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(MAL)ASSIMILATIE BIJ MAAG-DARM AANDOENINGEN
Lisbeth Mathus-VliegenMDL arts, Em. Hoogleraar Klinische Voeding
ENTRY QUESTIONSWhich of the macronutrient assimilation is the most complex?1. Protein2. Carbohydrates3. Fat In celiac disease, which of the phases of assimilation are disturbed (may be more
answers possible)?1. Ingestion 4. Transport2. Digestion 5. Absorption3. ExcretionWhich part of the bowel can hardly be missed (may be more answers possible)?1. Duodenum2. Jejunum3. Ileum In the treatment of fluid/ electrolyte disturbances, the following holds true1. ORS can be used to diminish the diarrhoea2. Magnesium supplements are well tolerated3. In case of treatment-resistant hypocalcemia magnesium supplements
should be given 4. ORS can easily be home-made
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ENTRY QUESTIONSWhich of the following statements is true (may be more answers possible)?1. Oligopeptides offer a kinetic advantage over amino acids 2. Monosaccharides and disaccharides are equally easily absorbed3. Fat malabsorption cannot be influenced
In Crohn’s disease when enteral nutrition is considered, the formula (may be more answers possible)
1. Should always consist of polymeric feeds2. Should always be reduced in fat3. Has only a role to play in children with Crohn’s disease4. Should preferably contain oligopeptides and MCTs
When do you think MCTs have an advantage (may be more answers possible)?1. When the pancreas function is impaired2. When there is insufficient luminal digestion3. When fat absorption is impaired4. When fat transport is impaired
TEACHING AIMS
• To understand the normal assimilation of nutrients
• To understand the 3 phases of malabsorption with representative examples
• To recognise physical signs of malabsorption
• To understand the diagnostic tests
• To understand the different treatment modalities
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TEACHING AIMS
• To understand the normal assimilation of nutrients
• To understand the 3 phases of malabsorption with representative examples
• To recognise physical signs of malabsorption
• To understand the diagnostic tests
• To understand the different treatment modalities
ASSIMILATION OF DIETARY NUTRIENTS
DIGESTION – intestinal lumen
ABSORPTION – luminal surface
TRANSPORT – cell
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MALABSORPTION/ MALASSIMILATIONsubnormal intestinal absorption of dietary constituents
and thus excessive loss of nutrients in the stool
• MALDIGESTION – luminal processing: luminal phase
• MALABSORPTION sensu strictu – absorption into intestinal mucosa: mucosal phase
• DEFECTIVE TRANSPORT – postabsorptive processing in enterocyt cell and transport into the circulation or lacteals: transport phase
• GLOBAL – by diffuse mucosal disease or reduced mucosal surface after resection
• PARTIAL/ ISOLATED – concerning specific nutrients
(MAL)ASSIMILATIE MACRONUTRIËNTEN
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EIWIT ASSIMILATIE
• DIGESTIE– Maag zuur en pepsine: denaturatie van eiwitten
pepsine: Ca, Fe, vitamine B12, foliumzuur
– Duodenum/jejunum secretine, enterokinase
– Pancreas trypsine, chymotrypsine, elastase, carboxypeptidasen
• ABSORPTIE– Brush border endopeptidasen, aminopeptidasen,
dipeptidasen
– Enterocyt membraan aminozuren, oligopeptiden
Z-E syndroomPancreasinsufficiëntie
Coeliakie
CHARACTERISTICS OF TRANSPORT MECHANISMS
Characteristic ACTIVE TRANSPORT
Facilitated diffusion
Simple diffusion
Carrier involvedCompetition for transport between substratesTransport kineticsEnergy dependentTransport against electrochemical gradient
??
???
??
???
??
???
PASSIVE TRANSPORT
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CHARACTERISTICS OF TRANSPORT MECHANISMS
Characteristic ACTIVE TRANSPORT
Facilitated diffusion
Simple diffusion
Carrier involvedCompetition for transport between substratesTransport kineticsEnergy dependentTransport against electrochemical gradient
Yes Yes
SaturationYesYes
Yes Yes
SaturationNoNo
No No
No saturationNoNo
PASSIVE TRANSPORT
EIWIT ABSORPTIE
• AMINOZUREN (AA) ABSORPTIE– Neutrale aminozuren
• Aromatische AA (tyr, trp, phe)
• Alifatische AA (ala, ser, thr, val, leu, ile)
• Monoamino-monocarboxyl AA (gly, pro)
• Restant AA (met, his, gln, asn, cys)
– Basische aminozuren• Di-aminozuren (lys, arg, orn)
• Neutrale S-aminozuren (cys)
– Zure aminozuren• Dicarboxyl AA (glu, asp)
• OLIGOPEPTIDEN (DI- EN TRI-)
actief, carrier-mediated, Na+
afhankelijk, zeer snel
actief, carrier-mediated, Na+
afhankelijk, snel
actief, carrier-mediated, deelsNa+ afhankelijk, snel
actief, carrier-mediated, deelsNa+ afhankelijk, zeer snel
Hartnup diseaseCystinurie
allersnelst
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EIWIT ASSIMILATIE
• DIGESTIE– Maag zuur en pepsine: denaturatie van eiwitten
pepsine: Ca, Fe, vitamine B12, foliumzuur– Duodenum/jejunum enterokinase – Pancreas trypsine, chymotrypsine, elastase,
carboxypeptidasen
• ABSORPTIE– Brush border endopeptidasen, aminopeptidasen,
dipeptidasen– Enterocyt membraan aminozuren, oligopeptiden
• TRANSPORT– Enterocyt cytoplasma peptidasen– Capillairen
EIWIT ASSIMILATIE
Maag: zure pH, pepsine
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KOOLHYDRATEN IN DE VOEDING
Lactose
AmylaseStarch/glycogen
Sucrose
HCl
Lactose
Pancreatic α-amylaseDextrinsMaltotriose
Maltose
Sucrose
LactaseGalactoseGlucose
Dextrinase IsomaltaseMaltase
Glucose
SucraseGlucoseFructose
GalactoseGlucose
Glucose
GlucoseFructose Facilitated diffusion
MOUTH STOMACH
INTESTINE
LUMEN EPITHELIAL CELLBrush border Cytosol
NaCP
NaCP
NaCP
NaCP
ASSIMILATIE VANKOOLHYDRATEN
FODMAPs
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FODMAPS
Koolhydraten die niet of niet voldoende worden opgenomen in de dunne darm en in het colon slecht verdragen worden
• Fermentable• Oligosaccharides Fructanes en galacto-oligosacchariden (GOS)
– Fructanen F-F-F-F-G (geen enzym)– GOS Ga-Ga-Ga-Ga-G (geen enzym)
• Disaccharides Lactose (Ga-G) (soms geen enzym)• Monosaccharides Fructose
– Absorpie bepaald door G:F ratio (idealiter 1:1); bij > 30-35 g fysiologische malabsorptie
• And• Polyols Suikeralcoholen sorbitol, xylitol, mannitol
– Sorbitol fysiologische malabsorptie bij 20-50 g
HYPOTHESE EFFECTEN VAN FODMAPS
�Osmotische activiteit in dunne darm�Toegenomen motiliteit in dunne darm
�Door fermentatie in colon toegenomen osmotische activiteit en toegenomen gasvorming�Door vorming van korte-keten-vetzuren (SCFA) daling pH met verminderde methanogene bacteriën en minder CH4en meer H2 vorming�Toegenomen motiliteit in colon
Barrett et al., APT 2010;31:874-882 Khan et al., Dig Dis Sci 2015;60:1169-1177
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NUTRIENT TRAFFICKING GENES AND TRANSPORT PROTEINS
SGLT-1 sodium-dependent D-glucose transporterbrush border membrane (villus)jejunum > ileum > duodenumGLUT-2-dependent
GLUT-5 sodium-independent facilitative fructose transporterbrush border membrane (villus)
GLUT-2 sodium-independent facilitative hexose transporterbasolateral membrane (villus)
ASSIMILATIE VAN KOOLHYDRATEN
SGTL-1
GLUT-5
GLUT-2
GLUT-2
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Lipase met colipaseFosfolipase A2Cholesterolesterase
Simpele diffusie ExocytoseCarrier-mediated FATP-4, CD-36
NPCILItransporter
Linguaal lipase (Von Ebner’sglands) en maag lipase:TAG → DAG + FAvooral SCFA en MCFA
ASSIMILATIE VAN VET
MCT
PHYSICOCHEMICALCHARACTERISTICSMCT more interfacial
surface for enzyme
action/unit time
greater water solubility
of MCT hydrolysis products
smaller molecular size
of MCT vs LCT
short length of chain
of FA from MCT
small molecular size &
lower pK of FA from MCT
greater water solubility
of MCFA
PHYSIOLOGICCONSIDERATIONSMore rapid and complete
intraluminal hydrolysis
of MCT
no bile salts required
small amounts may enter
cells without hydrolysis
more efficient penetration
of diseased mucosa
decreased affinity for
esterifying and activating
enzymes, minimal reesteri-
fication of MCFA to MCT,
no chylomicron formation
portal transport of MCT as
MCFA
THERAPEUTICAPPLICATIONSdecreased intraluminal
digestion (pancreatic/
intestinal origin)
decreased intraluminal
concentration of bile salts
pancreatic insufficiency
(non) tropical sprue
a- or hypo–β
lipoproteinemia
lymphatic obstruction;
lymphangiectasia
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ASSIMILATIEKOOLHYDRATEN (vertering in lumen en borstelzoom, rate
limiting = absorptie: Na-afhankelijk actief transport)
absorptie proximale 70 (40-100) cm jejunumcolonic salvage door fermentatiemonosacchariden vs di-/ oligosacchariden
EIWIT (vertering in lumen en borstelzoom, rate limiting = absorptie: Na-afhankelijk actief transport)
absorptie proximale 20 cm jejunumcolonic salvage door fermentatieaminozuren vs di-/ tripeptiden
VET (digestie in lumen, rate limiting = lipolyse en micel vorming)
absorptie proximale 100 (60-100) cm jejunumeffecten op colonmedium chain vs long chain triglyceridenvet absorptie coëfficiënt, type van vet
KINETISCHE VOORDELEN VAN ABSORPTIE
• Aminozuren uit oligopeptidenoplossingen versus aminozuuroplossingen
• Monosacchariden uit disaccharidenoplossingen versus monosacharidenoplossingen
• MCT vs LCT
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(MAL)ASSIMILATIE WATER EN ZOUTEN
WATER- EN ELECTROLIETBALANS
Water Na K Chlml mEq mEq mEq
nutritionele intake 1500 50 80 150secretie maagdarmstelsel 7000 1000 40 750 totaal 8500 1050 120 900
faecale excretie 200 5 10 3
Absorptie EfficiëntieJejunum 4-5 L van 9 L 50%Ileum 3-4 L van 4-5 L 75%Colon 1-2 L van 1-2 L >90%
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RESORPTIE WATER EN ZOUTEN
• Resorptie wijze– Passief bepaald door poriënwijdte en lading
– Actief carriers en ATP, maximum
• Passagesnelheid– Jejunum sneller dan ileum
• Plaats in darm– Duodenum passief transport van water voor isotoniciteit
natrium passief en actief
natrium actief (1 mmol → 180 mmol H2O), solvent drag voor K, Mg, Zn
– Jejunum glucose passieve opname met actief Na transport en passief H2O transport
– Ileum Na en K uitgewisseld tegen H en bicarbonaat
– Colon Na uitgewisseld tegen K
ABSORPTIE VAN VOCHT IN MAAGDARMSTELSEL
Reservecapaciteit 15 L Reservecapaciteit 5 L
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Na/GLUCOSE OR Na/AMINOACID COTRANSPORTERS
DAILY TURNOVER OF WATER AND ELECTROLYTES IN COLON
Concentrationmmol/l
Amount mmol
Concentration mmol/l
Amount mmol
Water mlNaKClHCO3
-14067050
1500210910575
-409016-
100492-
ENTERING COLON LEAVING COLON IN STOOL
Water Na K Chlml mmol mmol mmol
nutritionele intake 1500 50 80 150secretie maagdarmstelsel 7000 1000 40 750
totaal 8500 1050 120 900
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Lumen colon COLON – WATER
EN ELECTROLYTBEWEGINGEN
Aldosteron
SCFA enhanced water and electrolyte absorptionmetabolic energy production (500 kcal)increased colonocyte proliferationenhanced colonic blood flowincreased gastrointestinal hormone production
DIETARY FIBRE: COLONIC SALVAGE
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KORTE KETEN VETZUREN (KKV)Butyraat voeding voor de colonocyt (replicatie/ differentiatie)
via ketonvorming voeding voor enterocytionische/niet ionische absorptie water en electrolytenstimulatie pancreasenzymen en hormonen
Propionaat via levercel omzetting in glucose en energieeffect op Kupfer cel in de levertoename insuline gevoeligheid en glucosetolerantie
Acetaat via levercel omzetting in glutamine en ketonen (voeding voor enterocyt)
vaatverwijdingenergiebron voor perifere weefsels, hartspier en
hersenentoename insuline gevoeligheid
KINETISCHE VOORDELEN VAN ABSORPTIE
• Aminozuren uit oligopeptidenoplossingen versus aminozuuroplossingen
• Monosacchariden uit disaccharidenoplossingen versus monosacharidenoplossingen
• MCT vs LCT
• Natrium gekoppeld aan co-transport van glucose en aminozuren, bij intacte basolaterale Na+-K+-ATP-ase pomp
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(MAL)ASSIMILATIE MICRONUTRIËNTEN
ASSIMILATIE
VETOPLOSBARE VITAMINESabsorptie proximale 100 (60-100) cm jejunum
WATER OPLOSBARE VITAMINES/ MINERALENabsorptie 30-120 cm dunne darm
15-20 cm distaal ileum (vitamine B12) GALZUREN
absorptie 50 cm distale ileum
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PROPERTIES OF VITAMIN TRANSPORT
Vitamin Site Mechanism of transport
Other properties
Ascorbic acid (vitamin C) ileum Active Na-dependent cf. glucose; high dose diffusion
Thiamine (vitamin B1)Riboflavin (vitamin B2)Niacine
Pyridoxal, pyridoxine/ pyridoxamine(vitamin B6)Cobalamine (vitamin B12)
jejunumjejunumproximal jejunum ??
distal ileum
ActiveActiveActive/ CarrierFacilitated diffusionActive
Similar to vit. CBile salts neededNa-dependent
PL>PN>PM
IF, Ca, pancreas bicarbonate
Folic acid proximal jejunum
Active/facilita-ted diffusion
Na-dependent; high dose diffusion
PROPERTIES OF MINERAL TRANSPORT
Mineral Site Mechanism of transport
Other properties
Iron anorganic Fe3+
Iron organic (haem)
Duodenum/ jejunum
Mucosal protein carrier/ passive diffusion
Chelated/Fe2+, dependent on pHIndependent of pH
Calcium ActivePassive
Vitamin D dependent by calcium-binding protein, bile salts
Copper Stomach, duodenum
ActiveMucosal protein carrier
Aminoacids needed
Zinc ?? ActiveLigand/ mucosal protein carrier
Na-dependent
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Laatste ileumlis: opname van vitamine B12 en galzure zouten
Twaalfvingerige darmFolic acid
CAUSES OF VITAMIN B12 DEFICIENCY
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CAUSES OF FOLATE (FOLIC ACID) DEFICIENCY
MALABSORPTIONsubnormal intestinal absorption of dietary constituents
and thus excessive loss of nutrients in the stool
• MALDIGESTION – luminal processing: luminal phase
• MALABSORPTION sensu strictu – absorption into intestinal mucosa: mucosal phase
• DEFECTIVE TRANSPORT – postabsorptive processing in enterocyt cell and transport into the circulation or lacteals: transport phase
• GLOBAL – by diffuse mucosal disease or reduced mucosal surface after resection
• PARTIAL/ ISOLATED – concerning specific nutrients
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EXAMPLES OF MALABSORPTION
Phase and nature of malabsorption Example
Luminal phase (maldigestion)a. Substrate hydrolysis
1. digestive enzyme deficiency2. digestive enzyme inactivation3. dyssynchronicity of enzyme release,
inadequate mixingb. Fat solubilisation
1. diminished bile salt synthesis2. impaired bile secretion3. bile salt deconjugation4. increased bile salt losses
c. Luminal availability of nutrients1. diminished gastric acid2. diminished intrinsic factor3. bacterial consumption of nutrients
Chronic pancreatitisZollinger –EllisonBII resection, gastric bypass
CirrhosisChronic cholestasisBacterial overgrowthIleal disease/resection
Atrophic gastritisPernicious anaemiaBacterial overgrowth
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EXAMPLES OF MALABSORPTION
Phase and nature of malabsorption Example
Mucosal phase (malabsorption)a. Brush border hydrolysis
1. congenital disaccharidase defect
2. acquired disaccharidase defect b. Epithelial transport
1. nutrient-specific defects in transport
2. global defects in transportCellular phase/ postabsorptive processing
phase/ transport phasea. Enterocyte processingb. Lymphatic transport
Sucrase-isomaltase deficiencyLactase deficiency
Hartnup disease, cystinuriaGlucose-galactose malabsorptionCoeliac disease
A-β-lipoproteinaemiaLymphangiectasia
DRUGS CAUSING MALABSORPTION
• Luminal effect– Neomycin– Cholestyramine– Alcohol
• Mucosal defect– Villous flattening (colchicine, methotrexate)– Stricture (NSAIDs)
• Brush border enzyme effect– Neomycine– Alcohol
• Enterocyte damage– Alcohol
• Intracellular effects– Laxatives– Colchicine– Biguanides
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MINERAL AND TRACE ELEMENTS ABSORPTION
Mineral/trace element
Absorption increased by
Absorption decreased by
Calcium Vitamin D, vitamin A Magnesium
Magnesium Vitamin D Calcium, sodium
Sodium Aminoacids, glucose Calcium, magnesium
Zinc Aminoacids Calcium, iron, copper, manganese, selenium,
Copper Aminoacids Calcium, iron, zinc, molybdenum, vitamin C
Chromium Aminoacids chelates Zinc, iron, manganese
TEACHING AIMS
• To understand the normal assimilation of nutrients
• To understand the 3 phases of malabsorption with representative examples
• To recognise physical signs of malabsorption
• To understand the diagnostic tests
• To understand the different treatment modalities
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MALABSORPTION
• FAT MALABSORPTION– Diarrhoea, steatorrhoea and weight loss
• CARBOHYDRATE MALABSORPTION– Diarrhoea, bloating, flatulence but no weight loss
• PROTEIN MALABSORPTION– Diarrhoea, oedema, ascites
SIGNS AND SYMPTOMS OF MALABSORPTION
Malabsorption Clinical features Laboratory findings
CaloriesFat
Protein
Carbohydrates
Weight lossPain; voluminous foul-smelling, grey, sticky, floating stools; diarrhoea without flatulence, steatorrhoea Edema, muscle atrophy
Watery diarrhoea, flatulence, acidic pH stools, stool osmotic gap, lactose intolerance
Fractional fat excretion > 6%
Hypoalbuminaemia, hypoproteinaemiaIncreased breath H2
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SIGNS AND SYMPTOMS OF MALABSORPTION
Malabsorption Clinical features Laboratory findings
Vitamin B12
Folic acid
Vitamin B general
Anaemia, sub-acute combined degeneration of spinal cord
Anaemia
Cheilosis, painless glossitis, angular stomatitis, acro-dermatitis
Macrocytic anaemia, vitamin B12 decreased, abnormal Schilling test, methylmalonic acid & homocysteine increased, increased serum iron, LDH, indirect bilirubin, decreased haptoglobin, antibodies IF and parietal cellsMacrocytic anaemia, serum/red cell folate decreased, homo-cysteine increased, increased serum iron, LDH, indirect bilirubin, decreased haptoglobin
SIGNS AND SYMPTOMS OF MALABSORPTION
Malabsorption Clinical features Laboratory findings
Iron
Calcium and vitamin D
Vitamin A
Vitamin K
Anaemia, glossitis
Paresthesia, tetany, pathologic fractures, positive Chvostek and Trousseau signsFollicular hyperkeratitis, night blindnessHaematoma, bleeding disorders
Microcytic anaemia, serum iron and ferritin decreased, total iron binding capacity increasedHypocalcemia, serum alk. phosphatase increased, abnormal bone density
Serum retinol decreased
Prolonged prothrombine time, vitamin K dependent clotting factors decreased
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TEACHING AIMS
• To understand the normal assimilation of nutrients
• To understand the 3 phases of malabsorption with representative examples
• To recognise physical signs of malabsorption
• To understand the diagnostic tests
• To understand the different treatment modalities
DIAGNOSIS OF MALABSORPTION
• Tests to objectify/ exclude malabsorption
• Tests to diagnose underlying diseases
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ABSORPTIE TESTEN EIWITTEN
• α-1 antitrypsine concentratie (instabiel bij pH ≤3) mg/g gedroogde ontlasting (N 5 g • Lactose – lactose tolerantie test ↑ glucose 1.1-2.0 mmol/l
– kwantitatieve meting lactase in dundarm biopt• Ademtesten
– H2 lactose ademtest 50 g lactose– H2/
13CO2 ademtest lactose, fructose, sucrose-isomaltose– Ademtesten bij bacteriële overgroei
• C13-glycochol ademtesten• H2-ademtest met 100 g glucose
– Ademtesten meting intestinale passagetijd• Lactulose ademtest met 10 g lactulose
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ABSORPTIE TESTEN VETTEN
• Sudan III kleuring feces portie met evt. tellen en meten grootte vetbolletjes – basaal: neutraal vet; – na acidificatie en verhitten: vetzuurnaalden
• 72-u vetbalans: 5 dagen hoog vet dieet, dag 3-5 collectie ontlasting– Gewicht ontlasting vaak > 200 g/dag
– Fractionele vetabsorptie = (vet in voeding minus vet in ontlasting) / vet in voeding; normaliter > 94%
• Near infrared reflectance analyse (NIRA): feces portie op vet, N en koolhydraten
• Acid steatocriet: gravidimetrie op feces portie
• Evt. testen op galzuur malaborptie
ABSORPTIE TESTEN GALZUREN
• Galzuren in portie feces
• 75SeHCAT (selenium homocholic acid taurine) test: 75Se gelabeld synthetisch galzuur (homotaurocholzuur) – meten na 7 dagen: < 5% retentie = malabsorptie
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ABSORPTIE TESTEN NUTRIËNTEN
• FOLIUMZUUR– Serum of erytrocyten foliumzuur
– Verhoogd homocysteïne spiegels in bloed bij normale methylmalonzuur waarden
• VITAMINE B12– Vitamine B12 assay in bloed
– Verhoogd methylmalonzuurspiegels in bloed in combinatie met verhoogd homocysteïne spiegels
– Schilling test• Standaard test
• Met missende factoren zoals intrinsic
factor, pancreasfermenten
• Met niet-absorbeerbare antibiotica of
na instellen van glutenvrij dieet
SCHILLING TEST1 mcg radioactive-labelled cristalline vitamin B12 orallyAfter 1 hr 1000 mcg non-labelled vitamin B12 intravenously to saturate B12 binders (transcobalamines)
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ROLE OF COBALAMINE (VITAMIN B12) AND TETRAHYDROFOLATE IN HOMOCYSTEINE AND
METHYLMALONIC ACID METABOLISM
LABORATORY FEATURES OF MALABSORPTION
DECREASED INCREASED
HaemoglobinSerum or red cell folateIronFerritinVitamin B12CalciumMagnesiumCholesterolCaroteneAlbumin25-OH vitamin D
Oxalate in urineProthrombine timePIVKAsSerum total iron binding capacityHomocysteineMethylmalonic acid
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TEACHING AIMS
• To understand the normal assimilation of nutrients
• To understand the 3 phases of malabsorption with representative examples
• To recognise physical signs of malabsorption
• To understand the diagnostic tests
• To understand the different treatment modalities
TREATMENT OF MALABSORPTION
• Identification and treatment of underlying disease
• Treatment of the diarrhoea
• Identification and treatment of nutritional deficits
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TREATMENT OF UNDERLYING DISEASES
• Identification and treatment of underlying disease– Coeliac disease: gluten free– Lactase deficiency/lactose intolerance: lactose reduction– Steatorrhoea: low fat diet: LCT < 40 g/d, Rx MCT oil or supplements– Fructose intolerance: avoid foods with fructose: glucose > 1 (apples,
pears, prunes, dates, cherries, honey)– Sorbitol intolerance: avoid artificially sweetened candy and cookies– Pancreatic insufficiency: pancreas enzyme replacement therapy, 30 000
IU/meal and 15 000/snack (combined with H2 receptor blockers or PPIs)
– Crohn’s disease: immunosuppressants, anti-TNF biologicals
• Treatment of the diarrhoea• Identification and treatment of nutritional deficits
TREATMENT OF MALABSORPTION
• Identification and treatment of underlying disease
• Treatment of the diarrhoea– Loperamide (≤12 mg/d), tinctura opii crocata, no coffee, no
hyperosmolar soft drinks, ORS
– < 100 cm distal ileal disease or resection: cholerrheic diarrhoa: Rx cholestyramine (3* 4g), colestipol 3*5-10 g, colesevelam (2.5-3.75 g)
– >100 cm distal ileal disease or resection: bile acid malabsorption and steatorrhoea: Rx synthetic conjugated bile salts cholylsarcosine
• Identification and treatment of nutritional deficits
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TREATMENT OF MALABSORPTION
• Identification and treatment of underlying disease
• Treatment of the diarrhoea
• Identification and treatment of nutritional deficitsVitamins
– Fat-soluble vitamins in polar forms or in emulsion
• Vitamin A (Aquasol A): 2dd 40.000-50.000 IU
• Vitamin E (Aquasol E) or d-α-tocopherol polyethylene glycol 1000 succinate (TPGS)
• Vitamin D: 25-OH vitamin D (calcifediol) or 1-OH vitamin D; vitamin D3 (cholecalciferol) 30.000-50.000 IU/d
• Vitamin K: 2.5-12.5 mg/d
– Folic acid: 5 mg, later 1 mg
– Vitamin B12: 1 mg/d im or sc 1st week, 4 weeks every week, then once a month
Minerals
• Iron: ferrous sulphate 3 dd 325 mg
• Calcium: calcium carbonate 2 dd 500 mg
• Magnesium: magnesium gluconate 1-4 g/d
EXIT QUESTIONSWhich of the macronutrient assimilation is the most complex?1. Protein2. Carbohydrates3. FatIn celiac disease, which of the phases of assimilation are disturbed (may be more
answers possible)?1. Ingestion 4. Transport2. Digestion 5. Absorption3. ExcretionWhich part of the bowel can hardly be missed (may be more answers possible)?1. Duodenum2. Jejunum3. Ileum In the treatment of fluid/ electrolyte disturbances, the following holds true1. ORS can be used to diminish the diarrhoea2. Magnesium supplements are well tolerated3. In case of treatment-resistant hypocalcemia magnesium supplements
should be given 4. ORS can easily be home-made
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EXIT QUESTIONSWhich of the following statements is true (may be more answers possible)?1. Oligopeptides offer a kinetic advantage over amino acids 2. Monosaccharides and disaccharides are equally easy absorbed3. Fat malabsorption cannot be influenced
In Crohn’s disease when enteral nutrition is considered, the formula (may be more answers possible)
1. Should always consist of polymeric feeds2. Should always be reduced in fat3. Has only a role to play in children with Crohn’s disease4. Should preferably contain oligopeptides and MCTs
When do you think MCTs have an advantage (may be more answers possible)?1. When the pancreas function is impaired2. When there is insufficient luminal digestion3. When fat absorption is impaired4. When fat transport is impaired
TEACHING AIMS
• To understand the normal assimilation of nutrients
• To understand the 3 phases of malabsorption with representative examples
• To recognise physical signs of malabsorption
• To understand the diagnostic tests
• To understand the different treatment modalities