INTESTINAL MALABSORPTION IN FOLATE-DEFICIENT ALCOHOLICS

Transcription

1 GASTROENTEROLOGY 64: , 1973 Copyright 1973 by The Williams & Wilkins Co. Vol. 64, No.4 Printed in U.S.A. INTESTINAL MALABSORPTION IN FOLATE-DEFICIENT ALCOHOLICS CHARLES H. HALSTED, M.D., ENRIQUE A. ROBLES, M.D., AND ESTEBAN MEZEY, M.D. Alcoholism Research Unit and the Department of Medicine of Baltimore City Hospitals, and Johns Hopkins University School of Medicine, Baltimore, Maryland Malnutrition with folate deficiency is frequently found among alcoholics, and could be caused in part by decreased intestinal absorption. To evaluate the relationship of nutrition and absorption in alcoholics, intestinal absorption was studied in patient volunteers placed on a folate-deficient diet with ethanol. Intestinal absorption was measured by conventional means and by the technique of triple lumen perfusion of the jejunum. In 2 patients who ingested ethanol, 200 g per day with a low folate diet, the dietary induction of folate deficiency was followed by decreased absorption of d-xylose, labeled folic acid eh-pteroylglutamic acid), glucose, fluid, and sodium. Mild net secretion of fluid and sodium into the intestinal lumen was observed in a patient who remained sober on the low folate diet and in a patient who ingested ethanol, 300 g per day, with a regular diet. The morphology of the jejunal mucosa was not affected. These preliminary data suggest that the combination of dietary folate deficiency and prolonged ethanol intake results in intestinal malabsorption of several water-soluble substances, which may account in part for the poor nutrition often found in binge drinkers. Excessive binge drinking is usually associated with malnutrition and weight loss. While alcoholics are known to eat Received August 14, Accepted November 15, This work was presented April 29, 1972, to the American Society for Clinical Nutrition, Atlantic City, New Jersey. Address requests for reprints to: Dr. Charles H. Halsted, Baltimore City Hospitals, 4940 Eastern Avenue, Baltimore, Maryland This work was supported by Grant 5 R01 MH from the National Institute of Mental Health. Dr. Halsted is a recipient of Clinical Investigator Award in Nutrition IK08 AM from the National Institute of Arthritis, Metabolism and Digestive Diseases. The authors are indebted to Dr. John Wright, Department of Pathology, Baltimore City Hospitals, and Johns Hopkins University School of Medicine, who interpreted the bone marrows and intestinal biopsies. They are also indebted to Miss Carolyn Ochs and to Mr. James Potter, for technical assist ance, and to the nursing staff on the Alcoholism Unit. 526 poorly while drinking, maldigestion and intestinal malabsorption may playa significant role in their poor nutrition. Malabsorption of d-xylose,l thiamine,2 folic acid,3, 4 and dietary fat 5 have been documented in recently drinking alcoholics without significant liver disease. A previous study from this unit has shown that the malnutrition which accompanies binge drinking results in decreased jejunal uptake of labeled folic acid [3H-pteroylglutamic acid (PGA)]. 4 Folate deficiency, which is present in the majority of binge drinkers, 6 could be a factor in the etiology of intestinal malabsorption found in alcoholics. Recently, morphologic changes have been described in the jejunal mucosa of several folatedeficient alcoholic patients. 7, 8 Retrospective analysis of the data obtained from 11 binge drinking alcoholics on admission to our previous study,4 revealed decreased absorption of 3H-PGA and sodium in fo-

2 April 1973 ABSORPTION IN FOLATE-DEFICIENT ALCOHOLICS 527 TABLE 1. Jejunal uptakes in binge drinking alcoholics (mean ± SD) n 3H-PGA Glucose Fluid Sodium % % ml/min/30 em IlEq/min/30 em Serum folate <5 ng/ml...,., ± ± ± ± Serum folate 5 or >5 ng/ml ± ± ± ± P <0.001 NS <0.1 <0.05 late-deficient subjects, compared with those whose serum folate level was 5 ng per ml or greater (table 1). To evaluate intestinal absorption in alcoholics further, a prospective study was made of 4 chronic alcoholic patients in whom the folate content of the diet and the administration of ethanol was varied. Patients and Methods Four chronic male alcoholic patients, ranging in age from 39 to 59 years, were admitted to the Alcoholism Research Unit after consenting to participate in the research protocol. In the month before admission, all had reportedly ingested more than a quart of whiskey daily and had been homeless, eating one meal or less daily. No patient had significant liver disease or complicating illness. Intestinal absorption was evaluated by conventional means and by the technique of jejunal perfusion, according to the following protocols: Folate deficiency with ethanol. Patients E. C. and G. R. were studied on three occasions: (a) after a 3-week base line regular 2200-cal hospital diet without ethanol; (b) after induction to folate deficiency by a low folate diet given with ethanol, 200 g daily; and (c) after reinstitution of the regular diet supplemented by oral folic acid, 5 mg per day, and continued ethanol administered for a period of 2 weeks. The amount of ethanol administered daily is equivalent to 18.5 ounces of 90-proof whiskey. Folate deficiency without ethanol. Patient E. S. was not given ethanol at any time. He was studied (a) after a 2-week base line regular hospital diet, and (b) after dietary induction of folate deficiency. A regular diet supplemented by folic acid was then given for 2 weeks before discharge. Regular diet with excessive ethanol. Patient J. M. was given a regular diet throughout his hospital stay. In order to maximize the possibility of an ethanol effect he was studied (a) after the administration of ethanol 300 g daily (equivalent to 28 ounces of 90-proof whiskey) for 26 days, supplemented by the acute intrajejunal administration of ethanol, 0.8 g per kg of body weight, 2 hr prior to intestinal perfusion. Levels of ethanol" were 190 mg per 100 ml in the blood and 145 mg per 100 ml in the jejunal contents at the start of perfusion. Studies were repeated (b) after 2 weeks of abstinence from ethanol. A 2200-cal balanced low folate diet was prepared by the thrice boiling method 10 and contained by assay with chick pancreatic extract, II 10 to 20 Ilg of folate per day. Each patient who ingested this diet received daily a multivitamin capsule (Squibb Vigran: thiamine 3 mg, riboflavin 3 mg, nicotinamide 20 mg, pyridoxine 1 mg, cyanocobalamin 2 Ilg, ascorbic acid 50 mg, calcium pantothenate 5 mg, vitamin A 5000 USP units, and vitamin D 400 USP units), 60 meq of elixir potassium chloride, and 900 mg offerrous sulfate. Ethanol was diluted with a carbonated beverage and served in eight daily doses from 8 AM to 10 PM. During each experiment, the patients were weighed daily and determinations were made of urinary nitrogen excretion using the Kjeldahl method of the Technicon AutoAnalyzer (Technicon AutoAnalyzer, Industrial Method 29-69A). Evaluation of liver function included measurements of serum glutamic oxaloacetic transaminase (normal <40 U per liter), and sodium sulfobromophthalein retention (normal <4%). To measure the development of folate deficiency, serum folate determinations l2 (normal 5 to 21 ng per m!) were obtained twice weekly, and average nuclear lobe counts of polymorphonuclear leukocytes were made by counting 100 cells in the peripheral blood smear. Periodic determinations were made of formiminoglutamic acid (FIGLU) excretion in the urine collected for 12 hr after a 15-g oral dose of histidine l3 (normal < 15 mg per 12 hr). At intervals, bone marrow aspirations were obtained from the iliac crest. Megaloblastic change was graded according to Dacie's criteria. I. Patients were considered folate-deficient when they had a low level of folate in the serum, increased excretion of FIGLU in the urine, and definite early megaloblastic change in the bone marrow.

3 528 HALSTED ET AL. Vol. 64, No.4 After each dietary regimen, measurements of intestinal absorption were repeated in each patient. d-xylose absorption was measured as the excretion of d-xylose in the urine collected for 5 hr after an oral dose of 25 g. l' The fecal excretion of fat was measured in a stool collected over 72 hr while each subject was ingesting at least 100 g of fat daily for 6 days.16 Intestinal biopsies were obtained with the Crosby capsule. Jejunal absorption of labeled pteroylglutamic acid (3H-PGA), glucose, water, and sodium was determined by the triple lumen perfusion method,17 using the same technique and isotonic solution described in our previous study.' The solution contained per liter: NaCI 140 meq, glucose 16.7 mmoles, polyethylene glycol 10 g, and tritium-labeled folic acid (3H-PGA) 25 J.Lg, with a final specific activity of 0.4 J.Lc per g (Amersham/Searle TRA 34, Batches 25 and 27). Intestinal samples were assayed for concentrations of polyethylene glycol,18 glucose by "glucostat," 19 and sodium by the Technicon AutoAnalyzer (Technicon AutoAnalyzer, Method N-206). Counts per minute were measured in a liquid scintillation solution by a Packard Tri-Carb counter. These measurements were used to calculate the transintestinal movement of fluid (milliliters per minute per 30 cm) and, from concentration difference, that of sodium (microequivalents per minute per 30 cm). Jejunal uptakes of 3H-PGA and glucose were similarly calculated and expressed as a percentage of the amount entering the test segment. The logarithmic Patient TABLE 2. Nutritional evaluation Procedure mean concentration of glucose in the test segment obtained from concentrations at the proximal and distal aspiration sites, was 4.07 mm ± 2.31 (mean ± SE). In previous studies using this method, the mean uptakes of 3H_ PGA have been reported to be 36.5% ± 5.75 in well nourished sober alcoholics' and 39.2% ± in healthy subjects. Results All patients gained weight during each protocol with the exception of patient E. C. who lost 3 lb during 40 days of ingestion of the folate-deficient diet with ethanol. Hemoglobin levels and liver function tests remained normal, except for a rise in serum glutamic oxaloacetic transaminase to 126 U per liter in patient E. C., which fell to normal after ethanol was discontinued. The mean daily urinary excretion of nitrogen was not affected by the various dietary and ethanol regimens (table 2). In the 3 patients on the low folate diet, variable time intervals were required for the development of folate deficiency (fig. 1). There was a steady decline of the serum folate level to the range of 1 to 2 ng per ml by 40 days in the 2 patients who took the folate-deficient diet supplemented by ethanol (E. C. and G. R). By contrast, in the patient who took the folate-deficient diet without ethanol (E. Mean urinary Serum Urinary nitrogen folate FlGLU Folate deficiency with ethanol b E.C. Regular diet Low folate diet, ethanol Regular diet, ethanol, folic acid G. R. Regular diet Low folate diet, ethanol Regular diet, ethanol, folic acid Folate deficiency without ethanol E. S. Regular diet Low folate diet Regular diet, folic acid Excessive ethanol C J.M. Regular diet, ethanol Abstinence g/24 hr ± so ng/ml mg/ 12 hr ± ± ± ± ± ± ± ± FIGLU, formiminoglutamic acid. b Ethanol, 200 g daily. C Ethanol, 300 g daily for 26 days.

4 April 1973 ABSORPTION IN FOLATE-DEFICIENT ALCOHOLICS Pati.nt E.e. Pati.nt G.R. Pati.nt E. S., -. ""'-'. ~.-... '. 0",,-,..,,. ~'t. " -... " /..... E.C. -G.R.... /' ~r ~.- I /, / e WEEKS ON LOW FOLATE DIET FIG. 1. Effect of the low folate diet on serum folate levels. In patients E. C. and G. R., who ingested 200 g of ethanol daily with the low folate diet, the serum folate level reached a deficient range more rapidly than in patient E. S. who remained sober. At the end of each dietary period, the bone marrow showed intermediate megaloblastic change and the urinary excretion of formiminoglutamic acid was increased. S.), a similar low serum folate level was not obtained until 60 days. After the serum folate had fallen to this level, the bone marrow in each case showed an intermediate megaloblastic change in the erythroid series. Gross megaloblastosis was not seen. The average nuclear lobe count in the polymorphonuclear leukocytes reached in all 3 patients at this time was similar: 4.00 in E. S., 3.84 in E. C., and 4.16 in G. R. The urinary excretion of FIGLU was markedly increased with folate deficiency (table 2). After reinstitution of the regular diet supplemented with folic acid, FIGLU excretion fell in the sober patient (E. S.) but remained moderately elevated in the 2 patients who continued to drink ethanol. Induction of folate deficiency by diet plus ethanol (E. C. and G. R.) was followed by a decrease in the absorption of 3H-PGA, glucose, fluid, and sodium (fig. 2). The low values for jejunal uptake of 3H-PGA were well below our normal range for abstinent well nourished alcoholics 9... J 'IO!----,---::----:,:---.:----=---:--...J.i~ WEEKS FOLATE: DfFICIENT DIET PLUS ETHANOL FOLIC ACIO+ETHANOL FIG. 2. Effect of the combination of low folate diet and ethanol 200 g daily on the jejunal uptakes of 'H-pteroylglutamic acid (PGA) and glucose, and on the net transintestinal movement of fluid and sodium in patients E. C. and G. R. The depression of the uptakes of 'H-PGA and glucose with folate deficiency correlated with decreased absorption of fluid and sodium. All values improved after 2 weeks of regular diet supplemented by oral folic acid 5 mg per day and continued ethanol ingestion. Negative values indio cate net secretion into the intestinal lumen. (29.3 to 43.8%).4 Institution of a regular diet supplemented by oral folic acid and continued ethanol ingestion was followed by improved absorption of each substance measured, with complete correction of 3H-PGA uptake by 2 weeks. The absorption of d-xylose paralleled the changes found by jejunal perfusion, decreasing with folate deficiency and returning to normal after reinstitution of the regular diet (table 3). Induction of folate deficiency by diet alone (E. S.) was followed by reversal of net fluid and sodium absorption to a mild net secretory state, while the jejunal uptakes of 3H-PGA and glucose and the absorption of d-xylose were unchanged. Administration of ethanol, 300 g daily with a regular diet for 26 days (J. M.), also resulted in mild net secretion of fluid and sodium into the jejunum (table 3).

5 530 HALSTED ET AL. Vol. 64, No.4 Patient Procedure TABLE 3. Intestinal absorption studies d-xylose execre tion Intestinal perfusion 'H-PGA" Glucose Fluid' Sodium' g/5 hr % % ml/min/ /leq/min/ 30cm 30 em Folate deficiency with ethanol' E. C. Regular diet Low folate diet, ethanol Regular diet, ethanol, folic acid G.R. Regular diet Low folate diet, ethanol Regular diet, ethanol, folic acid for 1 week weeks Folate deficiency without ethanol E.S. Regular diet Low folate diet Excessive ethanol d J.M. Regular diet, ethanol Abstinence a PGA, pteroylglutamic acid. b Net movement; negative sign indicates net secretion into the intestinal lumen. c Ethanol, 200 g daily. d Ethanol, 300 g daily for 26 days. After each dietary regimen in each patient, the morphology of the intestinal mucosa and the fecal excretion of dietary fat remained normal. Discussion In this prospective study, induction of folate deficiency by diet plus ethanol in 2 patients resulted in decreased absorption of 3H-PGA, water, sodium, glucose, and d-xylose. Absorption of each substance improved with a regimen of folic acid supplementation in spite of continued ingestion of moderate amounts of ethanol. Either dietary folate deficiency alone or prolonged administration of larger amounts of ethanol with a regular diet was followed by mild net secretion of water and sodium into the small intestinal lumen. These preliminary data suggest that either dietary folate deficiency or prolonged ingestion of excessive amounts of ethanol independently affects fluid absorption, and that the combination of folate deficiency and prolonged moderate ethanol intake may lead to potentially significant malabsorption of several watersoluble nutrients. Recently it has been shown that morphologic changes, similar to those described with vitamin B 12 deficiency, 21 occur in the intestinal mucosa of folate-deficient alcoholics. 7, 8 Since the intestinal mucosa, like the bone marrow, is a rapidly regenerative tissue, it is not surprising that deficiency of either of these vitamins would affect its morphology or function. 22 In 2 of these patients who were made folate-deficient while ingesting ethanol, decreased intestinal absorption was observed while the intestinal biopsy remained normal. This suggests that in dietary folate deficiency a functional abnormality may precede jejunal morphologic changes. Although the degree of folate deficiency reached in all 3 patients on the low folate diet appeared comparable, it is possible that a greater absorptive abnormality may have been observed in the sober patient with prolongation of the diet. Several in vitro experiments have demonstrated an effect of ethanol on intestinal function. An ethanol concentration of 3 g per 100 ml was shown to inhibit the absorption of amino acids and glucose,23

6 April 1973 ABSORPTION IN FOLATE-DEFICIENT ALCOHOLICS 531 and a concentration of 11 g per 100 ml to stimulate jejunal adenyl cyclase,24 the enzyme considered central to the mechanism of intestinal secretion of fluid. 25 Prolonged administration of ethanol to well fed volunteers resulted in malabsorption of vitamin B and in ultrastructural changes in the intestinal mucosa. 27 Ethanol could limit PGA uptake secondary to an effect on glucose absorption since PGA absorption may be mediated in part by glucose. 2o Sullivan and HerberP8 demonstrated that ethanol inhibits the hematopoetic response to physiologic amounts of folic acid in folate-deficient alcoholics. By analogy, ethanol could thus limit the uptake of folate by the absorptive cells of the gut. Recently, Eichner et a1. 29 showed that folate deficiency can be induced in 3 weeks by a folate-deficient diet given in conjunction with ethanol, whereas 5 to 10 weeks are required when ethanol is omitted from the regimen. 29 These data suggest that the more rapid response in the drinking patients may be partly due to malabsorption of folic acid. Although more substantiation is required of these preliminary data, they suggest that intestinal absorption of fluid and water-soluble substances is affected by the combination of folate deficiency and alcohol. This abnormality of absorption could account in part for the deficiencies of water-soluble vitamins, such as folate and thiamine, frequently found in binge drinking alcoholics. Whereas this study suggests that alcoholism with dietary folate deficiency leads to malabsorption of PGA, the effect of this combination on the digestion and absorption of the conjugates of folic acid found in food remains to be determined. REFERENCES 1. Small M, Longarini A, Zamcheck N: Disturbances of digestive physiology following acute drinking episodes in "skid-row" alcoholics. Am J Med 27: , Thomson AD, Baker H, Leevy CM: Patterns of "S-thiamine hydrochloride absorption in the malnourished alcoholic patient. J Lab Clin Med 76:34-45, Halsted CH, Griggs RC, Harris JW: The effect of alcoholism on the absorption of folic acid (H3- PGA) evaluated by plasma levels and urine excretion. J Lab Clin Med 69: , Halsted CH, Robles EA, Mezey E: Decreased jejunal uptake of labeled folic acid (3H-PGA) in alcoholic patients: roles of alcohol and nutrition. N Engl J Med 285: , Mezey E, Jow E, Slavin RE, et al: Pancreatic function and intestinal absorption in chronic alcoholism. Gastroenterology 59: , Herbert V, Zalusky R, Davidson CS: Correlation of folate deficiency with alcoholism and associated macrocytosis, anemia, and liver disease. Ann Intern Med 38: , Bianchi A, Chipman DW, Dreskin A, et al: Nutritional folic acid deficiency with megaloblastic changes in the small bowel epithelium. N Engl J Med 282: , Hermos JA, Adams WH, Lin YK, et al: Mucosa of the small intestine in folate-deficient alcoholics. Ann Intern Med 76: , Payne JP, Foster DU, Hill DW, et al: Observations on interpretation of blood alcohol levels derived from analysis of urine. Br Med J 3: , Herbert V: A palatable diet for producing experimental folate deficiency in man. Am J Clin Nutr 12:17-20, Chanarin I, Rothman D, Perry J, et al: Normal dietary folate, iron, and protein intake, with particular reference to pregnancy. Br Med J 2: , Herbert V: Aseptic addition method for Lactobacillus casei assay of folate activity in human serum. J Clin Pathol 19:12-16, Tabor H, Wyngarden L: Method for determination of formininoglutamic acid in urine. J Clin Invest 37: , Dacie JV, White JC: Erythropoiesis: with particular reference to its study by biopsy of human bone marrow. J Clin Pathol 2:1-32, Roe JH, Rice EW: A photometric method for the determination of free pentoses in animal tissues. J BioI Chern 173: , van de Kamer JH, ten Bokkel Huinink H, Weyers HA: Rapid method for the determination of fat in feces. J BioI Chern 177: , Whalen GE, Harris JA, Geenen JE, et al : Sodium and water absorption from the human small intestine: the accuracy of the perfusion method. Gastroenterology 51: , Malawar SJ, Powell DW: An improved turbidometric analysis of polyethylene glycol utilizing an emulsifier. Gastroenterology 53: , Washka ME, Rice EW: Determination of glucose by an improved "glucostat" procedure. Clin Chern 7: , 1961

7 532 HALSTED ET AL. Vol. 64, No Gerson CD, Cohen N, Hepner GW, et al: Folic acid absorption in man: enhancing effect of glucose. Gastroenterology 61: , Foroozan P. Trier JS: Mucosa of the small intestine in pernicious anemia. N Engl J Med 277: , Herbert V: Malabsorption syndrome secondary to B12 deficiency, Hematopoetic and Gastrointestinal Investigations with Radionuclides, vol 3. Edited by AJ Gilson, WM Smoak, MB Weinstein. Springfield, Ill, Charles Thomas, 1972, p Chang T, Lewis J, Glazko AJ: Effect of ethanol and other alcohols on the transport of amino acids and glucose by everted sacs of rat small intestine. Biochim Biophys Acta 135: , Greene HL, Herman RH, Kraemer S: Stimulation of jejunal adenyl cyclase by ethanol. J Lab Clin Med 78: , Greenough WB, Carpenter CCJ, Bayless TM, et al: The role of cholera exotoxin in the study of intestinal water and electrolyte transport, Progress in Gastroenterology, vol 2. Edited by JB Jerzy Glass. New York, Grune and Stratton, 1970, p Lindenbaum J, Lieber CS: Alcohol induced malabsorption of vitamin B-12 in man. Nature 224:806, Rubin E, Rybak B, Lindenbaum J, et al: Ultrastructural changes in the small intestine induced by ethanol. Gastroenterology 63: , Sullivan L, Herbert V: Suppression of hematopoiesis by ethanol. J Clin Invest 43: , Eichner ER, Pierce HI, Hillman RS: Folate balance in dietary induced megaloblastic anemia. N Engl J Med 284: , 1971