FAILURE TO THRIVE ( FTT ) =2=

MALDIGESTION

DISORDERS
INTRALUMINAL
-GASTER -PANCREAS -LIVER -GUT ENTEROKINASE (trypsinogen trypsin)

INTRACELLULARE MEMBRANE
- MALTASE - LACTASE - SUCRASE - GLUCOAMYLASE

PEPTIDASE LIPASE

MUCOSAL INJURY

ENTEROCYTE
-LUMINAL MEMBRANE -INTRACELL / CYTOPLASMA

TIGHT JUNCTION

-BASOLAT. MEMBRANE
-BASAL MEMBRANE INTERCELLULER SPACE

-SECRETION -MACROMOLECULAR ABSORPTION

LAMINA PROPRIA
-BLOOD/LYMPH VESSELS

SENSITIZATION

Causes of mucosal injury

1.

2.

3. 4.

ABS-BIKA FKUSU

Mucosal compromised Malnutrition Folic acid Deficiency Iron Deficiency Antioxidant Deficiency Infection Viral (rotavirus) Bacteria overgrowth Antibiotica ( e.g. Neomycine ) Immunological disorder SIgA Deficiency Parasitic Infestation Giardiasis
4

Consequences of mucosal injury

1.
2. 3.

4.
5.

Diarrhoea Malabsorption Protein losing enteropathy Sensitization macro moleculer absorption Necrotizing Enterocolitis

ABS-BIKA FKUSU

CLASSIFICATION OF MALABSORPTION

1.SUBSTRACTS

2.SELECTIVE/GENERALIZED

3.OBTAINED CONGENITAL --- ACQUIRED

4.PATHOPHYSIOLOGY

5.PATHOGENESE & ETIOLOGY

CARBOHYDRATE
FAT PROTEIN
SUBSTRACT

WATER & ELECTROLYTES VITAMIN

MIXED OR GENERALIZED

II
PAN MALABSORPTION

Congenital & genetic

Pathogenese & etiology

Bacterial overgrowth Bile acid def. sensitization

nutritional Drug induced

CARBOHYDRATE
1. INTRALUMINAL ENZYME : AMYLASE 2. BRUSH BORDER ENZYME OLIGO/DISACHARIDASE 3. ABSORPTION
GLUCOSE
FRUCTOSE GALACTOSE

4. COLONIC BACTERIA

SCFA

COLON NUTRITION

BOWEL NUTRITION

COLON

SMALL INTESTINE

70% INTRALUMINAL 30% INTRAVASAL

45% INTRALUMINAL 55% INTRAVASAL

TRYGLYCERIDE
FATTY ACID GLYCEROL

SHORTCHAIN FATTY ACID (SCFA)

LONG CHAIN FATTY ACID (LCFA)

MEDIUM CHAIN FATTY ACID (MCFA)

C<6 C=6-8(12) C>12

DIGESTION & ABSORPTION OF FAT

1.EMULSIFICATION 2.LIPOLYSIS LIPASE

3.MICELLE

BILE SALT

4.ENTER INTO MUCOSE 5.RE-ESTERIFICATION 6.CHYLOMICRON

7.BLOOD/LYMPH VESSELS

MCT(MEDIUM CHAIN TRIGLYCERIDE)

C=6-8(12)

1.LIPASE 70%
2.NO BILE SALT

3.NO REESTERIFICATION
4.NO CHYLOMICRON FORMATION 5.PORTAL VEIN

DIAGNOSTIC OF FAT MALABSORPTION

1. MICROSCOPIC

2. FLOATING TEST (ROSSIPAL) 3. LIPIODOL ABSORPTION TEST 4. SERUM CAROTEN 5. FAT BALANCE (VAN DE KAMER) 6. STEATOCRITE

LIPIODOL ABSORPTION TEST

LIPIODOL

FAT+IODINE

Drink of 5-10 mL

BLOOD URINE + AMYLUM 1% DILUTION 1:1 1:2 1:8 (+) N

DIGESTION & ABSORPTION OF PROTEIN

1.INTRALUMINAL DIGESTION (HCL, PEPSIN)
2.ACTIVATED PANCREATIC ENZYMES BY ENTEROKINASE

3.PROTEOLYSIS PEPTIDE & AMINO ACIDS 4.MUCOSE INTRACELLULER DIGESTION

5.PORTAL VEIN

MALABSORPTION

ACUTE

CHRONIC

DEF.

ABD. DISTENSION

DEHYDRATION

AVITAMINOSIS

- PERSISTENT DIARRHOEA - FAILURE TO THRIVE

TREATMENT OF MALABSORPTION
1. ETIOLOGY
-INFECTION -ENZYMS

2. DIET
PREDIGESTED FORMULA

3. SUPPORTIVE
- WATER & ELECTROLYTES - VITAMIN & MINERAL - PREVENTION OF MALNOURISHED

MALABSORPTION SYNDROME
1. LACTOSE INTOLERANCE

2. COWS MILK PROTEIN INTOLERANCE

3. PCM 4. CHOLESTASIS 5. PARASITIC INFESTATION 6. ANTIBIOTICS 7. POST ENTERITIS MALABSORPTION

Lactose Intolerance
Terminology

Lactase Defisiency :
Low / absence activity of lactase enzyme assay

Laktose Malabsorption :
Failure of the small intestine to absorb lactose conformity with the test

Lactose Intolerance : clinical symptoms/signs

LACTOSE
The Primary Carbohydrate Of Mammals Milk

Breast Milk Sea Lion Milk Cow Milk (7 %) (0 %) (4 %)

LACTOSE Lactase

Glucose & Galactose

In outer of brush border Smallest amount No adaptive enzyms

Developmental Primary Congenital alactasia Late onset hypolactasia

LACTASE Defisiency

Secondary

Mucosal damage eg rotavirus diarrhoea

UNABSORBED LACTOSE
OSMOTIC ACTION H2 COLON
FERMEN TATION

GASES

CO2 CH4

ABSORBED

WATER

LACTOSE

SHORT CHAIN FATTY ACID

COLONIC SALVAGE

L - LACTATE

OSMOTIC DIARRHOEA REDUCTION SUBSTANCE (LACTOSE) CLINITEST LACTIC ACID stools pH LACMUS

DIAGNOSTIC OF LACTOSE INTOLERANCE

Lactose tolerance test + Lactose malabsorption test a. Stools pH & clini test b. Lactose loading test c. Breath hydrogen test

Stools pH & clini test

Screening Test

Only drunk lactose Fast intestinal transit time Fresh stools Incomplete degradation of lactose

Breath hydrogen test

Night fasting Doses of lactose : 2 gr/kgBW (max. 50 gr) in concentration of solution 20 % Samples are then collected every 30 minutes for 3 hours to determine H2 concentration in expired air Malabsorption : > 20 ppm greater than fasting level

TREATMENT
LACTOSE INTOLERANCE

Primary

Secondary

1. Low/free lactose 2. Premature

Breast milk continued

Breast milk (-) ??

- Breast milk (+): continued - Breast milk (-) : lactose lowered + glucose polymer

COWS MILK PROTEIN INTOLERANCE

-SMALL BABY -DIARRHOEA

-ENTEROPATHY Lact. Intol.

1.FREQ. 2.Extra GI Tract manifestation 3.Phenomenon >>>

CMPI
>

(-)
DOSE DEPENDENT

(+)
DOSE INDEPEN.

Goldman Criteria
1.
2. 3.

Remission of symptoms after elimination of cow milk from the diet Relapse within 48 hours of beginning a milk challenge Positive reaction to 3 such challenges (similar onset, duration, and clinical features)
30

BIOPSY

MUCOSAL DAMAGE PERMEABILITY

-Dxylose absorption test
-L/M excretion ratio PROTEIN LOSING ENTEROPATHY

-Polyethylen glycol abs. test

INFLAMMATION

MUCOSAL DAMAGE

PROTEIN LOSING ENTEROPATHY

NONINFLAMMATION

LYMPHANGIECTASIA

LYMPH OBSTR.

CHD*

*Congenital Heart Disease

DIAGNOSTIC OF PROTEIN LOSING ENTEROPATHY

1. ISOTOP 2. FECAL 1- ANTITRYPSIN