126 (E4) M6: Malabsorption Syndromes

foods that contain gluten

wheat, barley, rye, other grains d/t cross-contamination, malt, dextrin, Brewer's yeast (beer, ale, porter), candies, caramel-colored foods, oats, processed meat and cheese, salad dressings, soy sauce, seasonings, soft drinks

malabsorption syndrome

when any area in digestive system cannot absorb vit, minerals, and/or nutrients

malabsorption disorders: Celiac disease (gluten-sensitive enteropathy)

(2x more risk women>men, Caucasians, any age) gluten causes toxic response (humoral and cell mediated) at epithelial surface leading to destruction of absorbing surface of intestine -unknown why rxn occurs -systemic nutritional deficiencies, wt loss, diarrhea, bloating/gas, iron/folate anemias, osteomalaxia, streatorrhea, azotorrhea, low d-xylose absorption, fatigue, malasise, depression, hypothyroidism, migraines, osteopenia, seizures, parastheias, red/shiny tongue, yellowing teeth, dermatitis herpetiformis (rash of macules develop into itchy papules and vesicles on arms, knees, fact, glutes) *no s/s if gluten avoided

malabsorption disorders: Whipple disease

-bacterial invasion of intestinal mucosa -arthritis, hyperpigmentation, lymphadenopathy, serous effusions, fever, wt los, steatorrhea, azotorrhea

malabsorption disorders: Immunoglobulinopathy

-dec intestinal defenses, lympoid hyperplasia (inc in # of cells in lymph nodes), lymphopenia (dec lymphocytes in blood) -frequent assoc c Giardia: hypogammaglobulinemia or isolated immunoglobulin A deficiency

malabsorption disorders: Pancreatic insufficiency (chronic pancreatitis, pancreatic carcinoma, pancreatic resection, cystic fibrosis)

-dec intraluminal pancreatic enzyme activity, maldigestion of lipids and proteins -abdom pain, wt loss, marked steatorrhea, azotorrhea (excess nitrogen in excretions), glucose intol

malabsorption disorders: gastric resection with gastrojejunostomy

-dec pancreatic stim d/t duodenal bypass, poor food mixing/bile/pancreatic enzymes, or dec intrinsic factor -wt loss, anemia combo of iron/B12/folate, moderate steatorrhea (fat in feces bc cant absorb)

malabsorption disorders: Lactose intolerance

-high concentration intestinal lactose, osmotic diarrhea -diarrhea, gas/bloating, cramps, nausea, possible vomiting, positive lactose intol test, dec intestinal lactase

bacterial overgrowth

-high risk if: lack ileococcal valve or stasis d/t obstruction or dilated part of bowel with poor motility -broad spectrum ABT (dec bacterial overgrowth, dec risk bacterial translocation, dec central line infection risk) -may lead to metabolic acidosis or gastric hypersecretion

malabsorption disorders: Zollinger-Ellison syndrome

-hyperactive duodenum inactivates pancreatic enzymes -ulcer diathesis (predisposition), steatorrhea

malabsorption disorders: Certain parasitic diseases (giardiasis, strongyloidiasis, coccidiosis, capillariasis)

-invasion and damage to surface mucosa -wt loss, diarrhea, organism on jejunal biospy, organism in stool

malabsorption disorders: Ileal dysfunction (resection or disease)

-loss illeal SA leads to dec bile salt, dec B12 absorb, bile in colon inhibits fluid absorption -diarrhea, wt loss, steatorrhea, dec B12 absorption

malabsorption disorders: Stasis syndromes (surgical strictures, blind loops, enteric fistulas, multiple jejunal diverticula, scleroderma)

-overgrowth intraluminal intestinal bacteroa (esp anaerobic) leads to deconjugation bile salts, dec bile salt pool, bacterial utilization of B12 -wt loss, steatorrhea, low B12 absorption, low d-xylose absorption

malabsorption disorders: Tropical sprue

-unknown toxic factor leads to mucosal inflam and partial villous atrophy -wt loss, diarrhea, iron/folate/B12 anemias, streatorrhea, low d-xylose absorption

categories of malabsorption syndromes

Gastric resection with gastrojejunostomy Pancreatic insufficiency Ileal dysfunction stasis syndromes Zollinger-Ellison syndrome Lactose intolerance Celiac disease Topical sprue Whipple disease parasitic diseases immunoglobulinopathy

nursing care

admin and monitor nutritional therapy PN therapy pt edu dec risk to central venous access device monitor tolerance of tube feedings and proper care f/u nutritional support devices ostomy care- how to protect skin, etc consider developmental needs of hospitalized child

malabsorption can be exacerbated by

bacterial overgrowth dysmotility

luminal disorders

bile acid deficiency Zollinger-Ellison syndrome pancreatic insufficiency small bowel bacterial overgrowth chronic pancreatitis

mucosal/transport disorders

celiac disease crohn's disease radiaton enteritis

types of surgical interventions

intestinal valve repair tapering enteroplasty stricturoplasty intestinal lengthening interposed segments intestinal transplant (mostly for children c permanent PN dependence, or c severe complications from long term PN)

1st phase of mgmt

child on PN

3rd phase of mgmt

d/c PN (but risk nutritional deficiencies: fat soluble vits, minerals) meds to dec secretory losses -H2 blockers, -PPI -octreotides (dec GH, blood flow to digestive organs, dec release serotonin, gastrin, secretin, etc) -cholestyramine - dec diarrhea assoc c malabsorp bile salts

assessment/diagnostic findings for Celiac disease

family hx PMH assess presenting s/s serologic testing (for IgA anti-tissue transglutaminase (tTG), 90% sensitive and 95% specific to celiac disease) endoscopic biopsy of prox sm int (to confirm) *still consume gluten during testing to dx!

risk factors for developing Celiac disease

family hx (esp first degree relatives) type 1 diabetes down syndrome turner syndrome

pt edu lactose intolerance

intol to diary d/t lactase enzyme deficiency avoid dairy bc trigger avoid foods with dry milk fillers pretreat food or eat food with lactase preparations most ppl can tol 1-2cups of milk/day, but split into smaller amnts throughout yogurt bacterial helps digest lactose calcium and Vit D supps

2nd phase of mgmt

introduce enteral feeds (as soon as possible after surgery) - elemental formulas, NG tubes dec PN as inc enteral attempt PO feeding (minimizes aversion and preservation of skills)

short-bowel syndrome

malabsorption and malnutrition d/t loss of a significant portion of functioning bowel/ dec mucosal SA need for PN parenteral nutrition

common causes of short-bowel syndrome

necrotizing enterocolitis (intestinal wall invaded by bacteria) volvulus (intestine twists around itself and the mesentery, results in obstruction) jejunal atresias (birth defect of lacking mesenteric membrane- causes the jejunum to twist around the marginal artery (supplies blood to colon) gastroschisis (intest found outside baby's body, exiting through a hole in abdom wall)

lymphatic disorders

neoplasms surgical trauma (products or digestive system interferes c fat transport)

mgmt of celiac disease

no cure avoid trigger foods, cross-contamination, and possible products c gluten (toothpastes, communion wafers. cosmetics, art supplies) pt edu on reading nutritional labels will take time to dec s/s while avoiding gluten 1yr to restore intestinal villi anemia tx osetoporosis tx

parenteral vs enteral nutrition

parenteral is into vein enteral is into any part of the GI tract

mgmt goals short bowel syndrome

preserve as much bowel as possible maintain nutrition, growth, development

surgical intervention purpose

to slow intestinal transit time, dec bacterial overgrowth, or inc mucosal SA