PROF. DR. SHAHENAZ M. HUSSIEN

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Digestive system II

• PROF. DR. SHAHENAZ M. HUSSIEN

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MALABSORPTION

• OBJECTIVES
• By the end of this lecture you will be able to
  know the followings
• -Definition and clinical manifestations of
  malabsorption.
• -Types of malabsorption.
• -Investigations required for diagnosis.
• -Lines of management of malabsorption.

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• Definition Condition causing insufficient
  assimilation of ingested nutrients.
• Presentation Watery diarrhea, acidic diarrhea,
  or steatorrhea.
• Clinically Abdominal distention, pale foul,
  bulky stool, muscle wasting, poor weight gain or
  weight loss.
• Types
• 1- Congenital Affect enzymes or transport,
  present in the first week of life, (life
  threatening). 1- Microvilus inclusion disease.2-
  Tufting enteropathy.
• 3- Glucose-galactose transport. 4- Chloride
  losing diarrhea.
• 5- Bile acid malabsorption. 6-
  Enterokinase deficiency.
• 2- Generalized -New food introduction Glutein,
  sucrose, lactose and fat.
• -Pancreas cystic fibrosis, malnutrition
• -Liver biliary atresia, cholestasis, hepatitis.
  
• -Intestine Massive resection, staginant loop,
  Giardiasis, celiac disease, milk and soy protein
  intolerance.

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• 3. Specific defect
• Fat A betalipoproteinemia
• Protein Enterokinase, cystinuria, methionine
• Carbohydrate Disacharridase, lactase.
• Vitamins B12 (Pernicious anemia) ,Folic acid
• Ions Chloride losing diarrhea, sodium losing
  diarrhea.
• Evaluation Observation of food, elimination,
  challenge

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• Investigations
• 1- Stools microscopy for fat Sudan III. Stain
  is used.
• - Normal lt 6 fat drops. - Malabsorption gt 6
  fat drops
• 2- Quantitative fecael fat test 72 hours
• Normal lt7 of total fat intake. -
  Malabsorption gt 7 .
• 4- Exocrine pancreatic function
• Direct tests secretin, cholecystokinin.
• Blood trypsinogen.
• - Duodenal aspirate analysis.
• 5- Serum albumin Less than 4.5 6.5 g/dl
• 6- Stool reducing substances Malabsorption of
  sugar gt 2

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• 7- Stool PH paper Normal gt 5.6
  -Malabsorption of sugar lt 5.6
• 8- Breath hydrogen test Malabsorption of
  lactose gt 20 ppm
• 9- Protein loss in Stool.
• 10- Hematologic -Hypochromic microcytic
  anaemia in iron deficiency, Macrocytic
  hyperchromic anaemia in Folic acid and vitamin
  B12.
• -Lymphocytopenia and Neutropenia in
  immunodeficiency disorders.
• 11- Imaging studies, plain x-ray and Barium
  contrast stasis multiple fluid levels in
  intestinal obstruction, Malrotation.
• 12- Ultrasound for pancreatic mass, biliary
  atresia and stones.
• 13- Retrograde study of pancreatic and biliary
  ducts abnormalities of pancreatic and biliary
  ducts.

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• Treatment
• Elimenate the offending agent like wheat and
  lactose.
• -Supply the lactose free or wheat free diet.
• Supply the missing enzyme lactase, or sucrase.
• Use metronidazole, cholestryramine.
• Use elemental formula or, hypoallergenic diet.
• Total parenteral nutrition of glucose, aminoacids
  and intralipids.
• Glutamine, soluble fibre, short-chain fatty acid
  and triglycerides
• Intestinal transplantation.
• Supply deficient vitamin A, D, E, K.
• Supply deficient mineral, iron, zinc, magnesium.
• Supply digestive enzymes trypsin, chemotrypsin.

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GASTROINTESTINAL DISEASES II

• PROF. DR. SHAHENAZ M. HUSSIEN

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CONSTIPATION

• OBJECTIVES
• By the end of this lecture you will be able to
  know the followings
• The types of constipation.
• The clinical features and investigations required
  for the diagnosis.
• How will you approach for assessment for a case
  of constipation?
• Lines of management of such cases.

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• CAUSES OF CONSTIPATION
• 1- Congenital Aganglionic Megacolon
• (Hirschsprungs Disease) -Usually Sporadic.
  -Dominant Recessive patterns of inheritance.
• Caused by- Abnormal innervation of bowel
  begining in the internal anal sphincter and
  extending proximaly to involve variable length of
  gut.
• Associated other congenital detect including
• -Cartilage-hair hypoplasia.
• - Congenital hypoventilation syndrome.
• - Urogenital or Cardiovascular abnormalities.
• Pathology -The aganglionic segment is limited
  to Rectosegmoid in 75. Entire colon in10.
  Total bowel aganglionosis is rare.

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• Clinical Manifestation
• A) Newborn
• Symptoms begin at birth with delayed passage of
  meconium (meconium pass within 48 hr of birth in
  99 of F.T infants) uncommon in preterm.
  -Abdominal distension
• Failure to thrive and hypoprotienaemia.
• B) Older children
• Dilatation of proximal bowel abdominal
  distension due to failure to pass stool. When
  the bowel dilates the intraluminal pressure
  increased and lead to
• - Decrease blood flow
  deterioration of mucosal barrier, Stasis allow
  proliferation of bacteria which may lead
  entercolitis with associated sepsis signs of
  bowel obstruction.

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• Examination
• Abdominal examination
• Large fecal mass palpable in the left lower
  abdomen
• P.R examination Empty rectum normal anal tone
• When the stool pass it may be
• Small pellets OR.
• Ribbon like OR.
• Have fluid consistency.
• Differential diagnosis-
• Neonates -Meconium plug syndrome.
  -Meconium ileus.
  -Intestinal atresia.
• Older children Functional constipation must be
  considered.

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• Diagnosis
• 1-Anorectal manometry
• Measure the pressure of the internal anal
  sphincter while a ballon is distended in the
  rectum.
• No sphincter relaxation.
• 2-Rectal biopsy
• Large numbers of hypertrophied nerve bundles.
• Stain ve for acetylcholinesterase with absence
  of ganglion cells.
• 3-Barium enema
• Transition Zone The aganglionic distal segment is
  narrow with Distended normal ganglionic bowel.
• -24 hr delayed films are helpful (delayed
  evacuation more than 24 hr)
• Treatment Surgical - Swenson - Duhamel

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• 2-Functional Constipation
• Definition Delay or difficulty in defecation
  present for 2 wks or longer.
• Clinical Manifestation
• Starts after the neonatal period Daytime
  encopresis is common.
• Physical examination- Large volume of stool
  palpated in suprapubic area.
• Rectal examination - Stool in ampulla normal
  anal tone
• Recurrent UTI.
• In refractory patients special tests should be
  done
  -Hypothyroidism Hypocalcaemia.
  
• -Celiac disease. - Lead toxicity.
  
• -Presence of hair tuft over spine, spinal
  dimple ,or absence of cremasteric or anal
  reflexes is suggestive of spinal cord lesion.

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• Investigation
• Anorectal manometry- Ditension of rectum causes
  relaxation of internal sphincter.
• Rectal biopsy- normal.
• Barium enema- large amount of stool No
  Transition Zone.
• Treatment
• 1-Patient education. 2-Softening of stool.
• 3-Regular bowel training program include sitting
  on toilet for 10 -15 minutes after meal.
• 4-Enema if impaction is present.
• - maintenance therapy is generally continued
  until regular bowel pattern established for
  several months.