Malabsorption

Manisha Hyongoju
Malabsorption
• Malabsorption is the inability of the digestive system to
absorb one or more of the major vitamins (especially A and
B12), minerals ( iron and calcium) and nutrients
( carbohydrates, fats and proteins).
• Interruptions in the digestive system and causes decreased
absorption.
• Impairment can be of single or multiple nutrients depending
on the abnormality.
Malnutrition
• This may lead to malnutrition and a variety of
anemias.
• The most common clinical presentation is chronic
diarrhea.
• The hallmark of malabsorption is steatorrhea.
• Lactose intolerance is most common malabsorption
disorder.
Causes
1. Enzymes deficiency
• Lactase deficiency
• Pancreatic insufficiency
• Chronic pancreatitis
• Zollinger Ellison syndrome
2. Disturbed vascular circulation
• Mesentric Ischemia
• Heart failure
Causes
3. Bacterial proliferation
• Tropical sprue
• Parasitic infection
4. small intestinal mucosal disruption
• Celiac’s disease
• Crohn’s disease
Causes
5. Surgery of the gastrointestinal tract that bypasses or
removes parts of the stomach or intestines
6. Biliary atresia (blockage of the ducts that transport
bile from the liver to the gallbladder)
7. Structural defect
1. Enzyme deficiency
• Enzymes deficiencies
Lactase deficiency :- lactase deficiency is most common cause
of lactose intolerance in which inability to digest lactose , the
main carbohydrate in dairy products.
• Pancreatic insufficiency :- It is the condition which occurs
when the pancreas doesn’t make enough of a specific
enzymes the body uses to digest food in the small intestine.
• Chronic pancreatitis :- It is a continuing, chronic
inflammatory process of the pancreas, characterized by
irreversible morphological changes and reduced the capacity
for enzyme secretion more than 90%.
• Zollinger Ellison’s syndrome:- It is caused by non- beta cell,
gastrin- secreting tumor of the pancreas that stimulates the
acid- secreting cells of the stomach to maximal activity with
consequent gastrointestinal mucosal ulceration.
2. Disturbed vascular circulation
• Mesenteric ischemia: interruption in blood flow to intestine.
This cause tissue hypoxia and progress to infraction and
necrosis. Which causes disruption of mucosal barrier
and perforation and hence leads to malabsorption.
• Heart failure: heart can’t supply sufficient blood to body cells
and body cannot function properly. Which disturbs in enzyme
secretion and leads to malabsorption.
3.Bacterial proliferation
 Tropical sprue:- It is a malabsorption disease with abnormal
flattening of the villi and inflammation of the lining of small
intestine.
 Parasitic infectious:- In hook worm infestation ,there is
reduces food intake( anorexia) and / or increase nutrient
wastage via vomiting, diarrhea or blood loss.
4. Small intestinal mucosal
disruption
 Celiac’s disease ;- It is hereditary intolerance to gluten that
cause characteristics changes in the lining of the small
intestine, resulting in malabsorption.
 Crohn’s disease:- It is an inflammatory or ulceration
condition of the GI tract that may affect the small intestine,
thus resulting malabsorption syndrome.
Risk factors
• Older age
• Male gender
• Abdominal disease or deformities
• Abdominal surgeries
• Radiation therapy
• Certain medications ( laxatives, antibiotics)
• Bodily fluid looses( emesis, polyuria, wound drainage, diarrhea)
• Excessive alcohol use
Pathophysiology
• In general, the digestion and absorption of food materials can be divided into
three major phases: luminal, mucosal, and postabsorptive.
1. The luminal phase is the stage in which dietary fats, proteins, and
carbohydrates are hydrolyzed and solubilized by secreted digestive
enzymes and bile.
2. The mucosal phase relies on the integrity of the brush-border membrane
of intestinal epithelial cells to transport digested products from the lumen
into the cells.
3. postabsorptive phase reassembled lipids and other key nutrients are
transported via the lymphatics and portal circulation from epithelial cells to
other parts of the body.
• When disease process disturb any these phase, malabsorption frequently
results.
Gastrointestinal
• Gastrointestinal
• Weight loss( malabsorption of fat, carbohydrates and protein
leading to loss of calories)
• Diarrhea(impaired absorption of water, sodium )
• Steatorrhea( undigested and unabsorbed fat )
• Glottis, stomatitis( deficiency of iron , riboflavin, folicacid)
Hematologic
• Anemia(impaired absorption of iron , cobalamin and folic
acid)
• Hemorrhagic tendency(vitamin c deficiency ,vitamin D
deficiency inhibiting production of clotting factors )
Musculoskeletal
• Bone pain( osteoporosis from impaired calcium
absorption)
• Tetany ( hypocalcemia, hypomagnesemia)
• Weakness muscles cramps( anemia, electrolyte
depletion especially potassium)
• Muscle wasting( protein malabsorption)
Neurologic

• Altered mental status (dehydration)

• Hypotension ( dehydration)
• Tachycardia ( hypovolemia , anemia)
• Peripheral edema ( protein malabsorption,
protein loss in diarrhoea).
Diagnostic measures
1. History taking
2. Physical examination
3. Stool test: Fecal occult blood, stool culture, test for stool fat
4. Blood test:
• Complete blood count : to evaluate red blood cells to detect
anemia due to iron deficiency or vitamin B12 or folate
deficiency.
• Prealbumin: used for protein malabsorption and indicates
general nutritional status.
Diagnostic measures
• Erythrocytes sedimentation rate (ESR):to detect
inflammation in the body
• Levels of vitamins , such as vitamin B12 , vitamin D,
vitamin A- to detect deficiency.
• Prothrombin time (PT) : to detect vitamin K deficiency
• Amylase , lipase – to evaluate pancreatic enzymes.
Diagnostic measures
5. Schilling test measures urinary excretion of vit B12 for
diagnosis of pernicious anemia and other malabsorption
syndromes.
6. Hydrogen breath test : to detect lactose intolerance and
bacterial overgrowth in the digestive system.
7. Bone density test is used to measure bone minerals content
and density. It may be done using dual – energy x-ray
absorptiometry for osteoporosis.
Diagnostic measures
8. Biopsy:- It can be done through endoscopy , if
suspected abnormal cells in the small intestine.
9. Ultrasonography is used to diagnose pancreatic
tumors and tumors of small intestine that is caused
by malabsorption.
ultrasonography
Medical Management …1/4
• Management depends upon the underlying cause .
• Celiac disease requires a strict gluten – free diet.
• Pancreatic insufficiency requires the oral administration
of enzymes with foods such as creon, pancreaze,
zenpep .
Medical management…2/4
• If there is folate deficiency and possibly vitaminB12
deficiency too, it is imperative to give an injection of
vitamin B12.
• Anti- diarrheal drugs:- loperamide 2mg ( per oral) and
bismuth subsalicylate that treat longer lasting diarrhea
from bowel problems.
• Take a vitamin and supplementation as advice by
doctors.
Medical management…3/4
• proton pump inhibitors are the first line of treatment
for decreasing acid production in Zollinger-Ellison
syndrome.
• Mesenteric ischemia that develops over time
(chronic) is treated with angioplasty or open surgery.
Medical management..4/4
• Antibiotics agents( metronidazole, rifaximin) may
be used to treat small intestinal bacterial overgrowth
• Corticosteroids and anti- inflammatory agents also
used.
• Parental fluids may be necessary to treat
dehydration.
Assessment
• Vital signs assessment
• Intake and output for positive and negative balance.
• Nausea, vomiting and signs of dehydration
• Assess the client’s weight.
• Pain assessment
• Obtain history about previous disease related to GIT.
Nursing diagnosis
• Imbalanced nutrition : less than body requirement
related to impaired absorption .
• Potential fluids volume deficit related to profuse
vomiting.
Nursing intervention
• Symptomatic management: Patient’s faced
different problems such as continue diarrhea,
anxiety for symptoms, acute pain, bloating , so we
provide psychological support, listen to patient
problems, promotes bedrest, provide bedside
commode, encouraged for oral fluids intake ,
liquids diet, oral rehydration solutions (ORS).
Nursing intervention
• The nurse provides patient and family education
regarding diet and the use of nutritional supplements.
• It is important to monitor patients with diarrhea for
fluids and electrolytes imbalance.
 Nursing intervention
• Record number and consistency of stools per day to gives
baseline and helps direct replacement fluids therapy
• If patient receiving intravenous calcium, the nurse needs
to monitor the IV site for infiltration or phlebitis every
hour.
 Nursing intervention
• If patient has problems of stomatitis due to deficiency of
riboflavin than patient should be avoid acidic, spicy hard
and hot foods,
• Also practice good personal hygiene( mild
toothpaste),avoid mouth washes containing alcohol,
hydrogen peroxide, iodine.
Nursing intervention
• Clean with mild soap and warm water after each stool in
order to decrease the problems in perineal area .
• Encourage patient for gluten – free diet and lactose – free diet
.
• Evaluation dehydration by observing skin turgor.
• Regular monitoring of symptoms, weight in relation to
nutritional status.
 Prevention
• Consume a high calorie diet to help absorb more nutrient
such as yoghurt , dark chocolate, banana , chicken , milk ,
egg, nut butter, avocado..
• Eat 6 small meals spaced throughout day.
• Work with dietician to plan a diet that meet nutritional needs.
• Eat more omega – 3 fatty acids such as salmon fish oil,
cauliflower, mackerel, chia seeds, walnuts because they
reduce inflammation.
 Prevention
• Avoid foods that trigger diarrhea, abdominal pain, or
excessive gas.
• Avoid gluten containing foods in celiac disease .eg wheat ,
barley , rye. and consume healthy gluten free foods include
vegetables, nuts, seeds , fruits , grains.
• Avoid foods that trigger diarrhea, abdominal pain, or
excessive gas.
 Prevention
• Dietary modification are changes made during food
preparation, processing, consumption to increase the
bioavailability of micronutrient and reduces
micronutrient deficiencies.
 Supplementation of fat soluble and water soluble
nutrient for energy metabolism , protects cell wall,
proper blood clotting, helps in immune system.
Avoid foods that triggers for crohn’s diseases:-
• Eat smaller meals .
• Drink small amount of water.
• Avoids nuts , seeds and popcorn.
• Avoid raw fruits and vegetables and their cooked
skins.
• Avoid fatty , greasy or fried foods.
• Avoid spicy foods and limit diary products.
 If patient has lactose -intolerance then keep the mind
not to gives dietary products include milk and milk
products.
 Limit alcoholic beverages :- alcohol can irritate
bowel that worsened the symptoms.
 Consumed foods that can easier to digest and better
to tolerance.
Complication
• Slower growth.
• Greater chance of infection.
• Osteoporosis ( low bone density) which increase
bone fracture.
references
1. Lewis S.L, Dirksen S.R, Heitkemper M.M, Buchor L. Medical surgical
nursing :assessment and management of clinical problems 9 th edition ( 2014):
mosbey elsevier page no : 997
2. kasper DL, fauci AS, Hauber S editor, Harrison’s principles of internal medicine ,
20th edition. New York :The Mc Graw- hill companies. Page no :267
3. https://labtestsonline.org/conditions/malabsorption
4. https://emedicine.medscape.com/article/180785-overview
5. https://emedicine.medscape.com/article/180785-treatment