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Malabsorption & Coeliac Disease

Malabsorption: Introduction

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Malabsorption: differential diagnosis

Common
C coeliac disease
C Crohn’s
C chronic pancreatitis

Small bowel
Brush border enzymes
- lactase deficiency (hypolactasia)

Autoimmune
- coeliac disease
- Crohn’s disease

Infective
- bacterial overgrowth
- Giardiasis
- HIV
- tropical sprue
- Whipple’s disease

Drugs
- EtOH
- metformin

Other organs
Exocrine pancreas
- CF
- chronic pancreatitis
- pancreatic cancer

Biliary
- PBC
- gallstones
- ileal resection
Iatrogenic
Gastrectomy
- post-gastrectomy syndromes
Small-bowel resection
- short-bowel syndrome

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Malabsorption: clinical features

General
- chronic diarrhoea + weight loss despite preservation of appetite
- differential diagnosis = hyperthryoidism

'Tetrad' of symptoms
- diarrhoea
- weight loss
- flatuelence
- fatigue

Macronutrients
- fat: steatorrhoea
- protein oedema
- CHO

Micronutrients: fat-soluble vitamins:
- A
- D: osteomalacia
- E
- K: bleeding

Micronutrients: fat-insoluble vitamins:
-B12, folate: low Hb, peripheral neuropathy
- Fe (iron): low Hb

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Malabsorption: investigation

Stool
Faecal fat analysis
- qualitative: stool microscopy (Sudan black stain)
- quantitative: 3-day faecal fat on standardised diet

Faecal elastase
- pancreatic insufficiency

MC&S
- infestations

Bloods
Consequences
- FBC
- albumin

- INR - Fe, B12, folate
- Ca²⁺, Mg²⁺, Zn²⁺

Causes
- CRP, ESR: Crohn’s
- LFTs: biliary
- EMAs: coeliac diease
- TFTs: differentials

Special (small bowel)
- lactulose H2 breath test: bacterial overgrowth
- lactose H2 breath test: lactase deficiency

Imaging
- Barium follow-through
- small-bowel enema
- OGD + biopsy

Special (pancreas)
- faecal elastase
- pancreolauryl test: monitor urine fluorosceine
- ¹⁴C-triolene breath test

Imaging
- MRCP
- ERCP

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Coeliac disease: introduction

Also known as 'gluten-sensitive enteropathy' or 'non-tropical sprue' (sprue / psilosis = deficient absorption due to disease in the small intestine).

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Coeliac disease: pathology

Pathogenesis
- gliadin (in gluten) exposure invokes Tc-mediated allergic response
- HLA DQw2 + in 95 %

Histology
- crypt hyperplasia + villous atrophy ? submucosal inflammatory infiltrate

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Coeliac disease: clinical features

Patient
- NW Europe: Ireland
- 50 year old: mean age @ diagnosis

Malabsorption
- macronutrients: weight loss, diarrhoea, flatulence, fatigue
- Fe deficiency: low Hb

Response to gluten
- symptoms improve on gluten-free diet
- villous atrophy resolves

Associations
- dermatitis herpetiformis

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Coeliac disease: investigation

Antibodies
- endomysial antibodies (EMA): -ve in IgA deficiency
- tissue transglutaminase antibodies

Biopsy
- duodenal / jejunal:+/- repeat after gluten-withdrawl

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Coeliac disease: management

Diet
- life-long gluten-free diet

Complications
- low Hb: supplemental Fe, B12, folate
- osteopenia: Ca²⁺, vit D

- T-cell lymphomas: not if strict diet followed
- other cancers: stomach, bladder, breast...
- hyposplenism

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