diaarrheal malabsorption

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Lecture Outline

• Definition
• Classification
• Mechanism
• Approach to the Patient

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Definition

• Diarrhea is loosely defined as passage of
  abnormally liquid or unformed stools at an
  increased frequency.
• For adults on a typical Western diet, stool
  weight gt200 g/d can generally be considered
  diarrheal, or bowel habit change gt3 times/day
• Diarrhea may be further defined as acute if lt2
  weeks, persistent if 24 weeks, and chronic if
  gt4 weeks in duration

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Acute diarrhea

• More than 90 of cases of acute diarrhea are
  caused by infectious agents
• These cases are often accompanied by vomiting,
  fever, and abdominal pain
• The remaining 10 or so are caused by
  medications, toxic ingestions, ischemia, food ,
  and other
• conditions.

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Acute diarrhea

• Infectious Agents
• Most infectious diarrheas are acquired by fecal
  oral transmission or, more commonly,via
  ingestion of food or water
• contaminated with pathogens from human or animal
  feces
• Disturbances of flora by antibiotics can lead to
  diarrhea by reducing the digestive function or
  by allowing the overgrowth of pathogens, such as
  Clostridium difficile
• Acute infection or injury occurs when the
  ingested agent overwhelms or bypasses the hosts
  mucosal immune and nonimmune (gastric acid,
  digestive enzymes, mucus secretion, peristalsis,
  and suppressive resident flora) defenses

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Etiology of infectious causes

• 1. Toxin producers
• Preformed toxin (Staph. Aureus, clostridium
  perfringens)
• It has an IP of 1-8hrs, presents with vomiting,
  pain, fever and watery diarrhea
• Entero-toxin (V. cholera, E. coli, klebsiela)
• Presents after IP of 8-72hrs with vomiting,
  pain, fever and watery diarrhea.
• 2. Entero-adherent (E.coli, Giardia,
  cryptosporidia, helminths)
• Presents after an IP of 1-8days with vomiting,
  /- pain, fever and watery diarrhea.

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Infectious Contd.

• 3. Cytotoxin producers C. difficile,E.
  Haermorrhagic E. coli)
• Has an IP of 1-3days presents with pain and
  fever, watery diarrhea occasionaly bloody (with
  E.coli becomes quickly.
• 4. Invasive organisms
• Minimal inflammation (viral -Rota,Norwalk) watery
  diarrhea, fever and pain.
• Variable inflammation- Salmonella,
  Compylobacter)-watery and bloody diarrhea with
  pain and fever.
• Sever inflammation-(Shigella, Entero-invasive
  E.colli, E.histolytica) Has an IP of 12hrs-8days
  with pain fever and bloody diarrhea)

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Contd.

• In HIV diarrhea seen in gt 50
• The virus it self causes diarrhea through
• Impairing epithelial function
• Opening of tight junction
• Stimulates cytokine
• Affects bile acid metabolism
• The classical pathogens are
• Cryptosporidium, lsospora belli, Microspordia,

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Chronic diarrhea

• Diarrhea lasting gt4 weeks warrants evaluation to
  exclude
• serious underlying pathology.

• In contrast to acute diarrhea, most of the causes
  of chronic diarrhea are noninfectious.

• The classification of chronic diarrhea by
  pathophysiologic mechanism facilitates a
  rational approach to management

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Chronic

• Secretary causes
• Secretory diarrheas are due to derangements in
  fluid
• and electrolyte transport across the
  enterocolonic mucosa
• They are characterized clinically by watery,
  large- volume fecal outputs that are typically
  painless and persist with fasting
• Common causesMedications,bowel resection,mucosal
  disease and enterocolic fistula,

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Chronic

• Osmotic causes
• Osmotic diarrhea occurs when ingested, poorly
  absorbable, osmotically active solutes draw
  enough fluid into the lumen to exceed the
  reabsorptive capacity of the colon.
• Fecal water output increases in proportion to
  such a solute load.
• Osmotic diarrhea characteristically ceases with
  fasting or with discontinuation of the causative
  agent
• Common causes
• Osmotic laxatives (Mg2, PO43, SO4)
• Lactase and other disaccharide deficiencies
• Nonabsorbable carbohydrates (sorbitol,
  lactulose, polyethylene glycol)

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Chronic

• Steatorrheal causes
• Fat malabsorption may lead to greasy, foul
  smelling, difficult-to-flush diarrhea often
  associated with weight loss and nutritional
  deficiencies due to concomitant malabsorption
• Common causes
• Intraluminal maldigestion,
• mucosal malabsorption, or
• lymphatic obstruction may produce steatorrhea

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oStool tests Stool tests can measure fat in
samples of stool. These tests are the most
reliable because fat is usually present in the
stool of someone with malabsorption syndrome.
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• oBlood tests
• Such as vitamin B-12 , vitamin D , folate , iron
  , calcium , albumin
• , phosphorus , and protein.
• A lack of one of these nutrients may not
  necessarily mean you have malabsorption
  syndrome. It can mean you are not choosing foods
  with healthy levels of nutrients. Normal levels
  of these nutrients suggest that malabsorption is
  not the problem.

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Chronic

• Inflammatory
• Inflammatory diarrheas are generally accompanied
  by pain, fever, bleeding, or other
  manifestations of inflammation.
• The mechanism of diarrhea may not only be
  exudation but, depending on lesion site, may
  include fat malabsorption, disrupted
• fluid/electrolyte absorption, and hypersecretion
  or hypermotility from
• release of cytokines and other inflammatory
  mediators.
• The unifying feature on stool analysis is the
  presence of leukocytes
• Common causes
• Inflammatory bowel diseases crohns disease and
  ulcerative colitis
• Primary or secondary forms of immunodeficiency
• Other causes like radiation enterocolitis

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Diagnosis
oImaging tests Imaging tests, which take
pictures of your digestive system, may be done
to look for structural problems. For instance, a
CT scan may be done to look for thickening of
the wall of your small intestine, which could be
a sign of Crohns disease.
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Diagnosis
oBiopsy Abnormal cells in the lining of your
small intestine. Sample by endoscopy.
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Chronic

• Dysmotility
• Rapid transit may accompany many diarrheas as a
  secondary or contributing phenomenon,
• but primary dysmotility is an unusual etiology of
  true diarrhea

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cont

• Factors that may cause malabsorption syndrome
  include
• Damage to the intestine from infection,
  inflammation, trauma.
• Prolonged use of antibiotics.
• Lactase deficiency, or lactose intolerance.
• Diseases of the gallbladder, liver, or pancreas.
• Radiation therapy.
• Some drugs, such as neomycin, colchicine, or
  cholestyramine.
• Other conditions such as celiac disease, Crohns
  disease, chronic pancreatitis, or cystic
  fibrosis.

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Principles of Treatment

• General assessment.
• Assessment of hydration status. A number clinical
  sign and symptoms can help in detecting
  dehydration.
• Correction of electrolyte and acid base
  imbalance.
• Proper feeding to provide normal nutritional
  requirements

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Management of Diarrhea

• The major goals in the management acute diarrhea
  is
• Assessment of fluid and electrolyte imbalance.
• Rehydration.
• Maintenance of fluid therapy.
• Re-introduction of adequate diet.

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MALNUTRITION IN ADULTS

• Complications of Adult malnutrution
• Specific nutritional deficiency
• High risk for TB/other opportunistic infections

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MANAGING MALNUTRITION IN ADULTS

• Adults (non-pregnant and non-post-partum) BMI lt
  16 kg/m2 (If cant measure BMI, MUAC lt 19 cm)
• OR
• Bilateral pitting oedema (both feet or legs are
  swollen, and the skin remains indented when
  pressed with a finger)
• Pregnant women and women up to 6 months
  post-partum MUAC lt 19 cm

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CONT

• Give client 7080 ml/kg/day of F-75 or F-100),
  especially if client has bilateral pitting oedema
  
• Treat all medical complications
• Give 200,000 IU of vitamin A
• If client(HIV Positive) is not on ART, provide
  Cotrimoxazole prophylaxis

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Thank You
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