Malabsorption Clinical Presentation

Updated: Jan 24, 2019
  • Author: Muhammad Bader Hammami, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Presentation

History

Malabsorption can present in a variety of ways, depending on the cause, nature, and severity of the underlying disorder.

The osmotic load resulting from the inability of the intestine to absorb certain nutrient elements causes the presenting symptoms. On occasion, the products of digestion produced by bacterial flora also result in a secretory reaction by the intestine.

Diarrhea

Diarrhea is the most common symptomatic complaint. [4, 5, 6, 7, 8]  It is frequently is watery, reflecting the osmotic load received by the intestine. Bacterial action producing hydroxy fatty acids from undigested fat also can increase the net fluid secretion from the intestine, further worsening the diarrhea.

Steatorrhea

Steatorrhea is the result of fat malabsorption. The hallmark of steatorrhea is the passage of pale, bulky, and malodorous stools. Such stools often float on top of the toilet water and are difficult to flush. Also, patients often find floating oil droplets in the toilet following defecation.

Weight loss and fatigue

Weight loss is common and may be pronounced; however, patients may compensate by increasing their caloric consumption, masking weight loss from malabsorption. The chance of weight loss increases in diffuse diseases involving the intestine, such as celiac disease and Whipple disease.

Flatulence and abdominal distention

Bacterial fermentation of unabsorbed food substances releases gaseous products, such as hydrogen and methane, causing flatulence. Flatulence often results in uncomfortable abdominal distention and cramps.

Edema

Hypoalbuminemia from chronic protein malabsorption or from protein loss into the intestinal lumen causes peripheral edema. Extensive obstruction of the lymphatic system, as seen in intestinal lymphangiectasia, can result in protein loss.

With severe protein depletion, ascites may develop.

Anemia

Depending on the cause, anemia resulting from malabsorption can be either microcytic (iron deficiency) or macrocytic (vitamin B12/cobalamin deficiency). [9]  

Iron deficiency anemia often is a manifestation of celiac disease. [10]  Ileal involvement in Crohn disease or ileal resection can cause megaloblastic anemia due to vitamin B12 deficiency.

Bleeding disorders

Bleeding usually is a consequence of vitamin K malabsorption and subsequent hypoprothrombinemia. Ecchymosis usually is the manifesting feature, although occasionally, melena and hematuria occur.

Metabolic defects of bones

Vitamin D deficiency can cause bone disorders, such as osteopenia or osteomalacia. Bone pain and pathologic fractures may be observed.

Malabsorption of calcium can lead to secondary hyperparathyroidism.

Neurologic manifestations

Electrolyte disturbances, such as hypocalcemia and hypomagnesemia, can lead to tetany, manifesting as the Trousseau sign and/or the Chvostek sign.

Vitamin malabsorption can cause generalized motor weakness (vitamin B5/pantothenic acid, vitamin D) or peripheral neuropathy (vitamin B1/thiamine), a sense of loss for vibration and position (vitamin B12/cobalamin), night blindness (vitamin A), and seizures (vitamin B7/biotin).

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Physical Examination

General physical examination

Patients may have orthostatic hypotension, complain of fatigue, and/or have signs of loss of subcutaneous fat.

Signs of weight loss, muscle wasting, or both may be present.

Abdominal examination

The abdomen may be distended, and bowel sounds may be hyperactive.

Ascites may be present in severe hypoproteinemia.

Dermatologic manifestations

Pale skin may reveal anemia. The following may also be present:

  • Ecchymoses due to vitamin K deficiency
  • Dermatitis herpetiformis, erythema nodosum, and pyoderma gangrenosum
  • Pellagra, alopecia, or seborrheic dermatitis

Neurologic examination

Motor weakness, peripheral neuropathy, or ataxia may be present.

The Chvostek sign or the Trousseau sign may be evident due to hypocalcemia or hypomagnesemia.

Other findings

Cheilosis, glossitis, or aphthous ulcers of the mouth

Peripheral edema

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