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In hypothyroid patients needing large doses of levothyroxine (L-T4) (>1.7-2 mg/kg/day) to reach euthyroidism, lactose intolerance (LI) needs to be excluded, owing to the high prevalence in the population. If LI is present, a lactose-free diet decreases the rate of L-T4 malabsorption. However, an increased requirement of L-T4 is described in patients with LI, which can be beneficially treated using lactose-free L-T4 formulation. The lactose-free liquid L-T4 formulation is able to circumvent LI malabsorption leading to the normalization of thyroid-stimulating hormone (TSH) in patients with subclinical hypothyroidism and long-term stable TSH levels. [ABSTRACT FROM AUTHOR]

Introduction: Over the past few decades, proton pump inhibitors (PPIs) have been used more often; nonetheless, there are concern regarding misuse and the severe adverse effects that have been described. Methods: This paper will present information from relevant professional/scientific sources including Scopus, EBSCO, PubMed regarding unwanted adverse events of PPIs. Topic: The causality of correlations between PPI usage and possible adverse effects is unknown. Increased risk of kidney, liver, and cardiovascular disease; dementia; gastrointestinal tract enteroendocrine tumors; susceptibility to respiratory and gastrointestinal infections; and reduced nutritional absorption are just a few of the long-term adverse effects of widespread use of PPI that have come to light. Thus, given growing concerns regarding PPI overuse in the general population, the purpose of this investigation is to review the relationship between PPI usage and the risk of major side consequences. Conclusion: Due to the numerous known side effects of PPIs on the system, further study is necessary, including changing the drug's molecular structure and creating a new medication from its parent. By administering these drugs effectively for the relevant diagnosis, reevaluating patients' symptoms on a regular basis to determine the least amount and duration of therapy, and closely monitoring any potential side effects, it is feasible to minimize expenditures with health risk and maximize beneficial outcomes.

Background: Disorders of gut–brain interaction (DGBIs) have a complex pathophysiology that is often characterized by a relationship between food ingestion and triggering of symptoms. Understanding of the underlying mechanisms and the role of nutrients as a therapeutic target are rapidly evolving. Aims and methods: We performed a narrative review of the literature using the following keywords, their acronyms, and their associations: nutrients, disorders of gut–brain interaction; functional dyspepsia; malabsorption; irritable bowel syndrome; diarrhea; constipation. Results: Functional dyspepsia displayed a significant correlation between volume, fat and/or wheat abundance, chemical composition of ingested food and symptoms of early satiety, fullness and weight loss. Carbohydrate malabsorption is related to enzyme deficiency throughout the GI tract. Food composition and richness in soluble vs. non-soluble fibers is related to constipation and diarrhea. The elimination of fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) has a significant and non-unidirectional impact on irritable bowel syndrome (IBS) symptoms. Conclusions: Food volume, nutritive and chemical composition, and its malabsorption are associated with symptom generation in DGBIs. Further multicenter, randomized-controlled clinical trials are needed to clarify the underlying pathophysiology. [ABSTRACT FROM AUTHOR]

Background/Aims: Longtime chronic malabsorption may among other things cause a lack of liposoluble vitamins. Vitamin E deficiency can lead to formation of lipofuscin aggregates. Its deficiency is also associated with an increased lipofuscinosis of the bowel, i.e. brown bowel syndrome. Methods: Systematic research via Medline on brown bowel syndrome, lipofuscinosis, and vitamin E deficiency was performed. We combined our own clinical experience and a review of the literature for this paper. Its goal is to inform about the possible consequences of severe malabsorption and brown bowel syndrome. Results: Systematic data about the occurrence of severe malabsorption and brown bowel syndrome are rare. Only about 27 scientific reports can be found on this subject. Brown bowel syndrome is found mostly in conjunction with vitamin E deficiency and lipofuscinosis of the bowel. The clinical findings are caused by both malabsorption and lipofuscinosis. Case reports show a therapeutic effect of vitamin E. Conclusion: Vitamin deficiency caused by longtime chronic malabsorption can lead to the development of brown bowel syndrome, which is seen as the expression of lipofuscinosis of the bowel, and can cause further clinical disorders. Patients with malabsorption should therefore be monitored regarding their vitamin E levels. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: Short bowel syndrome (SBS) is a malabsorption disorder of the intestine, which leads to an inadequate alimentary supply. A number of therapeutic approaches are already in use, but research advances may provide new options in the future. The purpose of this paper was to provide an overview of the established therapeutic approaches together with a discussion of the future perspectives in the treatment of patients with SBS. We review those studies dealing with the treatment of SBS patients and discuss both surgical and non-surgical approaches together with tissue engineering. Methods: A systemic review of Medline-cited studies dealing with current practice and future perspectives in the treatment of short bowel in children was performed. Results: Surgical approaches, non-surgical approaches, and tissue engineering which was used in the treatment of SBS were analyzed. Among the surgical approaches, the bowel lengthening procedures and small bowel transplantation are prevalent. Stimulants are most important concerning non-surgical approaches. Tissue engineering seems to be more experimental and was also evaluated. Conclusion: The treatment of SBS patients remains very complex. It is eminent to find the best therapeutic option for each patient and to individualize and modify the different possible types of applied techniques frequently. [ABSTRACT FROM AUTHOR]

Proton pump inhibitors have an excellent safety profile and have become one of the most commonly prescribed class of drugs in primary and specialty care. Long-term, sometimes lifetime, use is becoming increasingly common, often without appropriate indications. This paper is a detailed review of the current evidence on this important topic, focusing on the potential adverse effects of long-term proton pump inhibitor use that have generated the greatest concern: B12 deficiency; iron deficiency; hypomagnesemia; increased susceptibility to pneumonia, enteric infections, and fractures; hypergastrinemia and cancer; drug interactions; and birth defects. We explain the pathophysiological mechanisms that may underlie each of these relationships, review the existing evidence, and discuss implications for clinical management. The benefits of proton pump inhibitor use outweigh its risks in most patients. Elderly, malnourished, immune-compromised, chronically ill, and osteoporotic patients theoretically could be at increased risk from long-term therapy. [ABSTRACT FROM AUTHOR]

This paper examines the diagnostic potential of multislice computed tomography enteroclysis (MSCT–E) to detect and assess different diseases affecting the small bowel, emphasising the increasingly important role assumed by the technique in the study of this anatomical region. After a short summary of the technical aspects, we discuss the different findings that can be observed during an MSCT–E study and that enable detection of small–bowel disease and, if necessary, assessment of the extent and stage of disease. [ABSTRACT FROM AUTHOR]

Deficiencies in vitamins and other nutrients are common following the Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPDDS), and may become clinically significant if not recognized and treated with supplementation. This paper presents a review of the current literature and evidence of the most commonly deficient vitamins and minerals following weight loss surgery, including protein, iron, vitamin B12, folate, calcium, the fat-soluble vitamins (A, D, E, K), and other micronutrients. The deficiencies appear to be more substantial following malabsorptive procedures such as BPD, but occur with restrictive procedures as well. The review suggests that further studies are needed to evaluate the clinical significance of the nutritional deficiencies, and to determine guidelines for supplementation. [ABSTRACT FROM AUTHOR]

Iron is an essential nutrient to life and is required for erythropoiesis, oxidative, metabolism, and enzymatic activities. It is a cofactor for mitochondrial respiratory chain enzymes, the citric acid cycle, and DNA synthesis, and it promotes the growth of immune system cells. Thus, iron deficiency (ID) leads to deleterious effects on the overall health of individuals, causing significant morbidity. Iron deficiency anemia (IDA) is the most recognized type of anemia in patients with celiac disease (CD) and may be present in over half of patients at the time of diagnosis. Folate and vitamin B12 malabsorption, nutritional deficiencies, inflammation, blood loss, development of refractory CD, and concomitant Heliobacter pylori infection are other causes of anemia in such patients. The decision to replenish iron stores and the route of administration (oral or intravenous) are controversial due, in part, to questions surrounding the optimal formulation and route of administration. This paper provides an algorithm based on the severity of symptoms; its impact on the health-related quality of life (HRQL); the tolerance and efficiency of oral iron; and other factors that predict a poor response to oral iron, such as the severity of histological damage, poor adherence to GFD, and blood loss due to mucosal lesions. [ABSTRACT FROM AUTHOR]

Pancreatic enzyme replacement therapy (PERT) is a major factor associated with achieving optimum growth and nutritional status in cystic fibrosis (CF) patients with pancreatic insufficiency and consequent malabsorption. Currently in Australian CF clinics policies for the usage of PERT vary considerably. This paper highlights the current issues related to fat absorption and use of PERT in CF. It also provides evidence to support the recommendation of a PERT dose based on a standard ratio of lipase units per gram of dietary fat consumed for individual patients. A consistent approach to PERT doses will facilitate identification of patients whose PERT intake increases their risk of fibrosing colonopathy and for whom gastroenterological review is warranted. Recent reports indicate that PERT intake can be reduced with a secondary improvement in growth and nutrition status as a consequence of increased dietetic input. These Australian guidelines for the judicious use of PERT in CF should lead not only to a refinement in nutritional management of patients with CF but should also facilitate an improvement in compliance with therapy due to sophistication in patient education materials. The Australian guidelines for the use of PERT in CF if correctly applied, will also provide patients and their families with a better understanding of the relationship between PERT and nutritional status. [ABSTRACT FROM AUTHOR]

To determine whether or not purifiedI-triolein produces the same behavior asC-triolein in the intraluminal phase, and to assess whether or not 0.10±0.02 of the Digestion-Absorption Index (DAI) obtained from clinical cases is an adequate value for differentiating maldigestion from malabsorption of fat, dogs, pancreatic juice-deficient, short bowel and biledeficient were prepared. Both the pancreatic juice-deficient and bile-deficient groups indicated a high fecal excretion ofC-andI-radioactivity, and the short bowel group indicated a moderate fecal excretion of fat. Daily fecal fat levels in each group were in parallel to the 3-day fecal excretion of radioactivity. However, the Digestion-Absorption Index of the pancreatic juice-deficient group was 0.602 inC and 0.620 inI, and indicated that a considerable portion of the ingested triolein was excreted into the feces without hydrolysis. DAI in the short bowel group were 0.020 inC and 0.022 inI, and in the bile-deficient group, the indices were 0.031 inC and 0.021 inI. Both latter groups showed a malabsorptive defect. Additionally, the Digestion-Absorption Index of the pancreatic juice-deficient group was higher than 0.10±0.02 of the clinical borderline mentioned in the foregoing paper, and that of the other two groups was lower. Therefore, this borderline may represent adequate values for the differentiation of fat malassmilation. On the other hand, it was confirmed thatC-triolein andI-triolein showed similar behavior in the intraluminal phase, and that theI-triolein test was adequate for clinical testing for fat digestion and absorption. [ABSTRACT FROM AUTHOR]

Background: This paper evaluates biliopancreatic diversion combined with the duodenal switch, forming a hybrid procedure which is a combination of restriction and malabsorption. Methods: The evaluation is of the first 440 patients undergoing this procedure who had had no previous bariatric surgery. The mean starting weight was 183 kg, with 41% of our patients considered super morbidly obese (BMI > 50). Results: There was an average maximum weight loss of 80% excess weight by 24 months postoperation; this continued at a 70% level for 8 years. Major complications were found in almost 9% of the cases. There were two perioperative deaths, one from pulmonary embolism and one from acute pulmonary obstruction. There were 36 type II diabetics, all of whom have discontinued medication following the surgery. Seventeen revisions were performed to correct excess weight loss and low protein levels. There have been no marginal ulcers, no cases of dumping syndrome, no foreign material used, and the procedure is a pyloric saving procedure which is functionally reversible. Conclusions: This operation has vastly improved the lives of seriously obese patients with many co-morbidities. All type II diabetics have essentially been cured of their disease. The procedure was tolerated well and patients are quite satisfied. There was minimal regain of weight with this method. [ABSTRACT FROM AUTHOR]

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Microvillus inclusion disease (MVID) is a rare inherited and invariably fatal enteropathy, characterized by severe intractable secretory diarrhea and nutrient malabsorption. No cure exists, and patients typically die during infancy because of treatment-related complications. The need for alternative treatment strategies is evident. Several pharmacological interventions with variable successes have been tried and reported for individual patients as part of their clinical care. Unfortunately, these interventions and their outcomes have remained hidden in case reports and have not been reviewed. Further, recent advances regarding MVID pathogenesis have shed new light on the outcomes of these pharmacological interventions and offer suggestions for future clinical research and trials. Hence, an inventory of reported pharmacological interventions in MVID, their rationales and outcomes, and a discussion of these in the light of current knowledge is opportune. Together with a discussion on MVID-specific pharmacokinetic, -dynamic, and -genetic concerns that pose unique challenges regarding pharmacological strategies, we envision that this paper will aid researchers and clinicians in their efforts to develop pharmacological interventions to combat this devastating disease. [ABSTRACT FROM AUTHOR]

Although levothyroxine is one of the most prescribed medications in the world, its bioavailability has been reported to be impaired by many factors, including interfering drugs or foods and concomitant diseases, and persistent hypothyroidism with a high dose of levothyroxine is thus elicited. Persistent hypothyroidism can also be induced by noninterchangeability between formulations and poor compliance. To address these issues some strategies have been developed. Novel formulations (liquid solutions and soft gel capsules) have been designed to eliminate malabsorption. Some other delivery routes (injections, suppositories, sprays, and sublingual and transdermal administrations) are aimed at circumventing different difficulties in dosing, such as thyroid emergencies and dysphagia. Moreover, nanomaterials have been used to develop delivery systems for the sustained release of levothyroxine to improve patient compliance and reduce costs. Some delivery systems encapsulating nanoparticles show promising release profiles. In this review, we first summarize the medical conditions that interfere with the bioavailability of oral levothyroxine and discuss the underlying mechanisms and treatments. The efficacy of liquid solutions and soft gel capsules are systematically evaluated. We further summarize the novel delivery routes for levothyroxine and their possible applications. Nanomaterials in the levothyroxine field are then discussed and compared based on their load and release profile. We hope the article provides novel insights into the drug delivery of levothyroxine. [ABSTRACT FROM AUTHOR]

Malabsorption of fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs) in response to prolonged exercise may increase incidence of upper and lower gastrointestinal symptoms (GIS), which are known to impair exercise performance. This case study aimed to explore the impact of a low-FODMAP diet on exercise-associated GIS in a female ultraendurance runner diagnosed with irritable bowel syndrome, competing in a 6-day 186.7-km mountainous multistage ultramarathon (MSUM). Irritable bowel syndrome symptom severity score at diagnosis was 410 and following a low-FODMAP diet (3.9 g FODMAPs/day) it reduced to 70. The diet was applied 6 days before (i.e., lead-in diet), and maintained during (5.1 g FODMAPs/day) the MSUM. Nutrition intake was analyzed through dietary analysis software. A validated 100-mm visual analog scale quantified GIS incidence and severity. GIS were modest during the MSUM (overall mean ± SD: bloating 27 ± 5 mm and flatulence 23 ± 8 mm), except severe nausea (67 ± 14 mm) experienced throughout. Total daily energy (11.7 ± 1.6 MJ/day) intake did not meet estimated energy requirements (range: 13.9–17.9 MJ/day). Total daily protein [1.4 ± 0.3 g·kg body weight (BW)−1·day−1], carbohydrate (9.1 ± 1.3 g·kg BW−1·day−1), fat (1.1 ± 0.2 g·kg BW−1·day−1), and water (78.7 ± 6.4 ml·kg BW−1·day−1) intakes satisfied current consensus guidelines, except for carbohydrates. Carbohydrate intake during running failed to meet recommendations (43 ± 9 g/hr). The runner successfully implemented a low-FODMAP diet and completed the MSUM with minimal GIS. However, suboptimal energy and carbohydrate intake occurred, potentially exacerbated by nausea associated with running at altitude. [ABSTRACT FROM AUTHOR]

Collagenous colitis is a form of microscopic colitis, while Collagenous Sprue (CS) is a malabsorptive disorder that mimics celiac disease. Both conditions show increased Intraepithelial Lymphocytes (IELs) and basement membrane thickening due to collagen deposition. The simultaneous occurrence of both disorders is rare, and only a few such cases have been reported in the literature. A 60-year-old female presented with chronic, non bloody diarrhoea persisting for two years. Investigations revealed megaloblastic anaemia and hypoalbuminaemia. Gastroenteroscopy showed flattening and atrophy of the small intestinal mucosa. Biopsy results showed increased IELs, normal crypt architecture, and stripping of the epithelium. There was also patchy deposition of hyalinised band subepithelially, confirmed to be collagen through Masson’s stain. As both the upper and lower Gastrointestinal (GI) tracts were involved, a diagnosis of collagenous enterocolitis was made. A 70-year-old female presented with intermittent watery diarrhoea for the past 10 days, accompanied by urgency and tenesmus. She had a history of colicky abdominal pain four years ago, which improved with steroids, but the symptoms recurred. Clinically, she was considered to have inflammatory bowel disease, with recurrent anaemia. Both gastroduodenoscopy and colonoscopy were normal. Mapping biopsy showed increased IELs and focal atrophy in the duodenum, while the colon exhibited mild mononuclear inflammation with occasional minimal activity. Focal, irregular deposition of subepithelial collagen was also observed and confirmed through Masson’s stain. A diagnosis of collagenous enterocolitis was made. She is currently being monitored for any recurrence of symptoms, after which steroid treatment will be initiated. Collagenous colitis, CS, and collagenous duodenitis share similar histological features and can rarely co-exist. Further studies are needed to better understand their aetiology and association. [ABSTRACT FROM AUTHOR]

Bile acid malabsorption (BAM) represents a common cause of chronic diarrhea whose prevalence is under-investigated. We reviewed the evidence available regarding the pathophysiology and clinical management of bile acid diarrhea (BAD). BAD results from dysregulation of the enterohepatic recirculation of bile acids. It has been estimated that 25–33% of patients with functional diarrhea and irritable bowel syndrome with diarrhea have BAM. Currently, the selenium homotaurocholic acid test is the gold standard for BAD diagnosis and severity assessment. However, it is an expensive method and not widely available. The validation of the utility in the clinical practice of several other serum markers, such as 7α-hydroxy-4-cholesten-3-one (C4) and the fibroblast growth factor 19 (FGF19) is ongoing. The first-line treatment of patients with BAD is bile acid sequestrants. Patients that are refractory to first-line therapy should undergo further diagnostics to confirm the diagnosis and to treat the underlying cause of BAD. An early and correct diagnosis of BAD would improve patient's quality of life, avoiding additional diagnostic tests that burden health care systems. Considering the limited availability and tolerability of specific medications for BAD treatment, future research is awaited to identify other therapeutic approaches, such as gut microbiota modulating therapies. [ABSTRACT FROM AUTHOR]

Background: Symptoms following fructose ingestion, or fructose intolerance, are common in patients with functional gastrointestinal disorders (FGID) and are generally attributed to intestinal malabsorption. The relationships between absorption, symptoms, and intestinal gas production following fructose ingestion were studied in patients with FGID. Methods: Thirty FGID patients ingested a single dose of fructose 35 g or water in a randomized, double‐blind, crossover study. Blood and breath gas samples were collected, and gastrointestinal symptoms rated. Plasma fructose metabolites and short‐chain fatty acids were quantified by targeted liquid chromatography‐tandem mass spectrometry. Patients were classified as fructose intolerant or tolerant based on symptoms following fructose ingestion. Key Results: The median (IQR) areas under the curve of fructose plasma concentrations within the first 2 h (AUC0–2 h) after fructose ingestion were similar for patients with and without fructose intolerance (578 (70) µM·h vs. 564 (240) µM·h, respectively, p = 0.39), as well as for the main fructose metabolites. There were no statistically significant correlations between the AUC0–2 h of fructose or its metabolites concentrations and the AUCs of symptoms, breath hydrogen, and breath methane. However, the AUCs of symptoms correlated significantly and positively with the AUC0–2 h of hydrogen and methane breath concentrations (r = 0.73, r = 0.62, respectively), and the AUCs of hydrogen and methane concentrations were greater in the fructose‐intolerant than in the fructose‐tolerant patients after fructose ingestion (p ≤ 0.02). Conclusions & Inferences: Fructose intolerance in FGID is not related to post‐ingestion plasma concentrations of fructose and its metabolites. Factors other than malabsorption, such as altered gut microbiota or sensory function, may be important mechanisms. [ABSTRACT FROM AUTHOR]

Sometimes referred to as hidden hunger, micronutrient deficiencies persist on a global scale. For some micronutrients this appears to be due to inadequate intake, for others intake may not match increased requirements. However, for most micronutrient deficiencies there is uncertainty as to the dominant driver, and the question about the contribution of malabsorption is open. Environmental enteropathy (EE), formerly referred to as tropical enteropathy and also referred to as environmental enteric dysfunction, is an asymptomatic disorder of small intestinal structure and function which is very highly prevalent in many disadvantaged populations. Recent studies of the pathology and microbiology of this disorder suggest that it is driven by very high pathogen burdens in children and adults living in insanitary environments and is characterised by major derangements of the epithelial cells of the intestinal mucosa. Transcriptomic data suggest that it may lead to impaired digestion and absorption of macronutrients. Given the very high prevalence of EE, marginal malabsorption could have large impacts at population scales. However, the relative contributions of inadequate soil and crop micronutrient contents, inadequate intake, malabsorption and increased requirements are unknown. Malabsorption may compromise attempts to improve micronutrient status, but with the exception of zinc there is currently little evidence to confirm that malabsorption contributes to micronutrient deficiency. Much further research is required to understand the role of malabsorption in hidden hunger, especially in very disadvantaged populations where these deficiencies are most prevalent. [ABSTRACT FROM AUTHOR]