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__NOTOC__
!style="background:#eed; padding:0.3em; text-align:center;"|Alternative names
{{Malabsorption}}
{{CMG}}; {{AE}} {{SSH}}
 
==[[Malabsorption overview|Overview]]==
Malabsorption is a condition which is associated with impaired [[absorption]] of one or all dietary [[Nutrient|nutrients]]. There are multiple etiologies with diminished [[Intestine|intestinal]] [[absorption]]. Many of them present with [[diarrhea]], especially [[steatorrhea]]. They might have malabsorption of [[Carbohydrate|carbohydrates]], [[fat]], [[protein]], [[Vitamin|vitamins]], and/or [[Mineral|minerals]]. Malabsorption is occurred following [[Intestine|intestinal]] [[Mucous membrane|mucosal]] or structural defects. Malabsorption according to etiology may be classified into five main groups including [[infection]], structural defect, [[Digestive system|digestive]] failure, systemic disease, and [[Iatrogenesis|iatrogenic]] causes. Different workups might be used to differentiate diagnosis of malabsorption including [[Small intestine|small bowel]] [[biopsy]], [[Stool examination|stool exam]], breath testings, lab findings, and imagings.
 
==[[Malabsorption classification|Classification]]==
Malabsorption according to etiology may be classified into five main groups:<ref name="pmid23179329">{{cite journal |vauthors=Papadia C, Di Sabatino A, Corazza GR, Forbes A |title=Diagnosing small bowel malabsorption: a review |journal=Intern Emerg Med |volume=9 |issue=1 |pages=3–8 |year=2014 |pmid=23179329 |doi=10.1007/s11739-012-0877-7 |url=}}</ref><ref name="pmid11036541">{{cite journal |vauthors=Freeman HJ |title=Small intestinal mucosal biopsy for investigation of diarrhea and malabsorption in adults |journal=Gastrointest. Endosc. Clin. N. Am. |volume=10 |issue=4 |pages=739–53, vii |year=2000 |pmid=11036541 |doi= |url=}}</ref>
{| class="wikitable"
! colspan="2" |Malabsorption classification
|-
| colspan="2" align="left" style="background:#4479BA; color: #FFFFFF;" |Infection
|-
|[[Virus|Viral]]
|[[Human Immunodeficiency Virus (HIV)|HIV]]
|-
| rowspan="4" |[[Bacteria|Bacterial]]
|[[Tuberculosis]]
|-
|[[Tropical sprue]]
|-
|[[Whipple's disease]]
|-
|[[Small intestinal bacterial overgrowth syndrome]]
|-
| rowspan="2" |[[Parasitism|Parasitic]]
|[[Giardia lamblia|Giardia]]
|-
|[[Isospora]]
|-
| colspan="2" align="left" style="background:#4479BA; color: #FFFFFF;" |Structural or enzyme defect
|-
| colspan="2" |[[Blind loop syndrome]]
|-
| colspan="2" |[[Fistula]]
|-
| colspan="2" |[[Diverticular|Diverticula]]
|-
| colspan="2" |[[Stenosis|Stricture]]
|-
| colspan="2" |[[Lactose intolerance|Lactase deficiency]]
|-
| colspan="2" align="left" style="background:#4479BA; color: #FFFFFF;" |Digestive failure
|-
| rowspan="3" |[[Pancreatic insufficiency]]
|[[Cystic fibrosis]]
|-
|[[Chronic pancreatitis]]
|-
|[[Pancreatic cancer]]
|-
| colspan="2" |[[Zollinger-Ellison syndrome|Zollinger–Ellison syndrome]]
|-
| colspan="2" |[[VIPoma]]
|-
| colspan="2" |[[Carcinoid syndrome]]
|-
| colspan="2" |[[Bile acid malabsorption]]
|-
| colspan="2" align="left" style="background:#4479BA; color: #FFFFFF;" |Systemic disease
|-
| colspan="2" |[[Celiac disease]]
|-
| rowspan="2" |[[Inflammatory bowel disease]]
|[[Crohn's disease]]
|-
|[[Ulcerative colitis]]
|-
| rowspan="3" |Infiltrative disorders
|[[Amyloidosis]]
|-
|[[Lymphoma]]
|-
|[[Eosinophilic gastroenteritis]]
|-
| rowspan="6" |[[Endocrine system|Endocrine]] abnormalities
|[[Diabetes mellitus]]
|-
|[[Hypothyroidism]]
|-
|[[Hyperthyroidism]]
|-
|[[Hyperparathyroidism]]
|-
|[[Hypoparathyroidism]]
|-
|[[Addison's disease]]
|-
| rowspan="2" |[[Immunologic adjuvant|Immunologic]] disorders
|[[Common variable immunodeficiency]]
|-
|[[Abetalipoproteinemia]]
|-
| colspan="2" align="left" style="background:#4479BA; color: #FFFFFF;" |Iatrogenic
|-
| colspan="2" |[[Medication]]
|-
| colspan="2" |[[Radiation therapy|Radiation]]
|-
|-
|Malabsorption syndrome
| rowspan="3" |Post [[surgery]]
Malabsorption syndrome (disorder)
|[[Gastrectomy]]
|-
|-
|style="padding:0.1em; font-size:0.9em; background-color:#eed;"|'''Subordinate terms'''
|[[Bariatric surgery]]
|-
|-
|Intestinal malabsorption
|[[Short bowel syndrome]]
|}
|}
{{Infobox_Disease
| Name          = {{PAGENAME}}
| Image          = whipple2.jpg
| Caption        =[[Whipple's disease]]: Alcian blue with apparently [[eosin]] counterstain enlarged [[villus]] with many [[macrophages]]
| DiseasesDB    = 7698
| ICD10          = ({{ICD10|K|90||k|90}})
| ICD9          = {{ICD9|579}}
| ICDO          =
| OMIM          =
| MedlinePlus    = 000299
| eMedicineSubj  = med
| eMedicineTopic = 1384
| MeshID        =
}}
{{Search infobox}}
{{CMG}}


{{Editor Help}}
==[[Malabsorption differential diagnosis|Differentiating malabsorption  from other Diseases]]==
'''''To review the differential diagnosis of diarrhea, click [[Diarrhea#Differential Diagnosis of Diarrhea of other diseases|here]].'''''


'''''Synonyms and keywords:''''' Malabsorption syndrome
'''The following table outlines the major differential diagnoses of malabsorption.'''<ref name="Casburn-JonesFarthing2004">{{cite journal|last1=Casburn-Jones|first1=Anna C|last2=Farthing|first2=Michael Jg|title=Traveler's diarrhea|journal=Journal of Gastroenterology and Hepatology|volume=19|issue=6|year=2004|pages=610–618|issn=0815-9319|doi=10.1111/j.1440-1746.2003.03287.x}}</ref><ref name="KamatMathur2006">{{cite journal|last1=Kamat|first1=Deepak|last2=Mathur|first2=Ambika|title=Prevention and Management of Travelers’ Diarrhea|journal=Disease-a-Month|volume=52|issue=7|year=2006|pages=289–302|issn=00115029|doi=10.1016/j.disamonth.2006.08.003}}</ref><ref name="PfeifferDuPont2012">{{cite journal|last1=Pfeiffer|first1=Margaret L.|last2=DuPont|first2=Herbert L.|last3=Ochoa|first3=Theresa J.|title=The patient presenting with acute dysentery – A systematic review|journal=Journal of Infection|volume=64|issue=4|year=2012|pages=374–386|issn=01634453|doi=10.1016/j.jinf.2012.01.006}}</ref><ref name="pmid24506120">{{cite journal |vauthors=Barr W, Smith A |title=Acute diarrhea |journal=Am Fam Physician |volume=89 |issue=3 |pages=180–9 |year=2014 |pmid=24506120 |doi= |url=}}</ref><ref name="pmid29255768">{{cite journal |vauthors=Amil Dias J |title=Celiac Disease: What Do We Know in 2017? |journal=GE Port J Gastroenterol |volume=24 |issue=6 |pages=275–278 |year=2017 |pmid=29255768 |doi=10.1159/000479881 |url=}}</ref><ref name="pmid29254859">{{cite journal |vauthors=Kotloff KL, Riddle MS, Platts-Mills JA, Pavlinac P, Zaidi AKM |title=Shigellosis |journal=Lancet |volume= |issue= |pages= |year=2017 |pmid=29254859 |doi=10.1016/S0140-6736(17)33296-8 |url=}}</ref><ref name="Yamamoto-FurushoBosques-Padilla2017">{{cite journal|last1=Yamamoto-Furusho|first1=J.K.|last2=Bosques-Padilla|first2=F.|last3=de-Paula|first3=J.|last4=Galiano|first4=M.T.|last5=Ibañez|first5=P.|last6=Juliao|first6=F.|last7=Kotze|first7=P.G.|last8=Rocha|first8=J.L.|last9=Steinwurz|first9=F.|last10=Veitia|first10=G.|last11=Zaltman|first11=C.|title=Diagnóstico y tratamiento de la enfermedad inflamatoria intestinal: Primer Consenso Latinoamericano de la Pan American Crohn's and Colitis Organisation|journal=Revista de Gastroenterología de México|volume=82|issue=1|year=2017|pages=46–84|issn=03750906|doi=10.1016/j.rgmx.2016.07.003}}</ref><ref name="BorbélyOsterwalder2017">{{cite journal|last1=Borbély|first1=Yves M|last2=Osterwalder|first2=Alice|last3=Kröll|first3=Dino|last4=Nett|first4=Philipp C|last5=Inglin|first5=Roman A|title=Diarrhea after bariatric procedures: Diagnosis and therapy|journal=World Journal of Gastroenterology|volume=23|issue=26|year=2017|pages=4689|issn=1007-9327|doi=10.3748/wjg.v23.i26.4689}}</ref><ref name="CrawfordRamani2017">{{cite journal|last1=Crawford|first1=Sue E.|last2=Ramani|first2=Sasirekha|last3=Tate|first3=Jacqueline E.|last4=Parashar|first4=Umesh D.|last5=Svensson|first5=Lennart|last6=Hagbom|first6=Marie|last7=Franco|first7=Manuel A.|last8=Greenberg|first8=Harry B.|last9=O'Ryan|first9=Miguel|last10=Kang|first10=Gagandeep|last11=Desselberger|first11=Ulrich|last12=Estes|first12=Mary K.|title=Rotavirus infection|journal=Nature Reviews Disease Primers|volume=3|year=2017|pages=17083|issn=2056-676X|doi=10.1038/nrdp.2017.83}}</ref><ref name="pmid11068510">{{cite journal |vauthors=Kist M |title=[Chronic diarrhea: value of microbiology in diagnosis] |language=German |journal=Praxis (Bern 1994) |volume=89 |issue=39 |pages=1559–65 |year=2000 |pmid=11068510 |doi= |url=}}</ref><ref name="pmid4014291">{{cite journal |vauthors=Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH |title=Evaluation and diagnosis of acute infectious diarrhea |journal=Am. J. Med. |volume=78 |issue=6B |pages=91–8 |year=1985 |pmid=4014291 |doi= |url=}}</ref><ref name="pmid10575169">{{cite journal |vauthors=López-Vélez R, Turrientes MC, Garrón C, Montilla P, Navajas R, Fenoy S, del Aguila C |title=Microsporidiosis in travelers with diarrhea from the tropics |journal=J Travel Med |volume=6 |issue=4 |pages=223–7 |year=1999 |pmid=10575169 |doi= |url=}}</ref><ref name="WahnschaffeIgnatius2009">{{cite journal|last1=Wahnschaffe|first1=Ulrich|last2=Ignatius|first2=Ralf|last3=Loddenkemper|first3=Christoph|last4=Liesenfeld|first4=Oliver|last5=Muehlen|first5=Marion|last6=Jelinek|first6=Thomas|last7=Burchard|first7=Gerd Dieter|last8=Weinke|first8=Thomas|last9=Harms|first9=Gundel|last10=Stein|first10=Harald|last11=Zeitz|first11=Martin|last12=Ullrich|first12=Reiner|last13=Schneider|first13=Thomas|title=Diagnostic value of endoscopy for the diagnosis of giardiasis and other intestinal diseases in patients with persistent diarrhea from tropical or subtropical areas|journal=Scandinavian Journal of Gastroenterology|volume=42|issue=3|year=2009|pages=391–396|issn=0036-5521|doi=10.1080/00365520600881193}}</ref><ref name="pmid27765536">{{cite journal |vauthors=Mena Bares LM, Carmona Asenjo E, García Sánchez MV, Moreno Ortega E, Maza Muret FR, Guiote Moreno MV, Santos Bueno AM, Iglesias Flores E, Benítez Cantero JM, Vallejo Casas JA |title=75SeHCAT scan in bile acid malabsorption in chronic diarrhoea |journal=Rev Esp Med Nucl Imagen Mol |volume=36 |issue=1 |pages=37–47 |year=2017 |pmid=27765536 |doi=10.1016/j.remn.2016.08.005 |url=}}</ref><ref name="pmid19365159">{{cite journal |vauthors=Gibson RJ, Stringer AM |title=Chemotherapy-induced diarrhoea |journal=Curr Opin Support Palliat Care |volume=3 |issue=1 |pages=31–5 |year=2009 |pmid=19365159 |doi=10.1097/SPC.0b013e32832531bb |url=}}</ref><ref name="pmid23384808">{{cite journal |vauthors=Abraham BP, Sellin JH |title=Drug-induced, factitious, & idiopathic diarrhoea |journal=Best Pract Res Clin Gastroenterol |volume=26 |issue=5 |pages=633–48 |year=2012 |pmid=23384808 |doi=10.1016/j.bpg.2012.11.007 |url=}}</ref><ref name="pmid25692805">{{cite journal |vauthors=Reintam Blaser A, Deane AM, Fruhwald S |title=Diarrhoea in the critically ill |journal=Curr Opin Crit Care |volume=21 |issue=2 |pages=142–53 |year=2015 |pmid=25692805 |doi=10.1097/MCC.0000000000000188 |url=}}</ref><ref name="pmid17373914">{{cite journal |vauthors=McMahan ZH, DuPont HL |title=Review article: the history of acute infectious diarrhoea management--from poorly focused empiricism to fluid therapy and modern pharmacotherapy |journal=Aliment. Pharmacol. Ther. |volume=25 |issue=7 |pages=759–69 |year=2007 |pmid=17373914 |doi=10.1111/j.1365-2036.2007.03261.x |url=}}</ref><ref name="pmid23384801">{{cite journal |vauthors=Schiller LR |title=Definitions, pathophysiology, and evaluation of chronic diarrhoea |journal=Best Pract Res Clin Gastroenterol |volume=26 |issue=5 |pages=551–62 |year=2012 |pmid=23384801 |doi=10.1016/j.bpg.2012.11.011 |url=}}</ref><ref name="pmid3523719">{{cite journal |vauthors=Giannella RA |title=Chronic diarrhea in travelers: diagnostic and therapeutic considerations |journal=Rev. Infect. 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==Overview==
{| class="wikitable" style="border: 0px; font-size: 100%; margin: 3px;" align="center"
! colspan="2" rowspan="5" style="background:#4479BA; color: #FFFFFF;" align="center" |Categories
! colspan="2" rowspan="5" style="background:#4479BA; color: #FFFFFF;" align="center" |Cause
| colspan="9" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Clinical manifestation'''
! colspan="4" rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Lab findings'''
|-
! colspan="8" style="background:#4479BA; color: #FFFFFF;" align="center" |Symptoms
! rowspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" |Findings
|-
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Duration
! colspan="3" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal pain
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
|-
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Stool exam
| colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |'''CBC'''
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" |Acute
! style="background:#4479BA; color: #FFFFFF;" align="center" |Chronic
! style="background:#4479BA; color: #FFFFFF;" align="center" |Watery
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bloody
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fatty
! style="background:#4479BA; color: #FFFFFF;" align="center" |WBC
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hgb
! style="background:#4479BA; color: #FFFFFF;" align="center" |Plt
|-
! colspan="2" rowspan="9" style="background:#4479BA; color: #FFFFFF;" align="center" |Gastrointestinal
! colspan="2" style="background:#DCDCDC;" align="center" |[[Crohns disease|Crohn's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness]]
* Oral [[mucosal]] lesions
* [[Uveitis]]
* [[Arthritis]]
* [[Erythema nodosum]]
* [[Pyoderma gangrenosum]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[White blood cells|WBC]] +
[[Red blood cell|RBC]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Ulcerative colitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness]]
* [[Blood]] on [[rectal examination]]
* [[Skin rash]]
* [[Iritis]]
* [[Uveitis]]
* Seronegative [[arthritis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[White blood cells|WBC]] +
[[Red blood cell|RBC]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Celiac disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal distention]]
* Increased [[bowel]] sounds
* Oral [[Mucous membrane|mucosal]] lesions
* [[Hepatosplenomegaly]]
* [[Ascites]]
* [[Dementia]]
* [[Dermatitis herpetiformis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Fat droplets on [[sudan stain]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Cause
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Duration
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal pain
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Findings
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Stool exam
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |CBC
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" |Acute
! style="background:#4479BA; color: #FFFFFF;" align="center" |Chronic
! style="background:#4479BA; color: #FFFFFF;" align="center" |Watery
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bloody
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fatty
! style="background:#4479BA; color: #FFFFFF;" align="center" |WBC
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hgb
! style="background:#4479BA; color: #FFFFFF;" align="center" |Plt
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Cystic fibrosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Abdominal distension|Abdominal distention]]
*[[Hepatosplenomegaly]]
*[[Rectal prolapse]]
*Recurrent [[respiratory tract infection]]
* [[Bronchiectasis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Fat droplets on [[sudan stain]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Chronic pancreatitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Tenderness (medicine)|Abdominal tenderness]]
* [[Pancreatic pseudocyst]]
* [[Diabetes mellitus]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Fat droplets on [[sudan stain]]
Fecal elastase +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Bile acid malabsorption]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*[[Malabsorption]]
*[[Hypotension]]
*[[Tachycardia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Fat droplets on [[sudan stain]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Lactose intolerance]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness ]]
* [[Abdominal distention]]
* [[Abdominal distention|Headache]]
* [[Abdominal distention|Vertigo]]
* [[Abdominal distention|Memory impairment]]
* [[Abdominal distention|Lethargy]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! rowspan="10" style="background:#4479BA; color: #FFFFFF;" align="center" |Infection
! rowspan="7" style="background:#4479BA; color: #FFFFFF;" align="center" |Bacterial
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Cause
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Duration
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal pain
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Findings
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Stool exam
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |CBC
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" |Acute
! style="background:#4479BA; color: #FFFFFF;" align="center" |Chronic
! style="background:#4479BA; color: #FFFFFF;" align="center" |Watery
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bloody
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fatty
! style="background:#4479BA; color: #FFFFFF;" align="center" |WBC
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hgb
! style="background:#4479BA; color: #FFFFFF;" align="center" |Plt
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Whipple's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hepatosplenomegaly]]
* [[Ascites]]
* [[Ocular motility disorders|Abnormal extraocular movement]]
* [[Lymphadenopathy]]
* [[Hyperpigmentation]]
* [[Uveitis]]
* [[Endocarditis]]
* [[Encephalitis]]
* [[Dementia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Fecal fat]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓/↑
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Tropical sprue]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Angular [[stomatitis]]
* Oral mucosal lesion
* [[Myalgia]]
*[[Neuropathy]]
*[[Edema]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[White blood cells|WBC]] +


'''Malabsorption''' is a state arising from abnormality in [[digestion]] or [[absorption]] of [[Nutrient|food nutrients]] across the [[gastrointestinal tract|gastrointestinal(GI) tract]].
[[Stool culture]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Small bowel bacterial overgrowth syndrome|Small bowel bacterial overgrowth]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal distension|Abdominal distention]]
* [[Rosacea]] 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[White blood cells|WBC]] +


Impairment can be of single or multiple nutrients depending on the abnormality. This may lead to [[malnutrition]] and variety of [[anemia|anaemias]]<ref>{{cite web | last =  Jensen | first = Jonathan E  |title=Malabsorption Syndromes - Page 1| publisher =Colorado center for digestive disorders|url=http://www.gastromd.com/education/malabsorptionsyndromes.html  |accessdate=2007-05-10 |format= |work=}}</ref>.
[[Stool culture]] +


Some  prefer to classify malabsorption clinically into three basic categories<ref>Gasbarrini G,  Frisono M: Critical evaluation of malabsorption tests; in {{cite book |author=G. Dobrilla, G. Bertaccini, G. Langman (Editor) |title=Problems and Controversies in Gastroenterology |publisher=Raven Pr |location= New York |year= 1986 |pages= 123-130|isbn=88-85037-75-5 |oclc= |doi=}}</ref>:  
[[Fecal fat]] +
:(1) '''selective''', as seen in lactose malabsorption;  
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
:(2) '''partial''', as observed in a-Beta-lipoproteinemia, and
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
:(3) '''total''' as in celiac disease.
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Cause
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Duration
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal pain
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Findings
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Stool exam
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |CBC
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" |Acute
! style="background:#4479BA; color: #FFFFFF;" align="center" |Chronic
! style="background:#4479BA; color: #FFFFFF;" align="center" |Watery
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bloody
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fatty
! style="background:#4479BA; color: #FFFFFF;" align="center" |WBC
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hgb
! style="background:#4479BA; color: #FFFFFF;" align="center" |Plt
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" |Virus
! colspan="2" style="background:#DCDCDC;" align="center" |[[Human Immunodeficiency Virus (HIV)|HIV]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*[[Abdominal distension|Abdominal distention]]
*Diffuse [[Tenderness (medicine)|abdominal tenderness]]
*[[Lymphadenopathy]]
*Disseminated [[infection]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[White blood cells|WBC]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
| rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Parasite
! colspan="2" style="background:#DCDCDC;" align="center" |[[Giardia lamblia|Giardia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*[[Abdominal distension|Abdominal distention]]
*Diffuse [[Tenderness (medicine)|abdominal tenderness]]
*[[Urticaria]]
*[[Depression]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Ovum|Ova]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Isospora]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Abdominal distension|Abdominal distention]]
*Diffuse [[Tenderness (medicine)|abdominal tenderness]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[White blood cells|WBC]] +
[[Red blood cell|RBC]] +


== Pathophysiology==
[[Ovum|Ova]] +


The main purpose of the GI tract is to [[digestion|digest]] and [[absorption|absorb]] nutrients (fat, carbohydrate, and protein), micronutrients (vitamins and trace minerals), water, and [[electrolytes]]. [[Digestion]] involves both mechanical and enzymatic breakdown of food. '''Mechanical processes''' include chewing, gastric churning, and the to-and-fro mixing in the small intestine. '''Enzymatic hydrolysis''' is initiated by intraluminal processes requiring gastric, pancreatic, and biliary secretions. The final products of digestion are absorbed through the intestinal epithelial cells.
[[Fecal fat]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
|-
! colspan="2" rowspan="5" style="background:#4479BA; color: #FFFFFF;" align="center" |Tumors
! colspan="2" style="background:#DCDCDC;" align="center" |[[VIPoma]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
* [[Abdominal distention]]
* Abdominal [[RUQ]] [[tenderness]]
* [[Nausea]]
* [[Vomiting]]
* [[Rash]]
* [[Facial flushing]]
* [[Dehydration]]
* [[Lethargy]]
* [[Muscle weakness]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Zollinger-Ellison syndrome|Zollinger–Ellison syndrome]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
** [[Tenderness|Epigastric tenderness]]
** [[Jaundice]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |–
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Cause
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Duration
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal pain
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Findings
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Stool exam
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |CBC
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" |Acute
! style="background:#4479BA; color: #FFFFFF;" align="center" |Chronic
! style="background:#4479BA; color: #FFFFFF;" align="center" |Watery
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bloody
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fatty
! style="background:#4479BA; color: #FFFFFF;" align="center" |WBC
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hgb
! style="background:#4479BA; color: #FFFFFF;" align="center" |Plt
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Lymphoma]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*Diffuse [[Tenderness (medicine)|abdominal tenderness]]
*[[Hepatosplenomegaly]]
*[[Ascites]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Red blood cell|RBC]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Medication/Toxicity
! colspan="2" style="background:#DCDCDC;" align="left" |
* [[ACE inhibitor|ACE inhibitors]]
* [[Digoxin]]
* [[Cephalosporin|Cephalosporins]]
* [[Statins]]
* [[Thiazide|Thiazide diuretics]]
* [[Triptans]]
* [[Lactulose]]
* [[HIV AIDS medical therapy|Anti retroviral agents]]
* [[Chemotherapy|Chemotherapeutic agents]]
* [[Antifungal drug|Antifungals]]
* [[Magnesium]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*[[Abdominal distention]]
*[[Dehydration]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Iatrogenic
! colspan="2" style="background:#DCDCDC;" align="center" |[[Short bowel syndrome]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal distension|Abdominal distention]]
* [[Tenderness (medicine)|Abdominal tenderness]]
* Prior [[Intestine|intestinal]] surgery
* Peripheral [[edema]]
* [[Muscle atrophy]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Fecal fat]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ↑
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Radiation enteropathy|Radiation enteritis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
* [[Tenderness (medicine)|Abdominal tenderness]]
* Prior history of [[Cancer|malignancy]] and [[radiation therapy]]
*[[Telangiectasia|Telangiectasias]] 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[White blood cells|WBC]] +
[[Red blood cell|RBC]] +


Malabsorption constitutes the pathological interference with the normal physiological sequence of digestion (intraluminal process), absorption (mucosal process) and transport (postmucosal events) of nutrients<ref name="julio">{{cite journal |author=Bai J |title=Malabsorption syndromes |journal=Digestion |volume=59 |issue=5 |pages=530-46 |year=1998 |pmid=9705537}}</ref>.
[[Fecal fat]] +
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
Intestinal malabsorption can be due to<ref>{{cite journal |author=Walker-Smith J, Barnard J, Bhutta Z, Heubi J, Reeves Z, Schmitz J |title=Chronic diarrhea and malabsorption (including short gut syndrome): Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition |journal=J. Pediatr. Gastroenterol. Nutr. |volume=35 Suppl 2 |issue= |pages=S98-105 |year=2002 |pmid=12192177}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
* mucosal damage ([[enteropathy]])
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Nl
* congenital or acquired reduction in absorptive surface
|-
* Defects of specific hydrolysis
! colspan="2" rowspan="6" style="background:#4479BA; color: #FFFFFF;" align="center" |Others
* Defects of ion transport
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Cause
* pancreatic insuffeciency
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Duration
* impaired [[enterohepatic circulation]]
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
 
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
==Causes==
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal pain
 
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
'''Due to infective agents'''
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Findings
*[[Whipple's disease]]
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Stool exam
*Intestinal [[tuberculosis]]
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |CBC
*[[HIV]] related malabsorption
|-
*[[Tropical sprue]]
! style="background:#4479BA; color: #FFFFFF;" align="center" |Acute
*[[traveller's diarrhoea]]
! style="background:#4479BA; color: #FFFFFF;" align="center" |Chronic
*[[Parasites]] .e. g. [[giardiasis|''Giardia lamblia'']], [[Diphyllobothrium|fish tape worm]]  (B12 malabsorption); [[Strongyloides stercoralis|round warm]] , [[hookworm]] (''Ancylostoma duodenale'' and ''Necator americanus'')
! style="background:#4479BA; color: #FFFFFF;" align="center" |Watery
 
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bloody
'''Due to structural defects'''<ref>{{cite book |author=M. S Losowsky, |title=Malabsorption in clinical practice |publisher=Churchill Livingstone |location=Edinburgh |year= |pages= |isbn=0-443-01007-2 |oclc= |doi=}}</ref>
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fatty
*[[blind loop syndrome|Blind loops]]
! style="background:#4479BA; color: #FFFFFF;" align="center" |WBC
*Inflammatory bowel diseases commonly in [[Crohn's Disease]]
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hgb
*Intestinal hurry from Post-[[gastrectomy]]; post-[[vagotomy]], gastro-jejunostomy
! style="background:#4479BA; color: #FFFFFF;" align="center" |Plt
*[[Fistulae]], [[Diverticulum|diverticulae]] and [[strictures]],
|-
*Infiltrative conditions such as [[amyloidosis]], [[lymphoma]], Eosinophilic gastroenteropathy
! colspan="2" style="background:#DCDCDC;" align="center" |[[Abetalipoproteinemia]]
*[[Radiation enteritis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
*[[Systemic sclerosis]] and collagen vascular diseases
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
'''Due to mucosal abnormality'''
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
*[[Coeliac disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
*Cows' milk intolerance
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
*Soya milk intolerance
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
'''Due to enzyme defeciencies'''
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*Lactase deficiency inducing [[lactose intolerance]] (constitutional, secondary or rarely congenital)
* [[Abdominal distension]]
*[[Sucrose intolerance]]
* [[Ataxia]]
*Intestinal disaccharidase defeciency
* [[Visual field defect]]
*Intestinal enteropeptidase defeciency
* [[Dysarthria]]
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
'''Due to digestive failure'''
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
*Pancreatic insuffeciencies:
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
**[[cystic fibrosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
**[[chronic pancreatitis]]
|-
**[[carcinoma of pancreas]]
! colspan="2" style="background:#DCDCDC;" align="center" |[[Hyperthyroidism]]
**[[Zollinger-Ellison syndrome]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
*[[Bile salt]] malabsorption
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
**terminal ileal disease
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
**[[obstructive jaundice]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
**[[bacterial overgrowth]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
'''Due to other [[systemic disease]]s affecting GI tract'''
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
*[[Hypothyroidism]] and [[hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
*[[Addison's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Diabetes mellitus]]
* Lump in the neck
*[[Hyperparathyroidism]] and [[Hypoparathyroidism]]
*[[Carcinoid syndrome]]
*Malnutrition
*[[Abetalipoproteinemia|Abeta-lipoproteinemia]]
 
== Clinical features==
[[Image:Small-Intestine-highlighted.gif|thumb|left|Small intestine : major site of absorption]]
It can present in variety of ways and features might give clue to underlying condition. Symptoms can be intestinal or extra-intestinal, former predominates in severe malabsorption.
 
* [[Diarrhoea]],often [[steatorrhoea]] is the most common feature.  Watery, diurnal and nocturnal, bulky, frequent stools are the clinical hallmark of overt malabsorption.  It is due to impaired water, carbohydrate and electrolyte absorption or irritation from unabsorbed fatty acid. Latter also result in [[bloating]], [[flatulence]] and abdominal discomfort.  Cramping pain usually suggest obstructive intestinal segment e.g. in crohn's disease especially if persists after defecation. <ref name="julio"/>
* Weight loss can be significant despite increased oral intake of nutrients<ref>health ato z {{cite web |url=http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/malabsorption_syndrome.jsp |title=Malabsorption syndrome |accessdate=2007-05-10 |format= |work=}}</ref>.
* Growth retardation, failure to thrive, delayed puberty in children
* Swelling or [[oedema]] from loss of protein
* Anaemias, commonly from vitamin [[B12]], [[folic acid]] and [[iron]] defeciency presenting as fatigue and weakness.
* Muscle cramp from decreased [[vitamin D]], calcium absorption. Also lead to [[osteomalacia]] and [[osteoporosis]]
* Bleeding tendencies from [[vitamin K]] and other [[coagulation factor]] defeciencies.
 
== Diagnosis==
There is no specific test for Malabsorption. As for most medical conditions, investigation is guided by symptoms and signs. Moreover, tests for pancreatic function are complex and varies widely between centres.
 
'''Blood Tests'''
*Routine blood tests may reveal [[anaemia]], high [[ESR]] or low [[serum albumin|albumin]]; which has high sensitivity for presence of organic disease <ref>{{cite journal |author=Bertomeu A, Ros E, Barragán V, Sachje L, Navarro S |title=Chronic diarrhea with normal stool and colonic examinations: organic or functional? |journal=J. Clin. Gastroenterol. |volume=13 |issue=5 |pages=531-6 |year=1991 |pmid=1744388}}</ref><ref>{{cite journal |author=Read N, Krejs G, Read M, Santa Ana C, Morawski S, Fordtran J |title=Chronic diarrhea of unknown origin |journal=Gastroenterology |volume=78 |issue=2 |pages=264-71 |year=1980 |pmid=7350049}}</ref>. In this setting, [[Microcytic#Microcytic anaemia|microcytic anaemia]] usually implies iron deficiency and [[macrocytosis]] can be from impaired [[folic acid]] or [[B12]] absorption or both. Low cholesterol or triglyceride may give clue toward fat malabsorption as low calcium and phosphate toward [[osteomalacia]] from low vitamin D.
*Specific vitamins like [[vitamin D]] or [[micro nutrient]] like zinc levels can be checked. Fat soluble vitamins (A, D, E & K) are affected in fat malabsorption. Prolonged [[prothrombin time]] can be from [[vitamin K]] deficiency.
*Serological studies
:Specific tests are carried out to determine underlying cause.
:[[IgA]] tissue trans glutamate or IgA antiendomysium assay for [[Coeliac disease|gluten sensitive enteropathy]].
'''Stool studies'''
* Microscopy is particularly useful in diarrhoea, may show protozoa like giardia, ova, cyst and other infective agents.
*[[Fecal fat|Fecal fat study]] to diagnose [[steatorrhoea]] is less frequently performed nowadays.
*Low [[elastase]] is indicative of pancreatic insufficiency. [[Chymotrypsin]] and pancreolauryl can be assessed as well<ref>{{cite journal |author=Thomas P, Forbes A, Green J, Howdle P, Long R, Playford R, Sheridan M, Stevens R, Valori R, Walters J, Addison G, Hill P, Brydon G |title=Guidelines for the investigation of chronic diarrhoea, 2nd edition |journal=Gut |volume=52 Suppl 5 |issue= |pages=v1-15 |year=2003 |pmid=12801941}}[http://www.bsg.org.uk/pdf_word_docs/cd_body.pdf].
</ref>
 
'''Radiological studies'''
*[[Barium follow through]] is useful in delineating [[small intestine|small intestinal]] [[anatomy]]. [[Barium enema]] may be undertaken to see colonic or ileal lesions.
*CT abdomen is useful in ruling out structural abnormality,  done in pancreatic protocol when visualising pancreas.
*[[MRCP]] to complement or as an alternative to [[ERCP]]
 
'''Interventional studies'''
[[Image:Coeliac path.jpg|thumb|left|Biopsy of [[small bowel]] showing coeliac disease manifested by blunting of [[villi]], crypt hyperplasia, and [[lymphocyte]] infiltration of crypts.]]
*Endoscopy is frequently undertaken, but to visualise small intestine which can be up to 7m long is indeed a daunting task.
:[[OGD]] to reveal duodenal lesion also for D2 biopsy (for celiac disease, tropical sprue, Whipple disease, A-b-lipoproteinemia etc.)
:[[Enteroscopy]] for enteropathy and jejunal aspirate and culture for bacterial overgrowth
:[[Colonoscopy]] is helpful in colonic or ileal lesion.
*[[ERCP]]
 
'''Other investigations'''
*[[Radionuclide|Radio isotope]] tests e.g. 75SeHCAT, 95mTc to exclude terminal ileal disease.
*Sugar probes or sub 51Cr-EDTA to determine intestinal permeability<ref name="julio"/>.
*Glucose hydrogen breath test for [[bacterial overgrowth]]
*[[D-xylose]] absorption test. lower level in urine after ingestion indicates bacterial overgrowth or reduced absorptive surface. normal in pancreatic insufficiency.
*Bile salt breath test to determine [[bile salt]] malabsorption.
*[[Schilling test]] to establish cause of B12 deficiency.
*Lactose H2 breath test for [[lactose intolerance]]
 
== Management==
Treatment is directed largely towards management of underlying cause.
*Replacement of nutrients, electrolytes and fluid may be necessary. In severe defeciency hospital admission may be required for parentral administration, often advice from dietician is sought. People whose absortive surface are severely limited from disease or surgery may need long term [[total parenteral nutrition]]. Pancreatic [[enzymes]] are supplimented orally in insuffeciencies.
*Dietary modification is important in some conditions. Life long avoidance of particular food or food constituent may be needed in Celiac disease or lactose intolerence.
*Bacterial overgrowth usually respond well to course of antibiotic. Use of [[cholestyramine]] to bind bile acid will help reducing diarrhoea in bile acid malabsorption.
 
== See also ==
* [[Protein losing enteropathy]]
 
== External links ==
* Practice guideline from World Gastroenterology Organisation [http://www.omge.org/globalguidelines/guide03/g_data3_en.php]
* Tests for malabsorption; from British Society for Gastroenterology (2003)[http://www.bsg.org.uk/pdf_word_docs/cd_body.pdf]
 
== Reference==
 
{{Reflist|2}}
 
{{SIB}}
{{Gastroenterology}}
 
[[Category:Gastroenterology]]
 
[[de:Malassimilation]]
[[es:Malabsorción]]
[[fr:Malabsorption]]
[[sv:Malabsorption]]


* Lid lag
* [[Sweating]]
* [[Hyperpigmentation]]
* [[Proptosis]]
* [[Tremor]]
* Increased [[Deep tendon reflex|DTR]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Fecal fat]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Diabetic neuropathy]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*[[Fecal incontinence]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Fecal fat]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|-
! colspan="2" style="background:#DCDCDC;" align="center" |[[Scleroderma|Systemic sclerosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | –
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
*[[Abdominal pain|Epigastric tenderness]]
*[[Fecal incontinence]]
*[[Raynaud's phenomenon|Raynaud phenomenon]]
*[[Pulmonary hypertension]]
*[[Arthritis]]
*[[Telangiectasia]]
*[[Chronic renal failure]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Red blood cell|RBC]] +
[[Fecal fat]] +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Nl
|- }
|}


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Latest revision as of 17:26, 11 April 2018

Malabsorption

Home

Overview

Classification

Infection
Structural defect
Digestive failure
Systemic disease
Iatrogenic

Differentiating Malabsorption from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Overview

Malabsorption is a condition which is associated with impaired absorption of one or all dietary nutrients. There are multiple etiologies with diminished intestinal absorption. Many of them present with diarrhea, especially steatorrhea. They might have malabsorption of carbohydrates, fat, protein, vitamins, and/or minerals. Malabsorption is occurred following intestinal mucosal or structural defects. Malabsorption according to etiology may be classified into five main groups including infection, structural defect, digestive failure, systemic disease, and iatrogenic causes. Different workups might be used to differentiate diagnosis of malabsorption including small bowel biopsy, stool exam, breath testings, lab findings, and imagings.

Classification

Malabsorption according to etiology may be classified into five main groups:[1][2]

Malabsorption classification
Infection
Viral HIV
Bacterial Tuberculosis
Tropical sprue
Whipple's disease
Small intestinal bacterial overgrowth syndrome
Parasitic Giardia
Isospora
Structural or enzyme defect
Blind loop syndrome
Fistula
Diverticula
Stricture
Lactase deficiency
Digestive failure
Pancreatic insufficiency Cystic fibrosis
Chronic pancreatitis
Pancreatic cancer
Zollinger–Ellison syndrome
VIPoma
Carcinoid syndrome
Bile acid malabsorption
Systemic disease
Celiac disease
Inflammatory bowel disease Crohn's disease
Ulcerative colitis
Infiltrative disorders Amyloidosis
Lymphoma
Eosinophilic gastroenteritis
Endocrine abnormalities Diabetes mellitus
Hypothyroidism
Hyperthyroidism
Hyperparathyroidism
Hypoparathyroidism
Addison's disease
Immunologic disorders Common variable immunodeficiency
Abetalipoproteinemia
Iatrogenic
Medication
Radiation
Post surgery Gastrectomy
Bariatric surgery
Short bowel syndrome

Differentiating malabsorption from other Diseases

To review the differential diagnosis of diarrhea, click here.

The following table outlines the major differential diagnoses of malabsorption.[3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]

Categories Cause Clinical manifestation Lab findings
Symptoms Findings
Duration Diarrhea Fever Abdominal pain Weight loss
Stool exam CBC
Acute Chronic Watery Bloody Fatty WBC Hgb Plt
Gastrointestinal Crohn's disease – + + + + ± + + WBC +

RBC +

↑ ↓ ↑
Ulcerative colitis – + + + + ± + + WBC +

RBC +

↑ ↓ ↑
Celiac disease – + ± – ± – + + Fat droplets on sudan stain Nl ↓ Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss Findings Stool exam CBC
Acute Chronic Watery Bloody Fatty WBC Hgb Plt
Cystic fibrosis – + – – + ± + + Fat droplets on sudan stain Nl ↓ Nl
Chronic pancreatitis – + + – + – + + Fat droplets on sudan stain

Fecal elastase +

Nl Nl Nl
Bile acid malabsorption – + + – + – – + Fat droplets on sudan stain Nl Nl Nl
Lactose intolerance + + + – – – + – – Nl Nl Nl
Infection Bacterial Cause Duration Diarrhea Fever Abdominal pain Weight loss Findings Stool exam CBC
Acute Chronic Watery Bloody Fatty WBC Hgb Plt
Whipple's disease – + + – + ± + + Fecal fat + ↓ ↓ ↓/↑
Tropical sprue + + + – + + + + WBC +

Stool culture +

Nl ↓ Nl
Small bowel bacterial overgrowth – + + – + – + + WBC +

Stool culture +

Fecal fat +

Nl ↓ Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss Findings Stool exam CBC
Acute Chronic Watery Bloody Fatty WBC Hgb Plt
Virus HIV – + + – – + + + WBC + ↓ ↓ Nl
Parasite Giardia – + + – + – + + Ova + Nl Nl Nl
Isospora + + + – + + + + WBC +

RBC +

Ova +

Fecal fat +

↑ Nl Nl
Tumors VIPoma + + + – + – + + – Nl Nl Nl
Zollinger–Ellison syndrome – + + + + – + + – Nl ↓ Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss Findings Stool exam CBC
Acute Chronic Watery Bloody Fatty WBC Hgb Plt
Lymphoma – + + + – + + + RBC + Nl ↓ Nl
Medication/Toxicity + + + – ± ± + + – ↑ Nl Nl
Iatrogenic Short bowel syndrome + + + – + – – + Fecal fat + Nl ↓ ↑
Radiation enteritis + + + + + – + + WBC +

RBC +

Fecal fat +

Nl ↓ Nl
Others Cause Duration Diarrhea Fever Abdominal pain Weight loss Findings Stool exam CBC
Acute Chronic Watery Bloody Fatty WBC Hgb Plt
Abetalipoproteinemia – + + – + – + + – Nl Nl Nl
Hyperthyroidism – + + – – ± + +
  • Lump in the neck
 Fecal fat + Nl Nl Nl
Diabetic neuropathy – + + – + – + + Fecal fat + Nl ↓ Nl
Systemic sclerosis – + + ± + – + + RBC +

Fecal fat +

Nl ↓ Nl

References

  1. ↑ Papadia C, Di Sabatino A, Corazza GR, Forbes A (2014). "Diagnosing small bowel malabsorption: a review". Intern Emerg Med. 9 (1): 3–8. doi:10.1007/s11739-012-0877-7. PMID 23179329.
  2. ↑ Freeman HJ (2000). "Small intestinal mucosal biopsy for investigation of diarrhea and malabsorption in adults". Gastrointest. Endosc. Clin. N. Am. 10 (4): 739–53, vii. PMID 11036541.
  3. ↑ Casburn-Jones, Anna C; Farthing, Michael Jg (2004). "Traveler's diarrhea". Journal of Gastroenterology and Hepatology. 19 (6): 610–618. doi:10.1111/j.1440-1746.2003.03287.x. ISSN 0815-9319.
  4. ↑ Kamat, Deepak; Mathur, Ambika (2006). "Prevention and Management of Travelers' Diarrhea". Disease-a-Month. 52 (7): 289–302. doi:10.1016/j.disamonth.2006.08.003. ISSN 0011-5029.
  5. ↑ Pfeiffer, Margaret L.; DuPont, Herbert L.; Ochoa, Theresa J. (2012). "The patient presenting with acute dysentery – A systematic review". Journal of Infection. 64 (4): 374–386. doi:10.1016/j.jinf.2012.01.006. ISSN 0163-4453.
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  8. ↑ Kotloff KL, Riddle MS, Platts-Mills JA, Pavlinac P, Zaidi A (2017). "Shigellosis". Lancet. doi:10.1016/S0140-6736(17)33296-8. PMID 29254859. Vancouver style error: initials (help)
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