Snapshot A 45-year-old woman presents to her primary care physician with a complaints of unintentional weight loss. She denies any fevers or night sweats. She does report having frequent diarrhea as well as pale, foul-smelling bowel movements. She recently went on a trip to the Carribbean. On physical exam, she appears thin but her physical exam is otherwise insignificant. Serum labs reveal increased prothrombin time. A small bowel biopsy shows the presence of PAS-negative microorganisms. She is started on antibiotics. (Tropical sprue) Introduction Overview malabsorption syndromes inability to absorb macronutrients or micronutrients often associated with chronic diarrhea and result in nutritional deficiencies treatment is targeted at correcting the underlying disorder Epidemiology etiology fat malabsorption celiac disease Whipple disease login to view 1 more bullet pancreatic insufficiency tropical sprue login to view 1 more bullet lactose intolerance bile salt deficiency short bowel syndrome Pathogenesis mechanism impairment in absorption of nutrients due to a variety of defects in intestinal mucosa malabsorption of fat-soluble vitamins vitamins A, D, E, and K vitamin B12 deficiency destruction of terminal ileum loss of pancreatic enzymes that aid in B12 absoprtion lactose intolerance lactase deficiency colonic bacteria ferment lactose and cause decreased stool pH, resulting in osmotic diarrhea Presentation History easy bruising Symptoms common symptoms frequent and loose watery stools login to view 1 more bullet pale, bulky, foul-smelling stools login to view 1 more bullet abdominal pain and flatus bloating and weight loss vitamin deficiencies login to view 3 more bullets Vitamin Deficiencies Vitamin A Deficiency Vitamin D Deficiency Vitamin E Deficiency Vitamin K Deficiency Night blindness Xeroderma Osteomalacia Ricketts Hemolytic anemia Muscle weakness Paresthesias Bleeding Easy bruising Imaging Abdominal computed tomography indications evaluate for chronic pancreatitis Studies Serum labs hypocalcemia ↑ prothrombin time/INR vitamin K malabsorption autoantibodies for celiac disease anemia microcytic or macrocytic depending on etiology of malabsorption syndrome Invasive studies Sudan black stain of stool stains and detects fat 72-hour fecal fat test most sensitive small bowel biopsy indication login to view 1 more bullet findings login to view 10 more bullets lactose hydrogen breath test indication login to view 1 more bullet D-xylose absorption test indications login to view 2 more bullets findings login to view 1 more bullet Differential Fat Malabsorption Syndromes Celiac Disease Whipple Disease Pancreatic Insufficiency Tropical Sprue Fat malabsorption Pale, bulky, and foul-smelling stools Pale, bulky, and foul-smelling stools Pale, bulky, and foul-smelling stools Pale, bulky, and foul-smelling stools Unique clinical features Positive autoantibodies Dermatitis herpetiformis Triad: cardiac symptoms arthralgia neurologic symptoms Caused by Tropheryma whipplei, a gram-positive rod History of alcoholism History of previous episodes of pancreatitis History of being in tropical regions or South Asia Negative autoantibodies Megaloblastic anemia due to folate and vitamin B12 deficiences Diagnostic testing Small bowel biopsy Abnormal D-xylose test Autoantibodies Small bowel biopsy Polymerase chain reaction of stool showing T. whipplei Abnormal D-xylose test Abdominal CT scan Secretin stimulation testing Small bowel biopsy Abnormal D-xylose test Treatment Dietary restrictions: avoid gluten Ceftriaxone Trimethoprim/sulfamethoxazole Tetracycline Enzyme replacement therapy Tetracyclines Treatment Lifestyle dietary restriction indication login to view 1 more bullet modality login to view 1 more bullet Medical treat underlying condition antibiotics indication login to view 2 more bullets drugs login to view 4 more bullets enzyme replacement therapy indication login to view 2 more bullets nutrition replacement therapy indication login to view 1 more bullet Surgical none Complications Malnutrition