eMedicine Specialties > Gastroenterology > Intestine

Protein-Losing Enteropathy: Differential Diagnoses & Workup

Author: Naeem Aslam, MD, Fellow, Department of Medicine, Division of Gastroenterology/Hepatology, University of Louisville School of Medicine
Coauthor(s): Richard Wright, MD, Professor and Chief, Department of Medicine, Division of Gastroenterology/Hepatology, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Jul 11, 2008

Differential Diagnoses

Cardiomyopathy, Restrictive
Mycoplasma Infections
Collagenous and Lymphocytic Colitis
Pericarditis, Acute
Hypoalbuminemia
Pericarditis, Constrictive
Hypogammaglobulinemia
Pericarditis, Constrictive-Effusive
Inflammatory Bowel Disease
Salmonellosis
Malabsorption
Yersinia Enterocolitica

Other Problems to Be Considered

Cutaneous burns
Parasitic infections
Viral enteritis

Workup

Laboratory Studies

  • The most prominent laboratory abnormality is a decrease in serum albumin and globulin.
  • A gastrointestinal disorder should be considered the cause of hypoalbuminemia after malnutrition, nephrotic syndrome, and chronic liver disease are excluded. The diagnostic workup can then be focused on gastrointestinal causes.
  • The presence of alpha1-antitrypsin in the stool is an important diagnostic clue because it is not normally absorbed or secreted into the bowel.
    • In patients with hyperacidity syndromes, this study is not accurate because of the degradation of alpha1-antitrypsin in an environment where the pH is less than 3.  
    • Measuring stool volume and stool alpha1-antitrypsin concentration shows the plasma clearance (PC) of alpha1-antitrypsin. The plasma clearance of alpha1-antitrypsin can be used to monitor response to therapy.
                                                             (stool volume) (stool alpha 1-AT)
                             Alpha 1-AT PC  =          ____________________________
                                                                     (serum alpha-1 AT)
         
    • Viral serologies may be helpful.

Imaging Studies

  • Radionuclide-labeled serum albumin can be administered intravenously, and stool can be collected as a measure of protein exudation into the gastrointestinal tract.
  • Computed tomography scanning may suggest lymphatic obstruction. This needs to be confirmed with lymphangiography.
  • Chest radiography, echocardiography, and radionuclide scanning of the heart detect cardiac disease.
  • Erosive or ulcerative conditions are diagnosed using radiographic contrast studies or, when possible, endoscopy and mucosal biopsies.

Other Tests

  • Primary gastrointestinal tract disease can be detected by endoscopy and biopsy, barium radiography, stools for ova and parasites, and culture. Primary gastrointestinal tract disease can be suggested by fecal occult blood.
  • Perform a hydrogen breath test for bacterial overgrowth in the small intestine.

Procedures

  • Findings on endoscopic studies are usually normal unless primary gastrointestinal disease (eg, ulcerative colitis, Crohn disease, Ménétrier disease, viral mucosal ulcerations) is present.

Histologic Findings

Mucosal abnormalities can be observed with inflammatory (colitis) and infectious (viral tuberculosis) causes and in lymphatic obstruction (lymphangiectasia).

More on Protein-Losing Enteropathy

Overview: Protein-Losing Enteropathy
Differential Diagnoses & Workup: Protein-Losing Enteropathy
Treatment & Medication: Protein-Losing Enteropathy
Follow-up: Protein-Losing Enteropathy
References
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References

  1. Akgün A, Tani Acar E, Taner MS, et al. Scintigraphic diagnosis of protein-losing enteropathy secondary to amyloidosis. Turk J Gastroenterol. Mar 2005;16(1):41-3. [Medline].

  2. Albright F, Bartter FC, Forbes AP. The fate of human serum albumin administered intravenously to a patient with idiopathic hypoalbuminemia and hypoproteinemia. Trans Assoc Am Physicians. 1949;204:62.

  3. Bindl L, Buderus S, Bindl C, Lentze MJ. Protein-losing enteropathy: report of four cases and review of etiology, diagnostic work-up and treatment. Klin Padiatr. 2005;217:201-210.

  4. Cheong JL, Cowan FM, Modi N. Gastrointestinal manifestations of postnatal cytomegalovirus infection in infants admitted to a neonatal intensive care unit over a five year period. Arch Dis Child Fetal Neonatal Ed. Jul 2004;89(4):F367-9. [Medline].

  5. Citrin Y, Sterling K, Halsted JA. The mechanism of hypoproteinemia associated with giant hypertrophy of the gastric mucosa. N Engl J Med. Nov 7 1957;257(19):906-12. [Medline].

  6. Ferrante M, De Hertogh G, Penninckx F, et al. Protein-losing enteropathy in Crohn's disease. Clin Gastroenterol Hepatol. Jun 2005;3(6):A25. [Medline].

  7. Florent C, L'Hirondel C, Desmazures C, et al. Intestinal clearance of alpha 1-antitrypsin. A sensitive method for the detection of protein-losing enteropathy. Gastroenterology. Oct 1981;81(4):777-80. [Medline].

  8. Gordon RS Jr. Exudative enteropathy: abnormal permeability of the gastrointestinal tract demonstrable with labelled polyvinylpyrrolidone. Lancet. Feb 14 1959;1(7068):325-6. [Medline].

  9. Ito R, Sakagami J, Kataoka K, et al. Chronic diarrhea and protein-losing gastroenteropathy caused by Dientamoeba fragilis. J Gastroenterol. Nov 2004;39(11):1117-9. [Medline].

  10. Jeffries GH, Chapman A, Sleisenger MH. Low-fat diet in intestinal lymphagiectasia: its effect on albumin metabolism. N Engl J Med. 1964;270:761-4.

  11. Laine L, Garcia F, McGilligan K, et al. Protein-losing enteropathy and hypoalbuminemia in AIDS. AIDS. Jun 1993;7(6):837-40. [Medline].

  12. Lee YT, Sung JJ. Protein-losing enteropathy. Gastrointest Endosc. Nov 2004;60(5):801-2. [Medline].

  13. Overholt BF, Jeffries GH. Hypertrophic, hypersecretory protein-losing gastropathy. Gastroenterology. Jan 1970;58(1):80-7. [Medline].

  14. Pratz KW, Dingli D, Smyrk TC, et al. Intestinal lymphangiectasia with protein-losing enteropathy in Waldenstrom macroglobulinemia. Medicine (Baltimore). Jul 2007;86(4):210-4. [Medline].

  15. Rybolt AH, Bennett RG, Laughon BE, et al. Protein-losing enteropathy associated with Clostridium difficile infection. Lancet. Jun 17 1989;1(8651):1353-5. [Medline].

  16. Samarkos M, Vaiopoulos G, Andreopoulos A, et al. Association of protein-losing enteropathy and cryoglobulinaemia. Scand J Gastroenterol. Mar 2003;38(3):334-6. [Medline].

  17. Stark ME, Batts KP, Alexander GL. Protein-losing enteropathy with collagenous colitis. Am J Gastroenterol. Jun 1992;87(6):780-3. [Medline].

  18. Venkatesh B, Gough J, Ralston DR, et al. Protein losing enteropathy in critically ill adult patients with burns: a preliminary report. Intensive Care Med. Jan 2004;30(1):162-6. [Medline].

  19. Vyas H, Driscoll DJ, Cetta F, et al. Gastrointestinal bleeding and protein-losing enteropathy after the fontan operation. Am J Cardiol. Sep 1 2006;98(5):666-7. [Medline].

  20. Waldmann TA. Protein-losing gastroenteropathy. Gastroenterology. 1966;50:422.

  21. Waldmann TA, Wochner RD, Strober W. The role of the gastrointestinal tract in plasma protein metabolism. Studies with 51Cr-albumin. Am J Med. Feb 1969;46(2):275-85. [Medline].

  22. Yeaton P, Frierson HF Jr. Octreotide reduces enteral protein losses in Ménétrier's disease. Am J Gastroenterol. Jan 1993;88(1):95-8. [Medline].

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Further Reading

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Keywords

protein losing enteropathy, protein loss, protein deficiency, GI protein loss, gastrointestinal protein loss, protein-losing gastroenteropathy, protein losing gastroenteropathy, gastroenteropathy, gastric protein loss, giant hypertrophic gastropathy, Menetrier disease, Ménétrier disease, loss of plasma proteins from the gastrointestinal tract, excessive leakage of plasma proteins into the lumen of the gastrointestinal tract, lymphatic obstruction, mucosal disease with erosions, ulcerations, swelling of the legs, peripheral edema, decreased plasma oncotic pressure

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Contributor Information and Disclosures

Author

Naeem Aslam, MD, Fellow, Department of Medicine, Division of Gastroenterology/Hepatology, University of Louisville School of Medicine
Naeem Aslam, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Richard Wright, MD, Professor and Chief, Department of Medicine, Division of Gastroenterology/Hepatology, University of Louisville School of Medicine
Richard Wright, MD is a member of the following medical societies: American College of Physician Executives, American College of Physicians, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Terence David Lewis, MBBS, FRACP, FRCPC, FACP, Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center
Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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