DISORDERS OF THE SMALL INTESTINE MALABSORPTION SYNDROMES I.

Transcription

1 DISORDERS OF THE SMALL INTESTINE MALABSORPTION SYNDROMES I. Gyula Mózsik M. D., Sc. D.(med.) University of Pécs 2008 DEFINITIONS: These medical symptomes include all of the clinical pictures in patients with diarhoea independently on the background produced these clinical symptomes (bacterial, viral, protozone infections or any other diseases of the liver pancreas, small intestine, large bowels, small bowel disease produced by surgical activity or any drugs). -1-

2 Maldigestions: Impaired preparation of carbohydrates, proteins and fatts to be suitable form for absorption of these components from the small intestine (maldigestion) Malabsorptions: The macronutriciens were prepared (digested) to be in a suitable form for absorption however they are not able to absorb from the small intestine because it is different disorders. -2-

3 Correlation between the malabsorption and medical sciences Immunology Cardiology Dietetics Haematology Pediatrics GASTROENTEROLOGY Nutrition Oncology Endocrinolog Radiology Pulmonology Pharmacology Patology Surgery -3-

4 DISORDERS OF THE SMALL INTESTINE MALABSORPTION SYNDROMES II. Clinical symptoms: Extremely decreased body weight (primary or secondary starvation); Decreased turgor in the skin (deficiency of vitamin A); Impaired nail, hair (deficiency of vitamin A); Anaemia (iron deficiency, folic acid deficiency, vitamin B 12 deficiency: microcyter-, macrocyter-anaemia or mixed form); Joint diseases (without major deformities); Decreased immunity and enhanced infections; Edema wide-spread location (hypalbuminaemia); Amenorrhea (impaired hormon production); Diarrhoea; -4-

5 Nutrition Digestion Absorption Transfer of nutriciens in the body (postabsorptive phase) Target organs (bone marrow, liver, other target organs) -5-

6 DISORDERS OF THE SMALL INTESTINE: MALABSORPTION SYNDROMES III. Physical examinations: According to the dominant clinical features (anaemia, cahexia, impaired moving in the joints, atrophia of muscles, absence of sexual characteristic hair, pubic hair, atrophized skin, typical palpation of the hair on the head ( mouse hair, bleedings on the skin) Time-course classification of these complex diseases: Acute ~ Bacterial origin (salmonellosis); ~ Virus origin (coxakie, etc.); ~ Protozones (Giardia lambria, amoeba); Chronic forms ~ Disorders after parcial or total gastrectomy; ~ Small bowel syndromes (after surgical intervention of small intestine); ~ Lactose intolerance; ~ Gluten-sensitive enteropathy ~ IBD, inflammatory bowel disease (Morbus Crohn, ulcerative colitis); ~ Drug-induced (iatrogenic) disorders (over consume of laxative agents, prokinetic drugs, etc.) -6-

7 GENERAL LABORATORY AND SPECIAL CLINICAL EXAMINATIONS I. General laboratoy examinations: Sedimentation Haemoglobin, haematocrite Serum iones Serum cholesterol and triglicerides Prothrombin index Serum proteins (albumins, immunglobulines) Blood pictures WBC (4000/ml 2 ) Eosisophylia Culturation examinations Bile (Giardia lambria) Stool (amoeba, Giardia lambria) Blood (different viruses) -7-

8 GENERAL LABORATORY AND SPECIAL CLINICAL EXAMINATIONS II. Special clinical examinations: Characterisation of excreted stool, Dominant location of absorption of different nutricients from the small intestinal, Absorption studies of carbohydrates in the clinical practice: Glucose, Lactose, Starch, D-xylose, Absorption studies of the fatts from the small intestinal in the clinical practice: Van der Kramer s method, Lipiodol-probe, Application of vitamin K, Schilling s test for testing of absorption of vitamin 12, -8-

9 PARTS OF THE SMALL INTESTINE CHARACTERIZATION OF THE STOOL EXCRETION Proximal Middle Distal Colour of the stool Yellow Yellow and shine stool Quantity of the stool Green Big mass Big mass Big mass Consistency of the stool Fluid Fluid Fluid PROTEIN-LOSING ENTEROPATHY Big mass, waterlike, no characteristic colour -9-

10 CHARACTERISTIC PLACES OF THE NUTRICIENS FROM THE SMALL INTESTINE Proximal Middle Distal Characteristic place of the food absorption Iron Fatts Bile acids Folic acid Monosacharides Glucose Fructose D-xylose Vitamines A, D, E, K Vitamin B 12 AMINOACIDS -10-

11 PHASES OF THE ABSORPTION OF DIFFERENT NUTRICIANTS FROM THE SMALL INTESTINE 1st) Preabsorptive phase (classical digestion ) ~ Physiological aims: the preparation of different foods to be place in a suitable form for the absorption: - Carbohydrates: monosacharides ( - amylase), - Fatts: fatty acids+glycerol (lipase, bile acids), - Proteines: aminoacids (oligopeptides) (Lisomers, racem, D-isomers). 2nd) Absorptive phase (real absorptive function) 3rd) Postabsorptive phase ~ Transportation from the small intestinal to the target organs (albumin), ~ Losing of absorbed proteins via: - by urine (nephrosis syndrome), - by GI tract (protein losing enteropathy), - by burning. ~ Insufficiency of target organ functions. -11-

12 CLINICAL TEST TO APPROACH THE IMPAIRED PLACE OF THE SMALL INTESTINE Proximal Middle Distal Iron loading test Sugar loading tests (75 g) Glucose loading test (75 g) Lactose loading test (75 g) Starch loading test (75 g) Fatty loading test 100 g fatt (3 days) Lipiodol-probe Schilling s test (B 12 ) -12-

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16 PROTEIN ABSORPTION X 100 Intake of protein (excreted protein in urine) + (exreted protein in stool) -17-

17 Measurement of protein losing by the stool Cr 51 anorganic chrome iv. application and it links to albumin. The measurement of isotopic activity in the stool (24 h) indicate the extent of albumin losing produced by increased permeability or obstructed lymphatic vessels by mechanic pathways (lymphonodes, TBC, lymphoma, malignant diseases). -18-

18 DETAILED MALABSORPTION SYNDROMES (CHRONIC DISEASES) 1st) Syndromes after parcial or total gastrectomy ~ Dumping syndrome, ~ Afferent loop syndrome, 2nd) Small bowel syndromes ~ Mesenteric thrombosis (Leiden mutation, APCresistence antibaby pill), ~ Surgical intervention upon small intestine, ~ Bypass operations, 3rd) Lactose intolerance ~ Enzyme adaptation, ~ Genetic disorders, ~ Aquired disorders (inflammations, vascular impairement, etc.). 4th) Glutene sensitive enteropathy ~ Hypersensitivity to glutene allergic diathesis, ~ Autoantibodies to tissue gamma glutamil transferase (Autoimmune disease) -19-

19 Ad 4.) RESPONSIBLE PROPERTIES OF GLUTENE TO INDUCE GLUTENE SENSITIVE ENTEROPATHY 1st) Primary, secondary and terciary structure of glutene 2nd) Clinical features: ~ Cahexia, ~ Very frequent stool excretion (15-20x), ~ Segmental location of dermatitis (dermatitis herpetiformis, Duhring-disease), ~ Laboratory approach (data prefering to the approximal middle and distal part of the small intestine), (serum ions, low blood sugar, serum cholesterol, triglicerids, total proteins, albumins, iron), ~ Typical clinical features, ~ Special examinations (identification of antibody test titer against the endomysium and tissue gamma glutamil transferase) (AUTOIMMUNE DISEASE), ~ Treatment: total elimination of glutene intake from the nutrition (for the whole lifespan), -20-

20 5th) Drug induced (iatrogenic) disorders ~ Over consume of laxative agents, ~ Prokinetic drugs, ~ Non-steroidal anti-inflammatory drugs induced small intestinal damage, 6th) Endokrine tumors ~ Zollinger-Ellisson syndrome, ~ Calcinoids. 7th) Inflammatory bowel disease -21-

21 Ad 7. Morbus Crohn Ulcerative Colitis Location small intestinal colon Impairement transmucosal only mucosa Fistulation frequent no Patients young ladies females Etiology non-specific inflammation autoimmun disease Prognosis no malignancy malignant transformation Therapy 5-ASA 5-ASA Glucocorticoid Glucocortioid TNF antibodies (biological treatment: preparation from the antibodies in mouses) Main problem of new drug production: can we use only the isolated human cell line for the production of a new product: International tragedy in London