Malabsorption in tropical sprue & coeliac disease

MALABSORPTIONTropical Sprue

&Coeliac Disease

MARYAM JAMILAH BINTI ABDUL HAMID082013100002

IMS BANGALORE

MARYAM JAMILAH BINTI ABDUL HAMID082013100002

IMS BANGALORE

LEARNING OUTCOME

• Define tropical sprue

• Understand the causes, clinical features, investigations and managements for tropical sprue

• Define coeliac disease

• Understand the causes, clinical features, investigations and managements for coeliac disease

MALABSORPTION

“Inadequate assimilation of dietary

substances due to defects in

digestion, absorption, or transport”Major factors causing malabsorption:• Defective digestion• Faulty absorption

TROPICAL SPRUE

Definition:

“A malabsorption disease commonly found in the tropical regions, marked with abnormal

flattening of the villi and inflammation of the small

intestine lining” 

ETIOLOGYThe etiology and pathogenesis areuncertain.Why?1) Its occurrence is not evenly distributed in

all tropical areas.• It is found in specific locations, southern

India, the Philippines and several Caribbean islands.

• Rarely observed in Africa, Jamaica or Southeast Asia.

2) An occasional individual will not develop symptoms of tropical sprue until long after having left an endemic area.

3) Multiple microorganisms have been identified on jejunal aspirate with relatively little consistency among studies but other studies have favoured a role for a toxin produced by one or more of these bacteria; Klebsiella pneumoniae, Enterobacter cloacae, or E. coli.

CLINICAL FEATURES

• Diarrhea

• Fatigue

• Weight loss

• Abdominal cramps

• Flatulence

• Malnutrition

INVESTIGATION

• Small-intestinal biopsy

– Less villous architectural alteration &

more mononuclear cell infiltrate in the lamina propria

– However, this resembles coeliac disease

– The way to differentiate these two is by having

gluten-free diet and it will not give clinical or histologic

improvement

• Endoscopy

– Abnormal flattening of villi and inflammation of

the lining of the small intestine can be observed

• Blood test

– Low levels of vitamins A, B12, E, D, and K, as

well as serum albumin, calcium, and folate

• Examination of stool

– Steatorrhoea

• Barium swallow– Thickened small bowel folds can be observed

MANAGEMENT

• Prescribe antibiotic – tetracycline or Sulfamethoxazole-

Trimethoprim (Co-trimoxazole) for 3 to 6 months

• Supplementation– vitamins B12

– folic acid

BEFORE TREATMENT

AFTER TREATMENT

with doxycycline and folic

acid therapy

Definition:

“An autoimmune disease where the immune system reacts

abnormally to gluten causing inflamed and flattened villi”

Coeliac Disease

Healthy villi Damaged villi

ETIOLOGY

• It is not known but environmental,

immunologic and genetic factors appear

to contribute to the disease.

1) Environmental

- Coeliac disease is associated with

gliadin (a component of gluten)

2) Immunologic

- Serum antibodies; IgA antigliadin,

IgA antiendomysial and IgA anti-tTG are

present.

- However, it is not known whether these

antibodies are primary or secondary to

the tissue damage.

3) Genetic factor

- Patients with coeliac disease express the

HLA-DQ2 allele (majority) and DQ2 allele

(minority) but 5% patients do not express any

of these alleles.

- Coeliac diseas varies widely in different

population groups (high in Caucasians, low in

blacks and Asians)

PATHOPHYSIOLOGY

• Partial villous atrophy in a mild lesion of small

intestinal lining

• Subtotal/total villous atrophy in a severe lesion of

small intestinal lining

– Forming flat mucosa due to more advanced

villous fusion (particularly of the upper jejunum)

• Surface epithelial cells are cuboidal or

low columnar type

• Lamina propria shows increased

number of plasma cells and

lymphocytes

NORMALPARTIAL VILLOUS

ATROPHYSUBTOTAL / TOTAL VILLOUS ATROPHY

Diagram shows histology of duodenal villi

CLINICAL FEATURES• Mild abdominal pain• Bloating• Steatorrhoea• Anaemia• Episodes of mild diarrhea or constipation• Loss of appetite• Weight loss• Tingling and numbness in your hands and feet • Vomiting (usually only affects children)• Alopecia (usually only affects adults)• Malnutrition

INVESTIGATION

• Blood test

– Positive tTG serology

– Low levels of vitamins A, B12, E, D, and K

• Small-intestinal biopsy

• Examination of stool

– Steatorrhoea

• Endoscopy– Usually duodenum appear normal but some

patients showing:-• scalloping of the small bowel folds• paucity in the folds• a "cracked-mud" appearance of mucosa• prominence of the submucosa blood vessels and a

nodular pattern to the mucosa

MANAGEMENT

• Diet

– Lifelong gluten-free diet

•  Steroids or immunosuppressants

– Such as azathioprine

– This is only for refractory disease where

they do not improve on a gluten-free diet.

REFERENCES

• Longo, D. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Jameson, J. L., & Loscalzo, J. (2012). Harrison's principles of internal medicine. (18th ed., Vol. 2, pp. 2151-2160). McGraw-Hill Companies Inc.

• https://www.mja.com.au/journal/2005/182/10/tropical-sprue-far-north-queensland

• http://www.celiac.com/articles/8/1/What-is-gluten-What-is-gliadin/Page1.html

• http://www.solunetti.fi/en/patologia/ohutsuolen_villusatropia_40x/• http://www.nhs.uk/Conditions/Coeliac-disease/Pages/

Symptoms.aspx