FAILURE TO THRIVE ( FTT)

Size: px

Start display at page:

Download "FAILURE TO THRIVE ( FTT)"

Janis Ferguson
5 years ago
Views:

1 FAILURE TO THRIVE ( FTT) Atan Baas Sinuhaji Sub Division of Pediatrics Gastroentero-Hepatology Department of ChildHealth,School of Medicine University of Sumatera Utara/Adam Malik Hospital Medan

2 GROWTH Increase in the mass of body tissues Anthropometric measurement Body Weight Body Lenght Head Circumference ABS-BIKA BIKA FKUSU 2

3 Development Skill ABS-BIKA BIKA FKUSU 3

4 Anthropometric asessment At the spesific time Repeated visit Poor Poor Malnutrition F T T 4

5 5

6 Table 1. WATER LOW S CLASSIFICATION NORMAL WASTING STUNTED WEIGHT/ AGE % WEIGHT/ HEIGHT % HEIGHT/ AGE %

7 F.T.T SUBOPTIMAL OF GROWTH REPEATED VISIT

8 Malnutrition is the sine qua non of the failure to thrive ABS-BIKA BIKA FKUSU 8

9 GENETIC MALNUTRITION FTT PSYCHOSOCIAL Malnutrition : inadequate nutrients 9

10 CALORI / NUTRIENTS Intake Stools Absorption Utilization Basal Metabolism Peripheral Utilization Growth 10

11 IMPAIRED OF PERIPHERAL UTILIZATION BASAL UTILIZATION NUTRIENTS MALABSORPTION INTAKE NUTRITION INADEQUATE MALNUTRITION 11

12 Etiology of growth disorders 1. Inadequate intake of 4. Impaired of peripheral calories/nutrients utilization 2. Excessive calories/nutrients Chronic infection losses Malignancy Vomiting Congenital heart Malabsorption diseases 3. Basal metabolism Anemia Fever Hyperthyroidea Inborn errors Hyperkinesia Hormonal Infection 12

13 FTT CAUSED BY BOWEL DYSFUNCTION INADEQUATE CALORY INTAKE EXCESSIVE CALORY LOSS -QUALITY -IGNORANCE -ANOREXIA -VOMITING -MALABSORPTION -PROTEIN LOSING ENTEROPATHY INCREASED NEED - FEVER 13

14 DISORDER OF DIGESTION MALDIGESTION MALABSORPTION 14

15 MALABSORPTION FAILURE OF THE DIGESTIVE SUBSTRACTS ACROSS LUMEN INTO MUCOSE VESSELS BLOOD LYMPH 15

16 MALABSORPTION 1.MALDIGESTION 2.HYPEROSMOTIC 3.PERISTALSIS 4. ABSORPTION AREA - SHORT GUT - MUCOSAL INJURY 16

17 MALDIGESTION DISORDERS INTRALUMINAL INTRACELLULARE MEMBRANE -GASTER -PANCREAS -LIVER -GUT ENTEROKINASE (trypsinogen trypsin) - MALTASE - LACTASE - SUCRASE - GLUCOAMYLASE PEPTIDASE LIPASE 17

18 MUCOSAL INJURY ENTEROCYTE -LUMINAL MEMBRANE -INTRACELL / CYTOPLASMA -BASOLAT. MEMBRANE -BASAL MEMBRANE INTERCELLULER SPACE LAMINA PROPRIA -BLOOD/LYMPH VESSELS TIGHT JUNCTION -SECRETION -MACROMOLECULAR ABSORPTION SENSITIZATION 18

19 Causes of mucosal injury 1. Mucosal compromised Malnutrition Folic acid Deficiency Iron Deficiency Antioxidant Deficiency 2. Infection Viral (rotavirus) Bacteria overgrowth Antibiotica ( e.g. Neomycine ) 3. Immunological disorder SIgA Deficiency 4. Parasitic Infestation Giardiasis ABS-BIKA BIKA FKUSU 19

20 Consequences of mucosa osal injury 1. Diarrhoea 2. Malabsorptionon 3. Protein losing enteropathy 4. Sensitization macro moleculer absorption 5. Necrotizing Enterocolitis ABS-BIKA BIKA FKUSU 20

21 CLASSIFICATION OF MALABSORPTION 1.SUBSTRACTS 2.SELETIVE/GENERALIZED 3.OBTAINED CONGENITAL --- ACQUIRED 4.PATHOPHYSIOLOGY 5.PATHOGENESE & ETIOLOGY 21

22 CARBOHYDRATE FAT PROTEIN SUBSTRACT WATER & ELECTROLYTES VITAMIN MIXED OR GENERALIZED I I PAN MALABSORPTION 22

23 Congenital & genetic Pathogenese & etiology Bacterial overgrowth Bile acid def. sensitization nutritional Drug induced 23

24 CARBOHYDRATE 1. INTRALUMINAL ENZYME : AMYLASE 2. BRUSH BORDER ENZYME OLIGO/DISACHARIDASE 3. ABSORPTION GLUCOSE FRUCTOSE GALACTOSE 4. COLONIC BACTERIA SCFA COLON NUTRITION 24

25 BOWEL NUTRITION COLON SMALL INTESTINE 70% INTRALUMINAL 30% INTRAVASAL 45% INTRALUMINAL 55% INTRAVASAL 25

26 TRYGLYCERIDE FATTY ACID GLYCEROL SHORTCHAIN FATTY ACID (SCFA) LONG CHAIN FATTY ACID (LCFA) C<6 MEDIUM CHAIN FATTY ACID (MCFA) C>12 C=6-8(12) 26

27 DIGESTION & ABSORPTION OF FAT 1.EMULSIFICATION 2.LIPOLYSIS LIPASE 3.MICELLE BILE SALT 4.ENTER INTO MUCOSE 5.RE-ESTERIFICATION 6.CHYLOMICRON 7.BLOOD/LYMPH VESSELS 27

28 MCT(MEDIUM CHAIN TRIGLYCERIDE) C=6-8(12) 1.LIPASE 70% 2.NO BILE SALT 3.NO REESTERIFICATION 4.NO CHYLOMICRON FORMATION 5.PORTAL VEIN 28

29 DIAGNOSTIC OF FAT MALABSORPTION 1. MICROSCOPIC 2. FLOATING TEST (ROSSIPAL) 3. LIPIODOL ABSORPTION TEST 4. SERUM CAROTEN 5. FAT BALANCE (VAN DE KAMER) 6. STEATOCRITE 29

30 LIPIODOL ABSORPTION TEST LIPIODOL FAT+IODINE Drink of 5-10 ml BLOOD URINE + AMYLUM 1% DILUTION 1:1 1:2 1:8 (+) N 30

31 DIGESTION & ABSORPTION OF PROTEIN 1.INTRALUMINAL DIGESTION (HCL, PEPSIN) 2.ACTIVATED PANCREATIC ENZYMES BY ENTEROKINASE 3.PROTEOLYSIS PEPTIDE & AMINO ACIDS 4.MUCOSE INTRACELLULER DIGESTION 5.PORTAL VEIN 31

32 MALABSORPTION ACUTE CHRONIC DEF. ABD. DISTENSION DEHYDRATION AVITAMINOSIS - PERSISTENT DIARRHOEA - FAILURE TO THRIVE 32

33 TREATMENT OF MALABSORPTION 1. ETIOLOGY -INFECTION -ENZYMS 2. DIET PREDIGESTED FORMULA 3. SUPPORTIVE - WATER & ELECTROLYTES - VITAMIN & MINERAL - PREVENTION OF MALNOURISHED 33

34 MALABSORPTION SYNDROME 1. LACTOSE INTOLERANCE 2. COW S MILK PROTEIN INTOLERANCE 3. PCM 4. CHOLESTASIS 5. PARASITIC INFESTATION 6. ANTIBIOTICS 7. POST ENTERITIS MALABSORPTION 34

35 Lactose Intolerance Terminology Lactase Defisiency : Low / absence activity of lactase enzyme assay Laktose Malabsorption : Failure of the small intestine to absorb lactose conformity with the test Lactose Intolerance : clinical symptoms/signs 35

36 LACTOSE The Primary Carbohydrate Of Mammals Milk Breast Milk (7 %) Cow Milk (4 %) Sea Lion Milk (0 %) 36

37 LACTOSE Lactase In outer of brush border Smallest amount No adaptive enzyms Glucose & Galactose 37

38 Developmental Primary Congenital alactasia LACTASE Defisiency Late onset hypolactasia Secondary Mucosal damage eg rotavirus diarrhoea 38

39 UNABSORBED LACTOSE OSMOTIC ACTION H 2 COLON FERMEN TATION GASES CO 2 CH 4 ABSORBED WATER LACTOSE SHORT CHAIN FATTY ACID COLONIC SALVAGE L - LACTATE OSMOTIC DIARRHOEA REDUCTION SUBSTANCE (LACTOSE) CLINITEST LACTAT ACID stools ph LACMUS 39

40 DIAGNOSTIC OF LACTOSE INTOLERANCE Lactose tolerance test + Lactose malabsorption test a. Stools ph & clini test b. Lactose loading test c. Breath hydrogen test 40

41 Stools ph & clini test Screening Test Only drunk lactose Fast intestinal transit time Fresh stools Incomplete degradation of lactose 41

42 Breath hydrogen test Night fasting Doses of lactose : 2 gr/kgbw (max. 50 gr) in concentration of solution 20 % Samples are then collected every 30 minutes for 3 hours to determine H 2 concentration in expired air Malabsorption : > 20 ppm greater than fasting level 42

43 TREATMENT LACTOSE INTOLERANCE Primary Secondary 1.Low/free lactose 2. Premature - Breast milk (+): continued - Breast milk (-) : lactose lowered + glucose polymer Breast milk continued Breast milk (-)?? 43

44 COW S MILK PROTEIN INTOLERANCE -SMALL BABY -DIARRHOEA -ENTEROPATHY Lact. Intol. CMPI 1.FREQ. 2.Extra GI Tract manifestation 3.Phenomenon >>> > (-) (+) DOSE DEPENDENT DOSE INDEPEN. 44

45 Goldman Criteria 1. Remission of symptoms after elimination of cow milk from the diet 2. Relapse within 48 hours of beginning a milk challenge 3. Positive reaction to 3 such challenges (similar onset, duration, and clinical features) 45

46 BIOPSY MUCOSAL DAMAGE PERMEABILITY -Dxylose absorption test -L/M excretion ratio PROTEIN LOSING ENTEROPATHY -Polyethylen glycol abs. test 46

47 INFLAMMATION MUCOSAL DAMAGE PROTEIN LOSING ENTEROPATHY NONINFLAMMATION LYMPHANGIECTASIA LYMPH OBSTR. *Congenital Heart Disease CHD* 47

48 DIAGNOSTIC OF PROTEIN LOSING ENTEROPATHY 1. ISOTOP 2. FECAL α1- ANTITRYPSIN 48

Abdulrahman Alhanbali. Lojayn Salah. Mohammad Khatatbeh. 1 P a g e

Abdulrahman Alhanbali. Lojayn Salah. Mohammad Khatatbeh. 1 P a g e 7 Abdulrahman Alhanbali Lojayn Salah Mohammad Khatatbeh 1 P a g e In this lecture we will talk about digestion and absorption of food in the alimentary tract. But first of all we have some important points