(mal)assimilatie bij maag- darm aandoeningen...5 eiwit assimilatie • digestie – maag zuur en...

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(MAL)ASSIMILATIE BIJ MAAG-DARM AANDOENINGEN

Lisbeth Mathus-VliegenMDL arts, Em. Hoogleraar Klinische Voeding

AMC [email protected]

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






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






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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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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



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






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






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 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 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

36

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






(mal)assimilatie bij maag- darm aandoeningen...5 eiwit assimilatie • digestie – maag zuur en...

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