MALABSORPTION SYNDROME (fr. mal disease + absorption; synonym: syndrome of disturbance of absorption, syndrome of the broken intestinal absorption) — the clinical symptom complex caused by disturbance of absorption through a mucous membrane of a small bowel of one or several nutrients. The syndrome of the broken intestinal absorption can be primary (hereditarily caused) and secondary (acquired).
Absorption of monomers (monoglycerides, fat to - you, amino acids, monosaccharides) is preceded by hydrolysis (splitting) of food polymers (proteins, fats, carbohydrates) under the influence of digestive enzymes. Disturbance of the proteolysis, fats and carbohydrates at insufficiency of digestive enzymes (digestivny enzymes) received the name of a syndrome of insufficiency of digestion (maldigestiya). The combination of both types of frustration (splitting and absorption) was offered to be designated as a malyassimilyation. However in literature the tradition to M. took roots page to refer the disturbances of absorption caused both by frustration of transport mechanisms, and insufficiency of digestive enzymes.
The etiology and a pathogeny
can be the Proximate cause of disorder of processes of absorption of food ingredients hypoactivity of enzymes of splitting and transport carriers of end products of digestion through an intestinal wall. Insufficient receipt in intestines of enzymes with digestive juices owing to obstruction of channels of glands of a mucous membrane of a small bowel a viscous secret as it is observed, e.g., at a mucoviscidosis is other reason of M. of page. The lack of formation of the enzymes splitting, e.g., proteins that leads to deficit of amino acids and proteinaceous starvation of an organism matters.
The inactivation of enzymes of splitting and transport carriers also serves as the reason of development of M. of page. So, some antibiotics (chlortetracyclin, Neomycinum) can suppress processes of splitting of lipids and strengthen steatorrhea (see).
At surplus in food of salts of calcium and magnesium disturbance of absorption of fat is observed. In M.'s emergence by the village morphological changes of a small bowel and disturbance of a vermicular movement matter went. - kish. path.
Pathogenetic mechanisms M. of page are diverse. At insufficiency of pancreatic enzymes suffers band, or pancreatic, the phase of digestion, at deficit of intestinal enzymes (disaccharidase, peptidase, etc.) is broken superficial, or membrane, a phase digestion (see). Intestinal dysbacteriosis causes structural change bilious to - t, gepatobiliarny diseases change their metabolism and are followed by a cholestasia — all this promotes disturbance of hydrolysis and transport of lipids (a biliary phase). At various diseases and defeats of a small bowel, especially in case of a mucosal atrophy, the structures responsible for processes of absorption (A cellular phase) in a varying degree suffer. At the same time there is a transformation of the soaking-up epithelium in ferruterous, diameter of holes decreases by mucosal surfaces of a cover through which there is an absorption (I eat.). There can be a row biochemical, defects: the quantity of transport carriers decreases, their structure changes owing to what their ability to take up with the transported substances decreases; the power processes providing membrane transport, etc. are broken. As a result of changes of endocrine functions of cells of an intestinal wall hormonal regulation of digestive and transport processes suffers. At disturbances of an intestinal lymph flow, mesenteric blood circulation further transport of the soaked-up substances (a phase of outflow) worsens. At acceleration of a passage of food masses on a small bowel, owing to motor disturbances time of contact of a chyme with the soaking-up surface of a gut is reduced.
Exists several classifications of M. of page. The following classification testifies to large number of the etiological and pathogenetic factors which are the cornerstone of M.'s emergence by the village. 1. Primary M. of page (hereditarily caused): intolerance of disaccharides (lactose, sucrose, isomaltose, trehalose) — disakharidazny insufficiency; insufficiency of peptidases (gluten disease); insufficiency of enterokinase; intolerance of monosaccharides (glucose, galactose, fructose); disturbance of absorption of amino acids (Hartnup's disease, Cystinuria, triptofanmalyabsorbtion, metioninmalyabsorbtion); disturbance of absorption of vitamins — cyanocobalamine (B12), folic acid. 2. Secondary M. of page (acquired): gastrogenic, observed after a gastrectomy, at gastritis, a carcinoma of the stomach; pankreatogenny, caused by various diseases of a pancreas (pancreatitis, a mucoviscidosis, cancer, tumors of the insular device, etc.); hepatogenous, observed at acute and hron, diseases of a liver, inside - and extrahepatic cholestasias; enterogenous, caused by various diseases of intestines (a coloenteritis, a Gee's disease, a disease Krone, a diverticulitis, a syndrome of «a blind loop», infectious, parasitic, vascular diseases of intestines), and also postoperative (enterectomy); endocrine, observed at a diabetes mellitus, hyper - and a hypothyroidism; so-called iatrogenic, caused by prolonged use of antibiotics, laxatives, tsitostatik and other drugs, and also radiation therapy.
There are also other classifications, napr, across Polonovskim (C. Po lonovski, J. Polonovski), M.'s division of page as its origin is the basis a cut (disturbance of absorption of a gastric and intestinal origin, owing to insufficiency of bile, in connection with pathology of a pancreas).
At primary M. of page the selection deficit of enzymes or transport carriers and thereof absorption of one feedstuff or several relatives longs for the structure of substances most often takes place.
At secondary M. of page usually there is a deficit of many enzymes and carriers, various mechanisms of malabsorption are implemented that causes disturbance of absorption of a number of feedstuffs. From primary disturbances of absorption the hl occurs at adults. obr. intolerance of disaccharides (disakharidazny insufficiency), preferential lactoses, other forms of primary M. of page are quite rare, the most part from them is observed at children. Secondary M. of page, especially in the erased form, is rather often noted in clinic of gastroenterological diseases of adults.
The clinical picture
One of the major a wedge, M.'s symptoms of page at children is hron, the diarrhea, and a peculiar indicator of insufficiency of absorption serves a steatorrhea — the increased removal of lipids with a stake. The child ceases to put on weight, the hypotrophy, and then exhaustion develops, lag in growth (gipostatur) is observed. Depending on duration and the nature of process changes from other bodies and systems accrue: skin becomes dry, with pellagroidny coloring; the glossitis, language red without nipples is expressed; there are hypostases due to disturbance of protein and water and electrolytic metabolism; hypochromia anemia, a hypopotassemia, the Hyponatremia, a hypocalcemia are noted. At some forms M. of page changes in urine, napr are observed, at the intolerance of milk connected with deficit of lactose, in urine in some cases it is noted lactosuria (see). There can be spasms, osteoporosis or osteomalacy in connection with insufficiency in an organism of calcium; abdominal distention, intestinal gripes in connection with a hypopotassemia and strengthening of fermentative processes in intestines. However M. of page can proceed and without sharp disturbances from outside went. - kish. path.
At adults a wedge, a picture M. of page it is in many respects caused by character of a basic disease. Intensity of intestinal symptoms (frustration of a chair, rumbling, etc.) depends on extent of damage of intestines, on involvement in patol, process of a large intestine, quite often intestinal symptoms in general are absent. The general manifestations testimonial of disturbances of basic processes of a metabolism and functions of a number of bodies and systems prevail that is connected with insufficient intake of feedstuffs to bodies and fabrics.
Patients complain of increased fatigue, reduced working capacity, weakness, a loss of appetite, weight loss, sometimes exhaustion up to cachexias (see). Their xeroderma, a hair loss, the increased fragility of nails is observed. There can be a diarrhea, a steatorrhea, a creatorrhea. In blood — a hypoproteinemia, a disproteinemia, shifts as a part of amino acids of blood, in urine — a hyper aminoaciduria (see. Aminoatsiduriya ). Concentration of cholesterol, the general lipids and their fractions in blood serum decreases. The wedge, signs of insufficiency of thiamin (paresthesia in extremities, an onychalgia, frustration of a dream), Riboflavinum (a cheilitis, angular stomatitis), nicotinic to - you (a glossitis, pellagroidny changes of skin), ascorbic to - you (bleeding of gums) and other vitamins are quite often observed (see. Vitamin deficiency ). A row a wedge, symptoms is caused by disturbance of exchange of electrolytes: a hyponatremia (arterial hypotension, tachycardia, a xeroderma and language, thirst), a hypopotassemia (muscular weakness, muscle pains, weakening of tendon jerks, decrease in intestinal motility, premature ventricular contraction etc.), a hypocalcemia (feeling of numbness of lips and fingers, the increased neuromuscular excitability, osteoporosis), a lack of manganese (decrease in sexual function). In hard cases osteomalacy with fractures of bones, a tetany can be observed. Often arise iron scarce and B12-foliyevodefitsitnaya anemia. In an oral cavity — atrophic processes, desquamative changes in language, sometimes a periodontopathy. Skin becomes atrofichny, dry, folded, gains dirty-gray color, pigmentation appears. Around a mouth, eyes, an anus there are cracks, in hard cases the disease is complicated by eczema, neurodermatitis. Changes from endocrine system are noted (a hypocorticoidism, disorders of sexual function, etc.), in hard cases the syndrome of multiglandular insufficiency with damage of a hypophysis, adrenal glands, gonads, a thyroid gland can develop (see. Polyglandular insufficiency ). Neurotic frustration, hypochiondrial states are quite often observed.
The wedge, a picture M. of page to a certain extent depends on localization patol. process in a small bowel. E.g., at preferential defeat of its proximal departments absorption of calcium, iron, folic to - you, vitamins of group B suffers. At defeat of average departments absorption fat to - t, amino acids is broken. Absorption of monosaccharides is broken at defeat of proximal and average departments of a gut. At defeat of distal departments of a small bowel insufficient absorption of B12 vitamin, bilious to - t therefore in case of an ileectomy, at some forms of a disease the Krone is broken enterogepatichesky circulation bilious to - t is noted.
At M. of page, in particular at defeat of distal department of an ileal gut, allocation of oxalates with urine — an enteral oksaluriya quite often increases, can lead edges to formation of oxalic stones.
the Diagnosis of a syndrome of the broken absorption shall be carried out as soon as possible to avoid deepening of metabolic shifts and disturbance of activity of various bodies and systems.
V. A. Tabolin, E. I. Shcherbatova, T. I. Korneva, V. P. Lebedev, E. K. Kurgasheva (1973) offered multi-stage system of kliniko-biochemical diagnosis of syndromes of the broken absorption in intestines at children. A research there begin with assessment of anamnestic data, carrying out the genealogical analysis (see. Genealogical method ). At the same time pay attention to existence at relatives of diseases went. - kish. path (gastritis, peptic ulcer, cholecystitis, coloenteritis, pancreatitis), respiratory system (hron, bronchitis), exchange disturbances (diabetes mellitus, hyperthyroidism). Along with carrying out the genealogical analysis carrying out screening tests, such as tests on various sugar in Calais and urine is provided; a koprologichesky research, definition of pH a calla, reaction of a filtrate a calla with trichloroacetic to - that, a heat test. Use the following tests: Benedict's tests on sugar, Velk's test on lactose and a maltose, Helman's test on sucrose, determination of content of carbohydrates in excrements by means of the tablets «Clinitest» by Anderson's method. These tests allow to reveal changes, characteristic of separate syndromes.
At suspicion on Gee's disease (see) the greatest value studying of content of crude protein, protein fractions, immunoglobulins, the general lipids, cholesterol and phosphorus, potassium and sodium in blood serum, rentgenol is. a research went. - kish. a path with a suspension of fixed white, a X-ray analysis of tubular bones, and also assessment of efficiency of the carried-out bezglyutenovy eliminative diet — an exception of food of products of rye, wheat, barley and grits (see. Gluten disease ).
For confirmation of the diagnosis of M. of page at mucoviscidosis (see) it is necessary along with definition of sodium and chlorine in stalemate liquid, nail plates, conducting test with DOKS to study the immune status, a functional condition of a liver, and also proximal departments of nephron.
At patients with an exudative enteropathy (see. Enteropathy exudative ) at a koprologichesky research muscle fibers come to light; qualitative tests indicate availability of plasma proteins in Calais. At disakharidazny insufficiency decrease in pH a calla to 5,0 and comes to light below; in a koprogramma extracellular starch is found; tests on sugar in urine and Calais are positive. In diagnosis of intolerance of disaccharides loading tests mono - and disaccharides (glucose, D-xylose, lactose, sucrose etc.) with the subsequent blood analysis and their hromatografichesky identification in Calais and urine, and also studying of daily excretion with urine of carbohydrates and proteins are of great importance.
At suspicion of Hartnup's disease (see. Hartnupa disease ) along with characteristic the wedge, symptoms is of great importance for the diagnosis determination of content in urine of an indican, amino acids of proline and an argin. Positive tests of test researches give the chance of carrying out more in-depth studies using quantitative analytical methods: blood, daily urine, kcal is investigated; by X-ray film test and test with Iodolipolum activity of trypsin and a lipase is estimated; identification of serum proteins and a calla is carried out. The research of daily excretion of carbohydrates with urine reveals melituria (see) at an intestinal form of a mucoviscidosis, disakharidazny insufficiency, intolerance of glucose and a galactose. Identification of serum proteins and calla by method immunoelectrophoresis (see) gives the chance to diagnose an exudative enteropathy. After carrying out kliniko-biochemical comparison of the received results the estimated diagnosis is confirmed by purposeful clinical, X-ray and gast-roduodenoskopichesky researches which are conducted taking into account the data obtained earlier.
All listed techniques are used and in practice for establishment of the diagnosis of M. of page at adults. Methods of recognition of disturbance of vsasyvatelny function of a small bowel — see. Intestines .
At primary (hereditarily caused) a syndrome of disturbance of intestinal absorption an important component of complex therapy is to lay down. food, a cut provides restriction or an exception of the products leading to development patol, symptoms. So, in therapy of a Gee's disease the basic is use of the diet deprived of gluten. The high-calorific diet with the sufficient content of proteins, vegetables, fruit is appointed, from a cut the products prepared from rye, wheat, oats are completely excluded.
At intolerance of disaccharides and monosaccharides the diet with restriction, and in certain cases with an exception of those sugars which the patient does not transfer is necessary.
The difficult task is represented by treatment of a lactose intolerance at babies since at severe forms of insufficiency it is necessary to exclude milk from a diet. In these cases apply the milk mixes deprived of lactose (Galantaminum, soyaval). At a lack of sucrose of the child it is not necessary to transfer to the mixed and artificial feeding early. Food of children, patients with the intestinal and mixed forms of a mucoviscidosis with dominance of disturbances from outside went. - kish. a path, the nek-eye restriction of fats, sufficient content of vitamins and mineral salts is under construction on the basis of respect for norms of the products and the menu accepted in usual conditions, but with high content of proteins and carbohydrates.
At intolerance of sucrose and isomaltose exclude sucrose and limit starch, at intolerance of glucose and a galactose sharply limit these monosaccharides, in the increased quantities appoint fructose, at a gluten enteropathy and other forms of a heavy coloenteritis recommend a bezglyutenovy diet. At the expressed disturbances of absorption of fats (e.g., at a mucoviscidosis) recommend to limit usual fats and to appoint the triglycerides containing fat to - you, received from piririma oil which are easily hydrolyzed and soaked up in intestines. At patients with severe forms of M. of page the good therapeutic effect is rendered by the so-called alimentary diet representing mix of amino acids, a dextrin, microelements, redoxons addition of small amounts of fat. This diet does not contain lactose, whole protein, is extremely poor in slags and fat, does not incorporate allergens.
Therapy of the secondary (acquired) syndrome of disturbance of intestinal absorption provides treatment of a basic disease. In hard cases of M. of page courses of parenteral food are very effective (glucose, proteinaceous a hydra lysates, the main electrolytes, vitamins). At M. short courses of antibiotics of a broad spectrum of activity or eubiotik are shown to page because of intestinal dysbacteriosis (derivatives 8 oxyquinolines, Bactrimum, etc.), drugs are recommended also biol (kolibakterin, bifikol, bifidumbacterium, etc.).
An essential role among to lay down. actions play means of replacement therapy. Appoint drugs of pancreatic enzymes (Pancreatinum, panzinorm forte, etc.), abomin and some other fermental drugs; only big dosages of these means are effective. Purpose of fermental drugs together with the antacids considerably oppressing gastric secretion promotes strengthening of therapeutic effect of enzymatic means at M. of page because of pancreatic insufficiency. In pharmakodinamichesky doses appoint vitamins (And, D, K, S, folic to - that, a complex B, B 12 ), drugs of calcium, magnesium, iron, cobalt. Administration of proteinaceous drugs is shown (plasma, protein hydrolyzates, a protein, etc.). At M. of page because of dysfunctions of an ileal gut (after its resection, at a disease Krone, etc.) recommend holestiramin, with the same purpose the lignin (Polyphepanum) adsorbing not soaked up bilious to - you and promoting their allocation with a stake can be used.
In secondary M.'s cases of the page caused by hl. obr. insufficient activity of enzymes of membrane digestion, showed diphryl (Corontinum) in sufficient doses (not less than 180 mg a day), and also the anabolic steroids (Nerobolum, etc.) stimulating processes of membrane hydrolysis in a small bowel. Inhibitor of phosphodiesterase the Euphyllinum and the inductor of lizosomalny enzymes phenobarbital also increase activity of enzymes of membrane digestion. Stimulate absorption of monosaccharides in a small bowel some adrenomimetichesky means — ephedrine, L-dopa, beta adrenoblocker propranolol (Obsidanum, anaprilin), cortexone acetate, an Euphyllinum. Inhibitor of kinin Prodectinum (Parmidinum), cholinolytic (atropine) and Ganglioblokiruyushchiye (petrolhexonium) drugs exert the normalizing impact on absorption of monosaccharides — and ri low initial indicators stimulate it, at high — brake. At diseases where M. of page is secondary when disturbances of absorption are not connected with deficit of digestive enzymes or transport carriers, correction of processes of intestinal absorption by means of medicamentous means can be effective.
The forecast and Prevention
the Forecast at primary M. of page depends on timeliness of diagnosis and correctness of the carried-out treatment, at secondary M. of page — on a basic disease and efficiency of the carried-out treatment.
Secondary M.'s prevention by the village consists in treatment of a basic disease.
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A. V. Frolkis; V. A. Tabolin (ped.).