Wanabsorpsie

Dr. WM SimmondsInternal Medicine

(Gastroenterology)

15 August 2011

Wanabsorpsie

Abnormale absorpsie van enkele of veelvuldige nutriente in die gastro-intestinale sisteem.

3 komponente nodig vir optimale absorpsie Intraluminaal WANVERTERING

– Galsuur of pankreas ensiem gebrek Mukosale WANABSORPSIE

– Abnormale mukosa or onvoldoende funksionele derm lengte (‘Brush border surface area’) bv. Dunderm reseksie.

Post-mukosale limfdreinering obstruksie

Malabsorption Syndrome

Pallor/AnaemiaNight blindness (Vit A)

Osteoporosis withpathological fractures

Muscle wasting Muscle weakness

Tetany (Low Calcium)

Hypopigmentation/Pellagra(Niacin)

Ascites (Low Albumin)

Dehydration (Diarrhoea)Ecchymoses (Vit K

factor deficiency)

SteatorrhoeaIncreased fecal fat

Oedema (Low Albumin)Peripheral neuropathy

(B12 def)

Glossitis, stomatitisApthous ulcers (Iron & BVitamin deficiency)

Pathological Weight loss

Oorsake van Wanabsorpsie

Due to infective agents – Intestinal tuberculosis – HIV related malabsorption – Tropical sprue – Parasites e.g. Giardia lamblia.

Due to structural defects– Inflammatory bowel diseases -

Crohn's Disease – Fistulae, diverticulae and

strictures, – Infiltrative conditions - amyloidosis– Short bowel syndrome

Due to mucosal abnormality– Celiac disease – Cows' milk intolerance – Soya milk intolerance – Fructose malabsorption

Due to enzyme deficiencies– Lactase deficiency– Sucrose intolerance – Intestinal disaccharidase deficiency – Intestinal enteropeptidase

deficiency Due to digestive failure

– Pancreatic insufficiencies: Cystic fibrosis Chronic pancreatitis Pancreas carcinoma Zollinger-Ellison syndrome

– Bile salt malabsorption Terminal ileal disease Obstructive jaundice Liver cirrhosis Bacterial overgrowth Primary bile acid diarrhea

Celiac siekte

Gluten sensitiewe enteropatie Algemeen in Europieërs (1:300) Seldsaam in swart mense HLA DQ2 en DQ8 Kan op enige ouderdom presenteer Gewoonlik - moegheid, gewigsverlies en

anemie in ‘n jong/middeljarige dame.

Celiac siekte

Celiac siekte

Word geasossieer met:– Tipe I diabetes– Tiroid siekte– Addison se siekte (Autoimmuun)

Diagnose:– Anti-endomesiale antiliggame– anti-tTG (weefsel transglutaminase)– Dun derm mukosale biopsie

Vermeerderde intraepiteliale limfosiete Kript hiperplasia Villus atrofie

Celiac siekte

Terapie/behandeling– Streng Gluten vrye dieet. Dietkundige belangrik.– Supplemente (FeSo4, Vitamiene)– Behandel osteoporose– Ander geasossierde autoimmuun toestande moet

uitgeskakel word.– Goeie opvolg

Klieniese beeld Antiligame

Kroniese Pankreatitis

Kroniese pankreatitisDefinisie

Onomkeerbare pankreatiese skade Histologiese or radiologiese bewys van

kroniese inflammasie en fibrose Verlies aan eksokrine (asinere selle) en

endokriene (eiland selle) pankreas weefsel.

Kroniese pankreatitisOorsake (TIGAR-O)

Toxic/Metabolic– Alcohol– Smoking– Hypercalcaemia– Hyperlipidaemia

Idiopathic– Early onset– Late onset– Tropical

Genetic– Autosomal dominant

Hereditary pancreatitis (PRSS1 mutations)

– Autosomal recessive or modifier genes

CFTR mutations SPINK1 mutations Others

Alcohol and Gallstones most common causes in developed countries (70%)

Autoimmune-Autoimmune pancreatitis-IgG4 related systemic disease

Recurrent•Post Necrotic•Chronic alcoholism•Diabetes Mellitus•Radiotherapy

Obstructive•Benign pancreatic duct obstruction

•Gallstones•Stricture•Pancreas divisum

•Malignant stricture•Ampullary of duodenal carcinoma•Pancreatic adenocarcinoma

Galstene

Kroniese pancreatitisPatofisiologie (Alcohol)

Direct toxins and toxin

metabolites

Necrosis with Fibrosis

Intraductal plugging and obstruction

Oxidative stress

Alcohol

Cytokine releasestimulate stellate

cells to form collagen(fibrosis) and increase

cell - mediated inflammation

Chronic Pancreatitis

Jaster, Molecular Cancer. 2004 3:26 doi:10.1186/1476-4598-3-2

Kroniese pankreatitisKliniese einskappe

Kroniese pankreatitisKliniese einskappe

Abdominale pyn

Kroniese pankreatitisKliniese einskappe

Abdominale pyn

Diabetes Mellitus

Kroniese pankreatitisKliniese einskappe

Abdominale pyn

SteatorrhoeaDiabetes Mellitus

Kroniese pankreatitisKliniese einskappe

Abdominale pyn

SteatorrhoeaDiabetes Mellitus

Ander:- Moegheid, etc- Gewigsverlies agv. wanabsorpsie- Pain geassosieered met hoe proteien and vet iname

Kroniese pankreatitisAbdominale pyn

Most common clinical problem Decreases appetite and limits food

consumption - weight loss and malnutrition Dramatic reduction in quality of life Character:

– Epigastric, often with radiation to the back. – Boring, deep, and penetrating and is often – Associated with nausea and vomiting.– Relieved by sitting forward or leaning forward, the

knee-chest position– Worsens after a meal and often is nocturnal.

Possible causes:– Acute inflammation/noxious stimuli– Increased intra-pancreatic pressure and ischaemia– Neuropathic (Alterations in nociceptive nerves) – Other

Kroniese pankreatitisSteatorrhoea

Exocrine insufficiency. Passage of bulky, floating, foul-smelling

stools or may even note the passage of frank oil droplets.

Occurs when pancreatic lipase secretion is reduced to less than 10% of the maximum output.

A feature of far-advanced chronic pancreatitis or complete blockage of the pancreatic duct.

Kroniese pankreatitisDiabetes Mellitus

Endocrine insufficiency Half of patients with chronic

pancreatitis who develop diabetes will require insulin.

Insulin-producing beta cells and glucagon-producing alpha cells are injured.

Increased risk of prolonged and severe hypoglycemia with over vigorous insulin treatment due to the lack of a compensatory release of glucagon.

Kroniese pankreatitisDiagnose(1)

Kliniese eienskappe (Abdominale pyn, Steatorrhoea, Diabetes Mellitus)

Pankreas funksie toetse– Direk

Direct hormonal stimulation tests are believed to be the most sensitive function test for chronic pancreatitis. Bicarbonate estimation after Secretin administration. (ERCP) – invasive, not routinely done.

– Indirek Serum Trypsinogen Pancreatic Enzymes in Stool eg chymotrypsin or elastase Fecal Fat Excretion/Steatocrit

Kroniese pankreatitisDiagnose(2)

Beelding– Abdominale x-straal with pankreas kalsifikasies– CT Scan/MRI– Ultrasound (Conventional/EUS)– ERCP/MRCP

Ander– IgG4, ESR, RF, Calcium, Triglyceride levels

Kroniese pankreatitisBehandeling

No curative therapy available Behandel die oorsaak. Stop rook. Stop alkohol. Abdominale pyn

– Analgesia– Anti-oxidante– Vermindering van intra-pankreatiese druk en onderdrukking van pankreas uitskeiding

Non-enteriese bedekte ensiem vervanging PPI

– Endoskopiese behandeling– Chirurgie

Steatorrhoea Verminder vet in diet (<20g/dag) Pankreatiese ensiem vervanging (bv. Pancrelipase - CreonTM) Suur onderdrukking met ‘n PPI (Verhoog duodenale pH for optimale lipase activiteit.

Diabetes Mellitus Insulin therapie (NB. Risiko hoer vir hypoglukemie)

Ander Supplemente, “fat soluble” vitamiene (A, D, E, K)

Kroniese pankreatitisKomplikasies

Pseudokiste Bloeding

– Pseudokiste– Pseudoaneurisme– Milt thrombose met varices wat bloei

Obstruksie (Gemene galbuis, duodenale) Pankreas Fistel

– Na Pseudokist– Externe (chirurgie)– Interne (Askites, pleurale effisie)

Kanker– Risk highest with hereditary pancreatitis

and smoking– Pancreatic adenocarcinoma – CA19-9

Dysmotiliteit– Gastroparese and antroduodenale dysmotiliteit

perigastric inflammation hormonal changes associated with chronic pancreatitis (e.g. CCK) side effect of narcotic analgesics.

Dankie.