroidism, uremia, and hypercalcemia

Lack of exercise Ignoring the urge to defecate Vascular disease of the large bowel Systemic neuromuscular disease leading to

deficiency of voluntary muscles Poor diet, low in fiber Pregnancy

FistulaAbnormal Opening Between Organs

Causes: birth defects; trauma; inflammatory disease; malignant disease

Rx:For fluid lossFor electrolyte lossAggressive nutritional support

Ileostomy or ColostomySurgical Opening of Intestine to Outside

Causes: ulcerative colitis; Crohn’s disease; colon cancer; trauma

Rx:Nutrition needs vary with location

and individualAvoid gas- or odor-forming foodsFluid and electrolyte needs

Hemorrhoidectomy

Delay stool formation until healing can

take place Rx:

Minimal-residue diet or elemental diet After recovery

High-fiber diet to prevent

High-Fiber Diets Most Americans = 10 – 15 g/day Recommended = 25 g/day More than 50g/day = no added

benefit, may cause problems

Low- or Minimum Residue Diet

Foods completely digested, well absorbed Foods that do not increase GI secretions Used in:

Maldigestion Malabsorption Diarrhea Temporarily after some surgeries, e.g.

hemorrhoidectomy

IBD Nutritional Management (acute)

Low-residue, low-fiber liquid diet “Bowel rest” with parenteral

nutrition Enteral nutrition may have

better success at inducing remission

Diet tailored to individual pt: Minimal residue for reducing diarrhea Limited fiber to prevent obstruction Small, frequent feedings Supplements , MCT with fat

malabsorption

IBD Nutritional Management (chronic)

High protein, high calorie diet with oral supplements

Monitor vitamin-mineral status of iron, calcium, selenium, folate, thiamin, riboflavin, pyridoxine, vitamin B12, zinc, magnesium, vitamins A, D, E

High fiber diet as tolerated Avoid unnecessary restrictions

Diverticulosis High fiber diet (increase gradually) Supplement with psyllium,

methylcellulose may be helpful 2 – 3 qt water daily with high fiber

intake Low fat diet may be helpful ? Avoid seeds, nuts, skins of plants

Colon Cancer/Polyps: dietary risk factors

Increased meat intake, esp. red meats

Increased fat intake Low intakes of vegetables, high

fiber grains, carotenoids Low intakes of vits D, E, folate Low intakes of calcium, zinc,

selenium

Colon Cancer/Polyps: possible dietary protective factors

Omega-3 fatty acids –fish oils, flaxseed, etc

Wheat bran Legumes Some phytochemicals (plants) Butyric acid – dairy fats,

bacterial fermentation of fiber in colon

Calcium

Summary Lower GI conditions—important for

nutritional consequences Important to note where obstruction

or surgery has taken place to determine impact on specific nutrients

Most dramatic: short bowel syndrome, which may require long-term TPN

Summary Food intolerances should be dealt

with individually Patients should be encouraged to

follow the least restrictive diet possible

Patients should be re-evaluated frequently and the diet advanced as appropriate

Documents

Nutrition in Malabsorption Syndrome1