eMedicine Specialties > Gastroenterology > Intestine

Protein-Losing Enteropathy

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

Introduction

Background

Protein-losing enteropathy is characterized by the severe loss of serum proteins into the intestine. Normal protein loss in the gastrointestinal tract mainly consists of sloughed enterocytes and pancreatic and biliary secretions. Albumin loss through the gastrointestinal tract normally accounts for 2-15% of the total body degradation of albumin, but, in patients with severe protein-losing gastrointestinal disorders, the enteric protein loss may reach up to 60% of the total albumin pool.

The serum protein level reflects the balance between protein synthesis, metabolism, and protein loss. Protein-losing enteropathy is characterized by more loss of proteins via the gastrointestinal tract than synthesis leading to hypoalbuminemia. It is not a single disease, but an atypical manifestation of other diseases.

Pathophysiology

The pathophysiology of this disorder is directly related to the excessive leakage of plasma proteins into the lumen of the gastrointestinal tract. Mechanisms for gastrointestinal protein loss include lymphatic obstruction, mucosal disease with erosions, ulcerations, or increased mucosal permeability to proteins as a result of cell damage or death. Proteins entering the gastrointestinal tract are metabolized into constituent amino acids by gastric, pancreatic, and small intestinal enzymes and are reabsorbed. When the rate of gastrointestinal protein loss exceeds the body's capacity to synthesize new proteins, hypoproteinemia develops. 

Frequency

United States

The prevalence rate is not known.

International

The prevalence rate is not known.

Mortality/Morbidity

Morbidity and mortality of this condition directly relate to its cause, either primary gastrointestinal disease or a multisystem disorder.

Race

No racial predilection exists.

Sex

No sex predilection exists.

Age

No age predilection exists.

Clinical

History

  • The most common presenting symptom is swelling of the legs or other areas due to peripheral edema secondary to decreased plasma oncotic pressure, with subsequent transudation of fluid from the capillary bed to the subcutaneous tissue.
  • If the protein-losing gastroenteropathy is related to other systemic diseases (eg, congestive heart failure, constrictive pericarditis, connective-tissue disease, amyloidosis, protein dyscrasias), the clinical presentation may be that of the primary disease process.
  • Patients with primary gastrointestinal disease present with diarrhea with or without bleeding, abdominal pain, and/or weight loss.
  • Along with a loss of proteins, a significant loss of immunoglobulins and lymphocytes can also occur. This may lead to the development of an immunological deficiency, predisposing to infections.

Physical

  • Physical examination reveals peripheral edema and, in rare cases, anasarca.
  • Evidence of the underlying medical problem (eg, cardiac disease, amyloidosis) may exist.
  • If a primary gastrointestinal etiology exists, the abdominal examination findings may be unremarkable. Hepatosplenomegaly may be present, depending on the underlying process.

Causes

  • Primary gastrointestinal mucosal diseases (typically ulcerative/erosive) include the following:
    • Erosions or ulcerations of the esophagus, stomach, or duodenum
    • Regional enteritis
    • Graft versus host disease
    • Pseudomembranous colitis (Clostridium difficile)
    • Mucosal-based neoplasia
    • Carcinoid syndrome
    • Idiopathic ulcerative jejunoileitis
    • Amyloidosis
    • Kaposi sarcoma
    • Protein dyscrasia
    • Ulcerative colitis
    • Neurofibromatosis
    • Cytomegalovirus infection
  • Increased interstitial pressure or lymphatic obstruction leading to protein loss can be caused by the following:
    • Tuberculosis
    • Sarcoidosis
    • Retroperitoneal fibrosis
    • Lymphoma
    • Intestinal endometriosis
    • Lymphoenteric fistula
    • Whipple disease
    • Cardiac disease (constrictive pericarditis or congestive heart failure)
    • Intestinal lymphangiectasia
  • Nonerosive upper gastrointestinal diseases include the following:
    • Cutaneous burns
    • Whipple disease
    • Connective tissue disorders
    • Acquired immunodeficiency syndrome (AIDS)
    • Enteropathy, such as angioedema (idiopathic or hereditary) and Henoch-Schönlein purpura
    • Celiac sprue
    • Tropical sprue
    • Allergic gastroenteritis
    • Eosinophilic gastroenteritis
    • Giant hypertrophic gastritis (Ménétrier disease)
    • Bacterial overgrowth
    • Intestinal parasites
    • Microscopic colitis
    • Dientamoeba fragilis

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

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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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