eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Malabsorption Syndromes: Treatment & Medication

Author: Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of Gastroenterology, Hepatology and Nutrition; Professor, Department of Pediatrics, University of Chicago Comer Children's Hospital
Coauthor(s): Richard E Frye, MD, PhD, Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Health Science Center at Houston; M Akram Tamer, MD, Program Director, Professor, Department of Pediatrics, University of Miami
Contributor Information and Disclosures

Updated: Oct 23, 2009

Treatment

Medical Care

  • Clearly, treatment of malabsorption syndromes depends on the specific entity being considered and thus widely varies.
  • Although several new possibilities of gluten predigestion and detoxification and ways of increasing intestinal barrier tightness to gluten penetration are currently under active investigation and offer promising results, the only current therapeutic option for celiac disease remains the gluten-free diet, which is a diet completely devoid of wheat, barley, and rye (see Celiac Disease).10,11
  • Chronic diarrhea due to proximal small bowel bacterial overgrowth is treated with oral broad-spectrum antibiotics, particularly those with anaerobic coverage (eg, metronidazole).12 More recently, rifaximin has also been found to be very effective in adults.13 Because this entity often occurs in individuals who have an anatomic or functional predisposition (eg, short gut, motility disorders), repeated courses are typically needed.
  • In children with chronic diarrhea secondary to bile acid malabsorption, the use of cholestyramine (Questran) to bind bile acids may help to reduce the duration and severity of the diarrhea.
  • Any loss of pancreatic enzymes can be replaced with oral supplements.
  • Immunosuppressive medications can be used to control autoimmune enteropathy and should be prescribed only by a specialist.
  • Children with malabsorption secondary to food allergic enteropathy need to be on an elimination diet, avoiding offending food antigens. Their identification is often the result of empiric trials because food allergic enteropathies cannot be diagnosed by immunoglobulin E (IgE) measurement, either by radioallergosorbent assay test (RAST) or skin prick tests.

Surgical Care

  • Most children with short gut syndrome are eventually weaned off parenteral nutrition and do not require surgery. However, in some children, disease is refractory to enteral feeding, and other children develop end-stage liver disease from the prolonged supplementation of parenteral nutrition. Consider liver, gut, or multivisceral transplantation in these children.

Consultations

  • In children in whom a malabsorption syndrome is suspected to cause growth failure or is associated with high morbidity, prompt referral to a pediatric gastroenterologist is recommended.

Diet

  • Carbohydrate intolerance
    • Initiate treatment in patients with severe acquired carbohydrate intolerance by eliminating all dietary carbohydrates until the diarrhea is resolved. Then, slowly reintroduce carbohydrates.
    • In infants, use a glucose polymer (Polycose)–based formula (eg, Pregestimil). In patients with the most severe carbohydrate intolerance, use MJ3232A, a casein-based formula that contains essential amino acids and medium-chain triglyceride (MCT) oil and no carbohydrates. If MJ3232A is used, parenteral dextrose must be supplied.
    • Once the diarrhea has resolved, slowly reintroduce fructose into the diet as the only enteral carbohydrate source.
    • Begin with 14 g fructose/L formula, and gradually advance in 14-g increments to a maximum of 56 g fructose/L formula. Once this goal is reached, slowly replace fructose with Polycose until 56 g Polycose/L formula is tolerated. Once 56 g Polycose/L formula is tolerated, begin introducing Pregestimil, a lactose-free formula.
    • For older children, eliminate simple carbohydrates and lactose from the diet until the diarrhea is resolved. Simple sugars, including fruit juices, should be avoided for several weeks.
    • If after several weeks of a relatively carbohydrate-free diet symptoms return when carbohydrates are reintroduced, the child most likely has a congenital defect in carbohydrate transport or digestion.
  • Fat intolerance
    • MCT oil is used to treat patients with poor weight gain that results from fat malabsorption. MCT oil does not require traditional fat metabolism and, thus, is more easily absorbed directly into the enterocyte and is transported through the portal vein to the liver.
    • Fat-soluble vitamin supplements are required for patients with fat malabsorption or short gut syndrome.
    • Supplements in patients with fat malabsorption should also include linoleic and linolenic fatty acids.
    • Patients with short gut syndrome may not be able to effectively absorb formula until mucosal hyperplasia has increased the mucosal absorption area. During this period of adaptation, appropriate parenteral nutrition may be needed to maintain optimal nutritional status.
  • Alternative formulas
    • Currently, soy formulas are not considered effective for the prevention or treatment of nutritional allergies. Instead, use hydrolyzed protein formulas.
    • High-degree protein hydrolysate formulas are used to treat infants with a cow's milk allergy, but these formulas may contain residual epitopes capable of provoking a severe allergic reaction. In these infants, use formulas with crystalline amino acids (eg, Neocate, EleCare, EO28) as the protein source.

Medication

Digestive enzymes

Pancreatic enzyme deficiency may occur because of steatorrhea secondary to malabsorption.


Pancrelipase (Ultrase, Pancrease, Creon)

Assists in digestion of protein, starch, and fat. Contains lipase, protease, and amylase.

Adult

Pediatric

Adjust dose according to severity of pancreatic enzyme deficiency and fat content of stools 500-1500 U/kg (based on lipase content) enteric-coated tab per meal; not to exceed 2500 IU/kg/dose, because colitis with strictures (fibrosing colonopathy) may occur at higher doses

Drugs that increase gastric pH (eg, H2 antagonists) may increase effects of pancreatic enzymes by inhibiting destruction of ingested pancreatic enzymes

Documented hypersensitivity; history of pork protein allergy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

High doses may be associated with fibrosing colonopathy, which has been evident in patients with cystic fibrosis who developed ascending colon strictures; enzyme products widely vary (do not interchange once stabilized)

Bile acid–binding agents

These agents are used in combination with antibiotics for bile acid malabsorption syndromes. Bacteria overgrowth may cause diarrhea by deconjugation and dehydroxylation of bile acids. Primary bile acid malabsorption may also occur.


Cholestyramine (Questran)

Binds bile acids, thus reducing damage to the intestinal mucosa. Also reduces induction of colonic fluid secretion. Forms a nonabsorbable complex with bile acids in the intestine, which in turn inhibits enterohepatic reuptake of intestinal bile salts.

Adult

Pediatric

2-4 g/d PO divided bid/qid for 8-10 d

Inhibits absorption of numerous drugs including warfarin, thyroid hormone, amiodarone, NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, phenobarbital, imipramine, niacin, methyldopa, tetracyclines, clofibrate, hydrocortisone, penicillin G, and fat-soluble vitamins

Documented hypersensitivity; biliary obstruction; neonates with history of structural intestinal abnormalities, abdominal surgery, or necrotizing enterocolitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution if constipation exists; avoid aspartame-containing cholestyramine with phenylketonuria; cholestyramine products containing added carbohydrates (ie, fructose, sorbitol) for flavoring (eg, LoCholest) may exacerbate diarrhea and should be avoided

Antibiotics

Metronidazole may be considered and provides anaerobic coverage. Although the use of rifaximin in children for the indication of small intestinal bacterial overgrowth is not US Food and Drug Administration (FDA)-approved, this antibiotic is virtually nonabsorbed (<0.4%) and has been proven useful in the treatment of small intestinal bacterial overgrowth in adults.


Metronidazole (Flagyl)

DOC for documented small bowel bacterial overgrowth. Provides good anaerobic coverage.

Adult

500 mg PO bid/tid

Pediatric

10-20 mg/kg/d PO divided bid/tid

May increase toxicity of anticoagulants, cyclosporine, lithium, phenytoin, tacrolimus, and carbamazepine; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol; coadministration increases amiodarone toxicity (QT prolongation); increases disulfiram toxicity (psychotic symptoms) with concurrent use; phenobarbital and rifampin may increase metabolism of metronidazole

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with liver impairment, blood dyscrasias, CNS disease; reduce dosage with severe hepatic disease; monitor for seizures and development of peripheral neuropathy


Rifaximin (Xifaxan)

Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie, Gram-positive, Gram-negative, aerobic and anaerobic). Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea.

Adult

1200 mg/d PO divided tid/qid

Pediatric

<12 years: Not established; suggested dose for children is 10-30 mg/kg/d PO divided tid/qid

Induces CYP450 3A4 in vitro; limited data exist; no significant interactions shown in single dose studies with midazolam and oral contraceptives

Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May promote intestinal bacterial overgrowth and cause superinfection; discontinue if diarrhea persists more than 24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge (tablets not effective); not effective for travelers' diarrhea due to suspected pathogens other than E coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and pruritus

More on Malabsorption Syndromes

Overview: Malabsorption Syndromes
Differential Diagnoses & Workup: Malabsorption Syndromes
Treatment & Medication: Malabsorption Syndromes
Follow-up: Malabsorption Syndromes
Multimedia: Malabsorption Syndromes
References
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References

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Further Reading

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Keywords

malabsorption syndromes, carbohydrate intolerance, chronic diarrhea of infancy, abdominal distention, failure to thrive, intestinal hydrolysis, creatorrhea, monosaccharide intolerance, steatorrhea, protein malabsorption, cystic fibrosis, Shwachman-Diamond syndrome, congenital lactase deficiency, amylase deficiency, adult-type hypolactasia, lactose intolerance, enteritis, mucosal atrophy, enterokinase deficiency, milk protein allergy enteropathy, steatorrhea, soy milk protein allergy, malnutrition, Giardia infections, abdominal pain, inflammatory bowel disease, borborygmi, protein sensitivity, pancreatic insufficiency, pancreatitis, pancreatic cancer, pancreatic resection, Johnson-Blizzard syndrome, Pearson syndrome, abetalipoproteinemia, protein-losing enteropathy, congenital enterokinase deficiency, Crohn disease

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Contributor Information and Disclosures

Author

Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of Gastroenterology, Hepatology and Nutrition; Professor, Department of Pediatrics, University of Chicago Comer Children's Hospital
Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Richard E Frye, MD, PhD, Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Health Science Center at Houston
Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and International Neuropsychological Society
Disclosure: Nothing to disclose.

M Akram Tamer, MD, Program Director, Professor, Department of Pediatrics, University of Miami
M Akram Tamer, MD is a member of the following medical societies: American Medical Association and Florida Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Alan D Schmetzer, MD, Professor and Vice-Chair for Education, Director of Residency Training, Department of Psychiatry, Indiana University School of Medicine
Alan D Schmetzer, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Society of Transplant Surgeons, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

B UK Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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