LA CONSULTA SEMANAL

MAYO 2001

CONSULTA

Gastrointest Endosc Clin N Am 2000 Oct;10(4):739-53, vii
Small intestinal mucosal biopsy for investigation of diarrhea and malabsorption in adults.
Freeman HJ
Department of Medicine, University of British Columbia, Vancouver, Canada.
The use of small intestinal biopsy for diagnosis in diarrhea and suspected malabsorption depends on an optimal interaction between the clinician-endoscopist and the pathologist. This necessitates open and interactive communication between involved physicians and an appreciation for correct tissue handling and biopsy orientation in the endoscopy unit and the pathology laboratory. Classification of biopsy changes on the basis of architectural abnormalities in the small intestinal biopsy may be helpful in defining the diagnosis and include severe (flat) or variably severe (mild or moderate) abnormalities. For some small intestinal disorders that are characterized by diarrhea or malabsorption, the biopsy findings may be distinctive and lead to a specific diagnosis. For others, like celiac disease, the changes are less specific, and it has become better recognized that an increasing number of conditions can produce similar histopathologic changes. Definition of typical gluten-sensitive biopsy changes in this disorder is critical.
Publication Types:
  Review
  Review, tutorial


Curr Gastroenterol Rep 2000;2(5):370-7
Malabsorption testing: a review.
Ginsburg PM, Janefalkar P, Rubin DT, Ehrenpreis ED
Department of Gastroenterology, University of Chicago Hospitals, 5841 South Maryland Avenue, MC 4076, Chicago, IL 60637, USA. eehrenpr@medicine.bsd.uchicago.edu
Malabsorption syndromes often present diagnostic dilemmas to even the most experienced clinicians. Several malabsorption screening tests are available, but d-xylose testing is our initial screening method of choice. Recent innovations such as serum assays for antibodies associated with celiac sprue are improving the work-up of patients with suspected malabsorption. In addition, physicians are applying technological advances in imaging to determine the underlying pathologies responsible for the occurrence of malabsorption and maldigestion. Breath testing remains a controversial modality in the work-up of patients with
malabsorption. Tubeless tests of pancreatic function are also the subject of debate due to a lack of sensitivity for diagnosing mild to moderate chronic pancreatic insufficiency. This review identifies and provides critical analysis of new developments in the field of malabsorption testing. The authors also provide a clinical algorithm for diagnosisng malabsorption.


Paediatr Drugs 2000 May-Jun;2(3):205-22
Control of malabsorption in cystic fibrosis.
Littlewood JM, Wolfe SP
Regional Paediatric Cystic Fibrosis Unit, St James Hospital, Leeds, England. jlittlewood@dial.pipex.com
Intestinal malabsorption is severe and of early onset in virtually all people who have cystic fibrosis. The main cause is deficiency of pancreatic enzymes, but bicarbonate deficiency, abnormalities of bile salts, mucosal transport and motility, and anatomical structural changes are other contributory factors. Appropriate pancreatic replacement therapy will achieve normal or near normal absorption in many patients. It is important to identify both malabsorption and evidence of a pancreatic lesion in all patients who are to receive pancreatic enzymes. All who have evidence of fat malabsorption are deemed pancreatic insufficient and candidates for enzyme replacement therapy. Effective treatment should allow a normal diet to be taken, control symptoms, correct malabsorption and achieve a normal nutritional state and growth. The occurrence of fibrosing colonopathy in some patients receiving very high doses of those enzymes that have the copolymer Eudragit L30 D55 in their covering has resulted in guidelines in the UK to avoid dosages greater than the equivalent of 10,000 IU lipase/kg/day for all patients and also to avoid preparations containing this copolymer in children and adolescents. For patients not responding to 10,000 IU lipase/kg/day, review of adherence to treatment, change of enzyme preparation, variation of the time of administration and reduction in gastric acid may improve absorption. The importance of excluding other gastrointestinal disorders as a cause of the patient's symptoms and the need for early investigations, rather than merely increasing the dosage of enzymes, is stressed. With modern enzymes, adequate control of gastrointestinal symptoms and absorption can be achieved at dosages of 10,000 IU lipase/kg/day or only slightly more, and a normal nutritional state and growth rate maintained in most patients with cystic fibrosis.
Publication Types:
  Review
  Review, tutorial


J Pediatr Gastroenterol Nutr 2000;30 Suppl:S61-6
Food-induced malabsorption syndromes.
Savilahti E
Hospital for Children and Adolescents, University of Helsinki, Finland.
A syndrome of chronic diarrhea, vomiting, and failure to thrive was described 35 years ago. The syndrome was caused by damage in the jejunum after ingestion of cow's milk. Symptoms appeared in young infants shortly after introduction of cow's milk formula. Patients had moderate steatorrhea, decreased absorption of D-xylose, and, often, iron-deficiency anemia and hypoproteinemia. They had strong IgA and IgG antibodies to cow's milk. IgE antibodies to cow's milk were negative, as a rule. Indicators of cell-mediated immune reaction to cow's milk proteins were often positive. Patients were tolerant to cow's milk by the age of 3 years. Malabsorption was due to damage to the jejunal mucosa: Varying villus atrophy was associated with inflammation in surface epithelium and lamina propria. The epithelial cell renewal rate increased. Surface epithelial cells decreased in height, with short, furry microvilli and large aggregates of lysozymes. The number of intraepithelial lymphocytes was markedly increased, but normalized during cow's milk elimination. Most of these lymphocytes had alpha/beta T-cell receptors, and many were cytotoxic. Some specimens had an increase in gamma/delta T-cell receptor-bearing cells. In the lamina propria, CD4+ cells predominated, and some of them were activated. IgA- and IgM-containing cells were markedly increased during cow's milk exposure, but IgE cells were not abnormal. The density of eosinophils was moderately increased. Secretion of interferon-gamma by cells isolated from patients' intestines was markedly increased. Morphologic and immunologic findings suggest that T-cell-mediated reaction to proteins in cow's milk is present in the small intestines of patients with this syndrome and causes this enteropathy.
Publication Types:
  Review
  Review, tutorial


Nutrition 1999 Feb;15(2):167-9
The mechanisms of fat malabsorption in cystic fibrosis patients.
Kalivianakis M, Verkade HJ
Publication Types:
  Editorial
  Review
  Review, tutorial


Am J Physiol 1998 Nov;275(5 Pt 1):G879-82 [Texto completo]
I. Glucose galactose malabsorption.
Wright EM
Physiology Department, University of California School of Medicine, Los Angeles, California 90095-1751, USA.
Glucose Galactose Malabsorption is a genetic disorder caused by a defect in glucose and galactose transport across the intestinal brush border. Normally, lactose in milk is broken down into glucose and galactose by lactase, an ectoenzyme on the brush border, and the hexoses are transported into the cell by the Na+-glucose cotransporter SGLT1. The mutations causing the defect in sugar transport have been identified in patients from 33 kindreds, and functional studies have established how these mutations cause the disease.
Publication Types:
  Review
  Review, tutorial


Hosp Med 1998 May;59(5):404-7
Malabsorption in the elderly. II: Treatment and further investigations.
Hossain J, Lewis RR
William Harvey Hospital, Ashford, Kent.
After the initial assessment of elderly patients suspected of having malabsorption, as discussed in the first of this pair of articles, more specific investigations may be necessary. These are described in this article, together with the main treatment options that are available.
Publication Types:
  Review
  Review, tutorial


Hosp Med 1998 Apr;59(4):277-80
Malabsorption in the elderly. 1: Examination, history and investigation.
Hossain J, Lewis RR
William Harvey Hospital, Ashford, Kent.
Malabsorption in elderly patients has varied presentations, and can be overlooked. A high index of clinical suspicion is required. This, the first of two articles, discusses the principal causes, clinical features and initial investigations of malabsorption in the elderly.
Publication Types:
  Review
  Review, tutorial


Digestion 1998 Aug;59(5):530-46
Malabsorption syndromes.
Bai JC
Universidad del Salvador, and Hospital de Gastroenterologia 'Dr. Carlos Bonorino Udaondo', Buenos Aires, Argentina.
BACKGROUND/AIMS: Malabsorption syndromes commonly result from a pathological interference of the normal digestive process. There have been major advances in the last 4 years. The purpose of this review is to highlight in the form of a brief summary the most outstanding information available. METHODS: The review was performed based on a medical literature search using MEDLINE (1993-1997), bibliographic reviews of book chapters and review articles. As a consequence of the extensive information incorporated in the period and the limited scope of this review, the review will focus in three aspects: (1) an overview on some clinical aspects of malabsorption; (2) diseases in which predominates the disturbed mucosal phase of the digestive process, and (3) providing information on diagnostic testing regarding malabsorption. RESULTS: Major advances on celiac disease, Whipple's disease, giardiasis, tropical sprue, malabsorption of oligo- and disaccharides, vitamin B12 and bile salts are discussed. New aspects on diagnostic procedures for malabsorption are also presented. CONCLUSION: Although major advances have given a great support to the investigation of malabsorption, yet the syndrome remains a major diagnostic dilemma. Based on the limited availability of most diagnostic tests, a simple and practical diagnostic algorithm is presented.
Publication Types:
  Review
  Review, academic


Gastroenterol Hepatol 1997 Aug-Sep;20(7):386
[A malabsorption syndrome, gastrointestinal leishmaniasis and HIV infection].
[Article in Spanish]
Alguacil GF, Moreno J, Ortolano A, Hallal H
Publication Types:
  Letter
  Review
  Review of reported cases


Pancreas 1997 May;14(4):323-33
Pancreatic steatorrhea, malabsorption, and nutrition biochemistry: a comparison of Japanese, European, and American patients with chronic pancreatitis.
Nakamura T, Takeuchi T
Third Department of Internal Medicine, Hirosaki University School of Medicine, Aomori, Japan.
This article reports on steatorrhea, daily food intake, and fecal substances other than fecal fat (e.g., neutral sterols, bile acids, short-chain fatty acids) in pancreatic exocrine dysfunction arising from chronic pancreatitis (CP) in Japanese. European, and American patients. Changes in upper small intestinal pH and lipase secretion, plasma fatty acid profiles, serum fat-soluble vitamin levels and symptoms of their deficiency, and nutritional status are discussed in detail. Treatment of pancreatic steatorrhea is described. Throughout this study, we compared characteristics of maldigestion and malabsorption in these patient populations and our study revealed that fecal fat excretion reflected quantitative differences in fat consumption, plasma fatty acid profiles reflected quantitative and qualitative differences in fish oil consumption, and there were no differences in pancreatic exocrine dysfunction among these three groups. Since differences in fecal fat excretion and plasma fatty acid profiles appear to depend on dietary fats, the pathology and treatment of CP patients should be evaluated and the findings used to prescribe treatments.
Publication Types:
  Review
  Review, tutorial


J Clin Invest 1997 Apr 15;99(8):1807-8 [Texto completo]
Point mutations in the ileal bile salt transporter cause leaks in the enterohepatic circulation leading to severe chronic diarrhea and malabsorption.
Small DM
Publication Types:
  Editorial
  Review
  Review, tutorial


Am J Clin Nutr 1997 Feb;65(2):564-7
Dairy sensitivity, lactose malabsorption, and elimination diets in inflammatory bowel disease.
Mishkin S
Department of Medicine, McGill University, Montreal, Quebec, Canada. dmishk@po-box.mcgill.ca
The ability of inflammatory bowel disease (IBD) patients to tolerate dairy products and the guidance they receive from physicians and nutritionists on this subject are important considerations in the management of their IBD. Although most affected persons are able to consume a glass of milk daily without discomfort, additional consideration must be given to specific factors that can be relevant to certain individuals. The declaration by patients that they are "dairy sensitive" may be related to lactose intolerance or malabsorption, the long-chain triacylglycerol content of milk, allergy to milk proteins, as well as psychologic factors and the misconception that dairy products can be detrimental to their health. The prevalence of lactose malabsorption is significantly greater in patients with Crohn disease involving the small bowel than it is in patients with Crohn disease involving the colon or ulcerative colitis. In the latter colonic conditions the prevalence of lactose malabsorption is mainly determined by ethnic risk, which is based on genetic factors. In addition, lactose malabsorption in Crohn disease of the small bowel may be determined by factors other than lactase enzyme activity, such as bacterial overgrowth and/or small bowel transit time. Physicians differ widely in the advice they give their patients: some dogmatically advise avoidance of dairy products when the diagnosis is made whereas others discount the possible role of dairy in the management of IBD. IBD patients avoid dairy products more than they would need to based on the prevalence of lactose malabsorption and/or milk intolerance, probably partly because of incorrect patient perceptions and arbitrary advice from physicians and authors of popular diet books. Adequate scientific and clinical information is now available to permit recommendations about the intake of dairy products for each IBD patient.
Publication Types:
  Review
  Review, tutorial


Pediatr Clin North Am 1996 Apr;43(2):307-31
Chronic diarrhea and malabsorption.
Branski D, Lerner A, Lebenthal E
Department of Pediatrics, Shaare Zedek Medical Center, Hebrew University, Israel.
Diarrhea is one of the major causes of infant morbidity and mortality worldwide. Major advances in understanding the pathophysiology of chronic diarrhea and malabsorption have taken place during the past three decades. Analysis of absorptive and secretory functions of the intestine has provided some insight into the possible causes of diarrhea. This article summarizes some of the specific causes of malabsorptive diarrhea in infancy and childhood, with emphasis on pathophysiology and approaches to therapy.
Publication Types:
  Review
  Review, tutorial


Pediatr Clin North Am 1995 Aug;42(4):899-915
Carbohydrate malabsorption.
Ushijima K, Riby JE, Kretchmer N
Department of Pediatrics and Child Health, Kurume University Medical Center, Fukuoka, Japan.
Carbohydrate malabsorption is a very important clinical entity, particularly in pediatrics, where, if untreated, it can lead to malnutrition and failure to thrive. Malabsorption that can be treated readily with elimination of the offending carbohydrate. Knowledge by the physician of the specific mechanisms involved in the physiology of carbohydrate absorption and digestion will help in the handling of the clinical situation of malabsorption.
Publication Types:
  Review
  Review, academic


Gut 1994 May;35(5):582-6
Persisting diarrhoea and malabsorption.
Cook GC
Hospital for Tropical Diseases, London.
Publication Types:
  Review
  Review, tutorial


Semin Gastrointest Dis 1994 Apr;5(2):78-87
Malabsorption syndromes and celiac disease.
Rosensweig JN, Perman JA
Department of Pediatrics, Johns Hopkins University, School of Medicine,
Baltimore, MD.
Publication Types:
  Review
  Review, tutorial