Whipple disease

Definition

Malabsorption syndrome is an alteration in the ability of the intestine to absorb nutrients adequately into the bloodstream.

Causes & symptoms

Protein, fats, and carbohydrates (macronutrients) normally are absorbed in the small intestine; the small bowel also absorbs about 80% of the eight to ten liters of fluid ingested daily. There are many different conditions that affect fluid and nutrient absorption by the intestine. A fault in the digestive process may result from failure of the body to produce the enzymes needed to digest certain foods. Congenital structural defects or diseases of the pancreas, gall bladder, or liver may alter the digestive process. Inflammation, infection, injury, or surgical removal of portions of the intestine may also result in absorption problems; reduced length or surface area of intestine available for fluid and nutrient absorption can result in malabsorption. Radiation therapy may injure the mucosal lining of the intestine, resulting in diarrhea that may not become evident until several years later. The use of some antibiotics can also affect the bacteria that normally live in the intestine and affect intestinal function.

Risk factors for malabsorption syndrome include:

• Family history of malabsorption or cystic fibrosis
• Use of certain drugs, such as mineral oil or other laxatives
• Travel to foreign countries
• Intestinal surgery
• Excess alcohol consumption.

The most common symptoms of malabsorption include:

• Anemia, with weakness and fatigue due to inadequate absorption of vitamin B₁₂, iron, and folic acid
• Diarrhea, steatorrhea (excessive amount of fat in the stool), and abdominal distention with cramps, bloating, and gas due to impaired water and carbohydrate absorption, and irritation from unabsorbed fatty acids. The individual may also report explosive diarrhea with greasy, foul-smelling stools.
• Edema (fluid retention in the body's tissues) due to decreased protein absorption
• Malnutrition and weight loss due to decreased fat, carbohydrate, and protein absorption. Weight may be 80-90% of usual weight despite increased oral intake of nutrients.
• Muscle cramping due to decreased vitamin D, calcium, and potassium levels
• Muscle wasting and atrophy due to decreased protein absorption and metabolism
• Perianal skin burning, itching, or soreness due to frequent loose stools.

Irregular heart rhythms may also result from inadequate levels of potassium and other electrolytes. Blood clotting disorders may occur due to a vitamin K deficiency. Children with malabsorption syndrome often exhibit a failure to grow and thrive.

Several disorders can lead to malabsorption syndrome, including cystic fibrosis, chronic pancreatitis, lactose intolerance, and gluten enteropathy (non-tropical sprue.)

Tropical sprue is a malabsorptive disorder that is uncommon in the United States, but seen more often in people from the Caribbean, India, or southeast Asia. Although its cause is unknown, it is thought to be related to environmental factors, including infection, intestinal parasites, or possibly the consumption of certain food toxins. Symptoms often include a sore tongue, anemia, weight loss, along with diarrhea and passage of fatty stools.

Whipple's disease is a relatively rare malabsorptive disorder, affecting mostly middle-aged men. The cause is thought to be related to bacterial infection, resulting in nutritional deficiencies, chronic low-grade fever, diarrhea, joint pain, weight loss, and darkening of the skin's pigmentation. Other organs of the body may be affected, including the brain, heart, lungs, and eyes.

Short bowel syndromes--which may be present at birth (congenital) or the result of surgery--reduce the surface area of the bowel available to absorb nutrients and can also result in malabsorption syndrome.

Diagnosis

The diagnosis of malabsorption syndrome and identification of the underlying cause can require extensive diagnostic testing. The first phase involves a thorough medical history and physical examination by a physician, who will then determine the appropriate laboratory studies and x rays to assist in diagnosis. A 72-hour stool collection may be ordered for fecal fat measurement; increased fecal fat in the stool collected indicates malabsorption. A biopsy of the small intestine may be done to assist in differentiating between malabsorption syndrome and small bowel disease. Ultrasound, computed tomography scan (CT scan), magnetic resonance imaging (MRI), barium enema, or other x rays to identify abnormalities of the gastrointestinal tract and pancreas may also be ordered.

Laboratory studies of the blood may include:

• Serum cholesterol. May be low due to decreased fat absorption and digestion.
• Serum sodium, potassium, and chloride. May be low due to electrolyte losses with diarrhea.
• Serum calcium. May be low due to vitamin D and amino acid malabsorption.
• Serum protein and albumin. May be low due to protein losses.
• Serum vitamin A and carotene. May be low due to bile salt deficiency and impaired fat absorption.
• D-xylose test. Decreased excretion may indicate malabsorption.
• Schilling test. May indicate malabsorption of vitamin B₁₂.

Treatment

Fluid and nutrient monitoring and replacement is essential for any individual with malabsorption syndrome. Hospitalization may be required when severe fluid and electrolyte imbalances occur. Consultation with a dietitian to assist with nutritional support and meal planning is helpful. If the patient is able to eat, the diet and supplements should provide bulk and be rich in carbohydrates, proteins, fats, minerals, and vitamins. The patient should be encouraged to eat several small, frequent meals throughout the day, avoiding fluids and foods that promote diarrhea. Intake and output should be monitored, along with the number, color, and consistency of stools.

The individual with malabsorption syndrome must be monitored for dehydration, including dry tongue, mouth and skin; increased thirst; low, concentrated urine output; or feeling weak or dizzy when standing. Pulse and blood pressure should be monitored, observing for increased or irregular pulse rate, or hypotension (low blood pressure). The individual should also be alert for signs of nutrient, vitamin, and mineral depletion, including nausea or vomiting; fissures at corner of mouth; fatigue or weakness; dry, pluckable hair; easy bruising; tingling in fingers or toes; and numbness or burning sensation in legs or feet. Fluid volume excess, as a result of diminished protein stores, may require fluid intake restrictions. The physician should also be notified of any shortness of breath.

Other specific medical management for malabsorption syndrome is dependent upon the cause. Treatment for tropical sprue consists of folic acid supplements and long-term antibiotics. Depending on the severity of the disorder, this treatment may be continued for six months or longer. Whipple's disease also may require long-term use of antibiotics, such as tetracycline. Management of some individuals with malabsorption syndrome may require injections of vitamin B₁₂ and oral iron supplements. The doctor may also prescribe enzymes to replace missing intestinal enzymes, or antispasmodics to reduce abdominal cramping and associated diarrhea. People with cystic fibrosis and chronic pancreatitis require pancreatic supplements. Those with lactose intolerance or gluten enteropathy (non-tropical sprue) will have to modify their diets to avoid foods that they cannot properly digest.

Prognosis

The expected course for the individual with malabsorption syndrome varies depending on the cause. The onset of symptoms may be slow and difficult to diagnose. Treatment may be long, complicated, and changed often for optimal effectiveness. Patience and a positive attitude are important in controlling or curing the disorder. Careful monitoring is necessary to prevent additional illnesses cause by nutritional deficiencies.

Key Terms

Anemia

A decrease in the number of red blood cells in the bloodstream, characterized by pallor, loss of energy, and generalized weakness.

Atrophy

A wasting away of a tissue or organ, often because of insufficient nutrition.

Biopsy

A tissue sample removed from the body for examination under the microscope.

Cystic fibrosis

A hereditary genetic disorder that occurs most often in Caucasians. Thick, sticky secretions from mucus-producing glands cause blockages in the pancreatic ducts and the airways.

Edema

From the Greek word meaning swelling, an excessive accumulation of fluid in the tissue spaces. Excessive generalized edema may also be referred to as ascites.

Gluten enteropathy

A hereditary malabsorption disorder caused by sensitivity to gluten, a protein found in wheat, rye, barley, and oats. Also called non-tropical sprue or celiac disease.

Intestines

The intestines, also known as the bowels, are divided into the large and small intestines. They extend from the stomach to the anus.

Short bowel syndrome

A condition in which the bowel is not as long as normal, either because of surgery or because of a congenital defect. Because the bowel has less surface area to absorb nutrients, it can result in malabsorption syndrome.

Steatorrhea

An excessive amount of fat in the stool.

Further Reading

For Your Information

Books

• Brunner, Lillian, and Doris Suddarth. The Lippincott Manual of Nursing Practice. Philadelphia: J.B. Lippincott Company, 1991.
• Doughty, Dorothy. Gastrointestinal Disorders. St. Louis: Mosby-Yearbook, Inc., 1993.
• Griffith, H. Winter. Complete Guide to Pediatric Symptoms, Illness and Medications. New York: Putnam Berkley Group, Inc., 1989.
• Monahan, Frances, and Marianne Neighbors. Medical-Surgical Nursing: Foundations for Clinical Practice. Philadelphia: W. B. Saunders Company, 1998.

  Other

• Ask the Mayo Dietitian. http://www.mayohealth.com. (24April1998).
• Malabsorption. http://www.thriveonline.com. (24April1998).

Gale Encyclopedia of Medicine. Gale Research, 1999.