The syndrome of impaired absorption (malabsorption) (START) is leading in the clinical picture of diseases of the small intestine. The disease is usually accompanied by chronic diarrhea, polyfecalia and steatorrhea.
Congenital absorption disorders caused by selective (selective) disruption of absorption (reverse absorption) of individual amino acids, mono- and disaccharides, vitamins and other nutrients (substances ingested with food), these types of malabsorption are observed in childhood.
In adulthood malabsorption develops in chronic diseases of the small intestine as gluten enteropathy, Whipple’s disease, a common variable hypogammaglobulinemia, gipogammaglo-bulinemicheskaya sprue, tropical sprue, collagenous sprue, intestinal limfangioektazyya, tuberculosis of the small intestine, short small intestine syndrome, amshyuidoz bowel disease Crohn, tumors of the small intestine (lymphoma, lymphogranulomatosis).
Manifestations of malabsorption (nutritional disorders): loss of body weight with good nutrition, later polyhypovitaminosis, disorders of various types of exchanges – protein, mineral and water – are added. When hypovitaminosis develops changes in the skin and mucous membranes – dryness and peeling, discoloration – the skin becomes dirty gray, pigment spots appear on the face and neck. In the corners of the mouth, behind the ears or on the wings of the nose, weeping cracks appear, the nails become dull, with transverse striation, exfoliate. Hair fall out, thin, split at the ends. The nails take the form of “watch glasses”, the terminal phalanges of the fingers – “drum sticks”. The tongue is pale, edematous, along its edges are visible imprints of the teeth; it may be crimson-red with deep furrows.
Atrophy of the papillae is possible, the tongue becomes completely smooth, “polished”, bleeding gums, hemorrhages increase.
Protein deficiency is manifested by loss of body weight, hypoproteinemia and hypoproteinemic edema, which are localized mainly in the legs and feet, may develop extensive edema. In patients with gluten enteropathy, the proximal small intestine, in which iron is absorbed, suffers predominantly, so iron deficiency anemia appears along with the symptoms of malabsorption.
Mineral metabolism is impaired in all patients with malabsorption. Calcium deficiency is manifested by impaired sensitivity, cramps, pain in muscles and bones.
In severe cases, osteoporosis of the tubular bones, spine, pelvis develops. Clinical symptoms of hypokalemia: lethargy, muscle weakness, sometimes pronounced weakness and bouts of dynamic intestinal obstruction, peristalsis visible through the anterior abdominal wall may appear, while palpation of the abdomen draws attention to the feeling of fullness, “testosity” associated with a decrease in intestinal wall tone.
The frequent signs of malabsorption are the symptoms of endocrine insufficiency, they are clinically manifested by impotence, decreased libido (sexual attraction) as a result of decreased function of the sexual glands. The menstrual cycle is broken, up to the termination of periods. Also characterized by hypotension (low blood pressure), persistent thirst, increased urine formation.
Allocate III severity of START.
I severity. General weakness, weight loss (no more than 5-10 kg) and health, vitamin deficiency.
II severity. The decrease in muscle mass is more pronounced (in 50% of patients more than 10 kg), pronounced symptoms of hypovitaminosis, electrolyte disturbances (potassium deficiency, calcium), hypochromic anemia, in some patients – hypofunction of the endocrine glands.
III severity. Lack of body weight over 10 kg, pronounced hypovitaminosis, water and electrolyte disturbances (gizhzalemiya, hypocalcemia, convulsions, osteoporosis), anemia, hypoproteinemia, hypoproteinemic edema, endocrine dysfunction.
Often the diagnosis of diseases occurring with malabsorption, causes considerable difficulties. Pay attention to recurrent diarrhea with polyfecalia and steatorrhea, especially at night. It is important to know about the onset of the disease in childhood, the lag in physical development, the connection of the first clinical symptoms with pregnancy and childbirth, which is characteristic of patients with celiac disease. The presence of chronic foci of infections in a patient as signs of a common variable (Changeable) hypogammaglobulinemia (decrease in blood gamma globulins).
Laboratory diagnostics includes a clinical blood test: anemia, leukocytosis, high ESR during exacerbation of foci of chronic infections or Crohn’s disease. Unmotivated leukocytosis with a stab shift is characteristic of purulent complications of small intestinal lymphoma, hypoproteinemia, hypoalbuminiemi, hypokalemia, hypocalcemia, metabolic acidosis or alkalosis. Coprological study allows to determine the daily mass of feces, which in patients with impaired absorption increases to 1-1.5 kg or more (the norm is 200 g). Also determine the blood pigment in the feces and pathogenic protozoa.
With instrumental diagnostic methods, the functional state of the small intestine is evaluated radiographically (tone, peristalsis, speed and nature of filling with a contrast suspension, state of the mucosal relief). X-ray examination allows to diagnose a tumor, intestinal lymphomas, mesenteric and retroperitoneal lymph nodes, Crohn’s disease, tuberculosis ileotiflit; detects organic stenosis, deformity of intestinal areas, hyperplasia of lymphoid elements.
Endoscopic examination: duodenoscopy or enterinoscopy with biopsy from the zalukovic part of the duodenal or jejunum is of major importance for the diagnosis of celiac disease, Whipple’s disease, lymphangiectasia and amyloidosis. When the syndrome of impaired absorption II, III severity is determined by a significantly reduced content of immunoglobulins G, A, and to a lesser extent M. Immunological study informatively with paraproteinemia, clinically manifested chronic, recurring diarrhea and malabsorption. Immune electrophoresis with monospecific sera determine the pathological immunoglobulins of class A.
In patients with untreated gluten enteropathy, the concentration of antibodies to a-fraction of gliadin in IgA and IgG is sharply increased. Their detection is important for diagnosis, evaluation of treatment results – the test is highly informative.
Diagnosis of celiac disease is facilitated by the detection of antibodies to reticulin (reticulin is a plant fiber protein that is similar in composition to collagen) and tissue transaminase. A high level of these antibodies is a specific sign of gluten enteropathy.
The suction capacity of the small intestine is evaluated by indirect signs: the definition in the blood, urine, saliva and feces of various substances taken orally. More often used test with d-xylose. After loading 5 g of d-xylose, its concentration is determined in 2- and 5-hour portions of urine. Normally, 2 hours stand out at least 0.7 g; for 5 hours – 1.2 g of xylose.
The Van de Kamer method is used to evaluate lipid digestion and absorption disorders. This method is based on the biochemical determination in the daily feces of neutral fat and fatty acids. Normally, fat loss from feces does not exceed 5 g / day. Radioisotope methods are based on the use of iodine-labeled 131 trioleate glycerol and oleic acid with the further detection of radioactivity of feces and blood. With START, the blood radioactivity is reduced, and the feces remain elevated.
The Schilling Test is used to determine the absorption of vitamin B12.