Medical and Surgical Conditions for the Treatment of Malabsorption

Question 1: In daily clinical usage the terms maldigestion, malabsorption, and malassimilation are not always clearly separated. What are the exact definitions as a basis for understanding as well as regarding reasonable differential diagnostics? Dietrich: Malassimilation is the umbrella term for a deficit of nutrients and includes maldigestion (failure of enzymatic intraluminal extraction of chyme) and malabsorption (failure of taking up the extracted nutrients by the intestinal epithe-lium). Question 2: You see a patient for the first time. In your opinion, which symptoms and clinical signs are potentially indicating malabsorption? In this situation, which basic laboratory findings do you deem necessary in order to confirm your suspicion of malabsorption? Al-Taie: Patients suffering from malabsorption can present with a broad spectrum of often non-specific symptoms such as bloating, flatulence, and diarrhea or fatty stools. In addition, weight loss, fatigue, ataxia, tetany, skeletal pain, and amenor-rhea can also be caused by malabsorption. In cases of mild malabsorption, no specific signs can be detected on examination. However, kachexia, hypoproteinamic edema, paleness, nail and hair dystrophy and ecchymosis, disturbances of deep sensibility, and osteoporotic fractures can indicate severe global or specific malabsorption. Basic laboratory tests to confirm malabsorption include different blood tests such as complete blood count, iron, fer-ritin, C-reactive protein, ALT, AST, albumin, creatinine, cholesterol, calcium and potassium, and international normalized ratio (INR). Depending on the suspected underlying disease, extended laboratory examinations comprise serum 25-hydroxyvitamin D, vitamin B 12 , folic acid, tissue trans-glutaminase antibodies, serum electrophoresis, gastrin, va-soactive intestinal polypeptide (VIP), fecal elastase, and fecal calprotectin. Dietrich: Malabsorption is marked by unspecific symptoms such as diarrhea, underweight, paleness, and wasting of muscles , in severe cases also by the presence of ascites. Determination of albumin, total protein, prothrombin time, cholesterol , electrolytes, and ferritin may contribute to a confirmation of this clinical impression. Schütte: The spectrum of symptoms seen in global malab-sorption is broad. Weight loss despite adequate food intake, diarrhea with voluminous and foul-smelling stools, and edema secondary to hypoalbuminemia are the classic clinical signs. While some patients may even be asymptomatic, the majority present with rather mild gastrointestinal symptoms like abdominal distension and flatulence. Malabsorption of specific nutrients results in more specific symptoms, e.g. vitamin B 12 deficiency resulting in polyneuropathy or pernicious anemia. A diagnosis of malabsorption cannot be established on the basis of blood tests alone. A diligent medical history frequently leads to the suspicion of malabsorption followed …