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Along with myasthenia, other paraneoplastic neurological syndromes (PNS) may occur in thymoma. Anti-Hu antibodies and a clinical "anti-Hu syndrome" characterized by encephalitis and/or painful neuropathies have been reported in only three patients at the time of the diagnosis of thymoma. We describe a severe anti-Hu-related autonomic neuropathy with gastrointestinal paresis and intestinal pseudo-obstruction with malabsorption that occurred concomitantly with the worsening of myasthenic symptoms long after the initial diagnosis of thymoma in a young patient. The clinical anti-Hu syndrome preceded the radiological diagnosis of thymoma recurrence. Treatment with plasma exchange led to a transient improvement of neurological symptoms.

Background: Pancreatic enzyme supplementation is standard treatment for malabsorption caused by chronic pancreatitis. The FDA recently required all manufacturers to submit New Drug Applications to continue to market these agents because published data demonstrated variation in formulation, bioavailability and shelf-life while providing limited data about efficacy and safety., Aim: To review systematically the design and results of randomized, parallel-design trials of pancreatic enzyme supplements in chronic pancreatitis patients with steatorrhea., Methods: A computer-assisted search of MEDLINE and EMBASE was performed to identify relevant studies. Two authors performed duplicate data extraction on study design, improvement in coefficient of fat absorption (CFA), diarrhoea and adverse events using pre-specified forms. Agreement between investigators for data extraction was greater than 95%., Results: Of 619 articles found through literature searching, 20 potentially relevant articles were identified and four manuscripts met inclusion criteria. No studies performed head-to-head comparisons of different supplements. Enzyme supplementation is more likely to improve CFA compared with placebo, but fat malabsorption remained abnormal. Important differences in patient population, study endpoint, study design, pancreatic enzyme dosage and measurement of CFA were present across trials, which precluded comparison of different agents., Conclusions: Enzyme supplementation improves CFA compared to placebo, but may not abolish steatorrhoea.

Akinetic crisis (AC) is a much-feared complication of Parkinson's disease (PD) which may appear upon abrupt cessation or malabsorption of dopaminergic medication due to gastrointestinal tract disorders or acute surgery. Intravenous infusion of amantadine sulphate or subcutaneous administration of apomorphine are established treatment strategies for AC. We speculate whether the use of a non-invasive transdermal application form (patch) of a dopaminergic drug (rotigotine) may represent a useful alternative treatment option. We describe the successful treatment of severe AC using rotigotine in a PD patient with gastro-oesophageal ulcers which precluded administration of any oral medication. This case demonstrates that a rotigotine patch might be effective in the treatment of AC. We suggest that rotigotine may represent a useful treatment option due to its favourable receptor profile and unique application form. In particular, it may be helpful in situations that might provoke AC, such as acute surgery. However, experience of the use of the rotigotine patch in this clinical setting is rather sparse and the patch is currently not approved for this indication.

Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.

A case of a brown tumor due to iatrogenic malabsorption following biliopancreatic diversion (BPD) is presented. A 52 year old women with a history of BPD 2 years before was referred to orthopedic surgery because of a painful lytic lesion of the left ankle. A bone biopsy revealed a giant cell tumor compatible with the diagnosis of a brown tumor. Subsequent metabolic evaluation showed severe 25-hydroxy vitamin D deficiency and secondary hyperparathyroidism (PTH 60 ng/L or twice the upper normal limit). Bone mineral density was decreased at the femoral neck (0.50 g/cm(2) ; T score of -3.92 or 66% of the expected value) and lumbar spine (T score of -1.75 or 93% of the expected value). A brown tumor can be the presenting symptom of iatrogenic malabsorption due to BPD. This case illustrates the severity of potential bone complications after BPD and the necessity of lifelong surveillance and vitamin supplements after BPD.

We report a case of a woman with secondary oxalosis after jejunoileal bypass surgery for obesity, who presented with oxalate stone disease and renal insufficiency requiring dialysis. Thirty years after surgery, longstanding osteoarticular symptoms were recognized as oxalate arthritis. Eventually, she also developed oxalate vasculitis, which improved with corticoid treatment and intensification of dialysis. Work-up for kidney transplantation revealed AA amyloidosis on gastric and colonic biopsies. Since no other cause of chronic inflammation could be identified, it was concluded that the amyloidosis was secondary to oxalate arthritis and vasculitis. To our knowledge, this is the first report on this association.

Morbid obesity is a significant problem in the Western world. Recently, there has been an increase in the number of patients undergoing surgical weight loss procedures. Currently, the most widely performed procedure is the Roux-en-Y gastric bypass operation which combines restriction of food intake with malabsorption of calories and various nutrients, resulting in weight loss and nutritional deficiencies, respectively. Various types of anemia may complicate Roux-en-Y and commonly include deficiencies of iron, folate, and vitamin B12. Iron deficiency is particularly common and may result from many mechanisms including poor intake, malabsorption, and mucosal bleeding from marginal ulceration. However, less appreciated etiologies of nutritional anemia include deficiencies of B-complex vitamins, ascorbic acid, and copper. Replacement of the missing or decreased constituent usually reverses the anemia. Since physicians of various medical and surgical specialties are often involved with the postoperative care of bariatric patients, a review of anemia in this patient population is warranted.

Background: Infants with short bowel syndrome (SBS) frequently have proximal enterostomies with the colon excluded from intestinal continuity. Restoring intestinal continuity may create difficulty with perineal soiling. We propose creation of a distal sigmoid colostomy as an option for select infants with SBS., Methods: This study involves the descriptive case series of all children with SBS who received a distal sigmoid colostomy., Results: Eight infants (mean age, 70 days) received creation of a distal colostomy. In 1, placement of the colostomy was done at the initial surgery for SBS, 2 at the time of intestinal lengthening, and 5 during another procedure. Median length of small bowel was 58 cm. At 60 days postprocedure, median gain in enteral tolerance was 21% (P = .09), with median stoma output of 125% enteral intake. There were no complications directly attributable to the distal colostomy., Conclusion: Establishment of a distal sigmoid colostomy is an excellent management strategy for select children with SBS. It provides the benefits of restoring bowel continuity such as increased fluid and electrolyte absorption, improved energy absorption from fermentation of carbohydrate to short-chain fatty acids, and the theoretical enhancement of glucagonlike peptide 2 secretion that may optimize intestinal adaptation-all while protecting the perineal skin and simplifying quantification and collection of stool.

As the number of persons living long lives following ostomy and bowel resection surgery increases, so do their questions about the effect of surgery on chronic conditions commonly associated with aging. The literature was reviewed to evaluate current evidence about the effect of bowel resection on the absorption of vitamins and minerals and related health concerns such as osteoporosis, gallstones, and renal calculi. Present knowledge about the process of vitamin and mineral absorption in the intestine and clinical study results suggest that chronic inflammation and corticosteroid use may adversely affect absorption. In general, a history of bowel resection does not appear to increase the risk of developing osteoporosis, gallstones, or renal calculi and the body can adjust to losing significant sections of intestine. Strategies to help prevent the majority of long-term complications should be encouraged, including monitoring hydration and transit time, consuming low-digestible carbohydrates, and avoiding processed foods as well as agents with chelating properties.

The pancreas is a retroperitoneal organ that releases water, bicarbonate and digestive enzymes by the main pancreatic duct (MPD) into the duodenum. Chronic pancreatitis (CP) is typically caused, in adults, by chronic alcohol abuse and, less frequently hypertriglyceridemia, primary hyperparathyroidism or cystic fibrosis. Exocrine dysfunction results in malabsorption of fat and subsequent steatorrhea. Damage to pancreatic endocrine function is a late finding in CP and results in hyperglycaemia or overt diabetes mellitus. Care of patients with CP principally involves management of pain. A significant change in the pain pattern or the sudden onset of persistent symptoms suggests the need to rule out other potential etiologies, including peptic ulcer disease, biliary obstruction, pseudocysts, pancreatic carcinoma, and pancreatic duct stricture or stones, then is important to establish a secure diagnosis. Management of pain should then proceed in a judicious stepwise approach avoiding opioids dependence. Patients should be advised to stop alcohol intake. Fat malabsorption and other complications may also arise. Management of steatorrhea should begin with small meals and restriction in fat intake. Pancreatic enzyme supplements can relieve symptoms and reduce malabsorption in patients who do not respond to dietary restriction. Enzymes at high doses should be used with meals. Treatment with acid suppression to reduce inactivation of the enzymes from gastric acid are recommended. Supplementation with medium chain triglycerides and fat soluble vitamin replacement may be required. Management of other complications (such as pseudocysts, bile duct or duodenal obstruction, pancreatic ascites, splenic vein thrombosis and pseudoaneurysms) often requires aggressive approach with the patient kept on total parenteral nutrition to minimize pancreatic stimulation.

Neonatal diabetes mellitus, which is defined as hyperglycemia presenting within the first six weeks of life, is a rare disorder. It may result in transient or permanent disease. Pancreatic agenesis is a rare cause of neonatal diabetes.We report a neonate who was small for gestational age and presented with diabetes mellitus and signs of malabsorption because of pancreatic agenesis.

Morbid obesity is a health problem that has been shown to be refractory to diet, exercise, and medical treatment. Surgeries designed to promote weight loss, termed bariatric surgery and typically involving a gastric bypass procedure, have recently been implemented to treat obesity with high success rates. However, long-term sequelae can result in micronutrient deficiencies. This review will focus on iron deficiency and its association with obesity and bariatric surgery. Iron deficiency develops after gastric bypass for several reasons including intolerance for red meat, diminished gastric acid secretion, and exclusion of the duodenum from the alimentary tract. Menstruating women, pregnant women, and adolescents may be particularly predisposed toward developing iron deficiency and microcytic anemias after bypass surgery. Preoperative assessment of patients should include a complete hematological work-up, including measurement of iron stores. Postoperatively, oral iron prophylaxis and vitamin C in addition to a multivitamin should be prescribed for bypass patients, especially for vulnerable populations. Once iron deficiency has developed, it may prove refractory to oral treatment, and require parenteral iron, blood transfusions, or surgical interventions. Bariatric surgery patients require lifelong follow-up of hematological and iron parameters since iron deficiency and anemia may develop years after surgery., (Copyright 2008 Wiley-Liss, Inc.)

Retractile mesenteritis is a rare benign inflammatory disease of the mesentery. Computed tomographic findings usually suggest the diagnosis, which is confirmed by surgical biopsies. Conservative treatment is empirical, based on corticosteroids, colchicine, immunosuppressive agents and progesterone. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. This report describes a 62-year old man with histologically proven retractile mesenteritis presenting with malabsorbtion syndrome, who presented pulmonary tuberculosis after initial therapy with corticosteroids. He was subsequently treated with oral pentoxifylline (800 mg/day), with substantial clinical and radiological improvement.

The liver plays a key role in the metabolism of nutrients. Therefore, liver failure is often associated with malnutrition. It is well-established that malnutrition is an independent prognostic factor in patients with cirrhosis and liver failure. Since standard anthropometric and biological indexes are associated with liver dysfunction, nutritional assessment is difficult in patients with cirrhosis. In this review, we explain the various causes and mechanisms leading to malnutrition in cirrhosis. We also describe reliable methods used to assess the nutritional condition of these patients. Finally, we stress the importance of nutritional care in cirrhosis and liver dysfunction, describing its specific characteristics and indications.

Background: Intestinal parasites not only cause diarrheal diseases but also significant malabsorption. Literature on the role of parasites, such as intestinal coccidia and microsporidia in malabsorption syndrome is limited., Methods: Three consecutive stool samples from 50 adult and 50 children patients with malabsorption syndrome and an equal number of healthy controls without diarrhea were examined for intestinal coccidia, microsporidia and other intestinal parasites by wet mount, Kinyoun's modified acid-fast staining and chromotrope 2R staining., Results: Celiac disease was the commonest cause of malabsorption syndrome in both adults (52%) and children (74%). Forty (80%) and 41 (82%) adults and children, respectively, with malabsorption syndrome were infected with parasites. These results were significantly higher in comparison to those from the healthy adults and children controls (22% and 16%), respectively (P < 0.001). Of them, 48% and 46% of the adults and children, respectively, with malabsorption had pathogenic parasitic infections. The pathogenic parasites detected in adults were Giardia lamblia 12 (24%), E. histolytica / dispar 5 (10%), Ancylostoma duodenale 4 (8%), H. nana 2 (4%) and Cyclospora cayetanensis 1 (2%). The pathogenic parasites detected in children with malabsorption syndrome were Giardia lamblia 8 (16%), Cryptosporidium 7 (14%), E. histolytica / dispar 3 (6%), Ancylostoma duodenale 3 (6%), Isospora belli 1 (2%), and H. nana 1 (2%). None of the stool samples from healthy controls were positive for Cryptosporidium spp., Cyclospora and Isospora belli. All the patients infected with intestinal coccidia were HIV sero-negative., Conclusion: Celiac disease is the most common cause of malabsorption syndrome in both adults and children. These people harbor significantly more pathogenic parasites and are more frequently colonized with harmless commensals as compared to healthy controls. Intestinal coccidia are associated with malabsorption syndrome, particularly in malnourished children.

Cystic fibrosis (CF) is now an adult disease. Approximately 30,000 children and adults are affected by this disease. CF, an autosomal recessive disease, is considered to be the most lethal inherited trait among Caucasians. The median age for the CF patient has significantly increased over the past 60 years. Today's oral and maxillofacial surgery practice is likely to include patients with CF with varying surgical needs. This article will review diagnosis, pathophysiology, and systemic complications of CF, and discuss relevant information for management of the CF patient for the oral and maxillofacial surgeon. Recommendations will be made for preoperative, perioperative, and postoperative care of these patients.

Amyloidosis is a unique metabolic storage disease that affects the gastrointestinal tract but rarely causes severe symptoms. We describe the case of a 51-year-old woman presenting with chronic small bowel diarrhoea and malabsorption. Barium contrast studies and enteroscopy revealed a coarse mucosal pattern and thickening of the jejunal and proximal ileal folds. Histological examination revealed massive deposits of amyloid in thejejunal wall. No predisposing factor was found and there were no other sites of deposition. This is a rare case report of primary selective small intestinal amyloidosis manifesting as the malabsorption syndrome.

Objective: Carbohydrate malabsorption causes more symptoms in patients with functional gastrointestinal disorders than in healthy individuals. The purpose of this study was to investigate whether this could be explained by differences in ileal brake hormone secretion., Material and Methods: Eighteen consecutive patients with functional abdominal complaints, referred to our clinic for investigation of self-reported food hypersensitivity, were included in the study and compared with 15 healthy volunteers. All subjects ingested a mixture of 25 g fructose and 5 g sorbitol. Pulmonary hydrogen and methane excretion and plasma glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) levels were measured during the next 3 h. Both habitual and post-test symptoms were assessed., Results: Malabsorption of fructose and sorbitol was present in 61% of the patients and 73% of the controls. Nevertheless, the patients experienced significantly more symptoms following carbohydrate challenge, and 78% of the patients claimed that the challenge replicated their habitual gastrointestinal complaints. No significant differences in gas excretion or GLP-1 and PYY levels were found between patients and controls or between symptomatic and asymptomatic carbohydrate malabsorbers. A weak correlation between hydrogen excretion and PYY levels was demonstrated in non-producers of methane., Conclusions: Neither intestinal gas production nor ileal brake hormone secretion seems to play a role in the symptomatology of carbohydrate intolerance in patients with self-reported food hypersensitivity. Other mechanisms related to bacterial fermentation may be involved and should be investigated further.

Introduction: Endocrine changes, particularly increases in parathyroid hormone (PTH), occurring after gastric bypass procedures have been reported but are not well characterized., Methods: We reviewed retrospectively patients who underwent Roux-en-Y (short limb (SL) = 75 cm, long limb (LL) = 165 cm) gastric bypass procedures at our institution from January-December 2005. Patient demographics, laboratory values of serum calcium, Vitamin D, and phosphorous concentrations as well as levels of alkaline phosphate and PTH were followed at quarterly intervals for one year., Results: 140 patients were identified. Mean age for the group was 45 years and 90% of patients were female. The average BMI was 49.2. The mean PTH levels increased from 29.4 immediately post-op to 43.1 ng/mL (P < .001) one year after surgery. Five percent of the patients had hyperparathyroidism (PTH>53 ng/mL) immediately postoperatively; the ratio then increased to 21% at one year. Only two patients had evidence of true primary hyperparathyroidism with increased PTH and hypercalcemia. Sixty percent of patients had at least a 10 ng/mL increase in PTH level at the end of one year, reflecting a 30% increase from baseline levels. Vitamin D deficiency (levels <20 ng/mL) were identified in 45 patients (32%) initially postoperatively and they continued to be low compared to the rest of the population (P = .004). Vitamin D levels did vary with seasonal sun exposure and were greatest in the third quarter (July-September). Sub-analysis of the group showed that patients with LL gastric bypass had lesser Vitamin D concentrations (22 vs 30 ng/mL, P < .01) compared to SL patients., Conclusion: Although preoperative endocrine abnormalities are present in patients undergoing gastric bypass procedures, the derangements intensify after gastric bypass surgery. A four-fold increase in patients with elevated PTH deserves special attention. When combined with the concurrent prevalence of low serum Vitamin D and normocalcemia in this population, we propose that this is a disorder of secondary hyperparathyroidism requiring medical treatment with Vitamin D supplementation.

Background: Growth in children with inflammatory bowel disease is often compromised., Aim: To explore the origins of growth retardation in paediatric inflammatory bowel disease and to consider management strategies., Methods: Relevant literature was identified and reviewed., Results: A combination of the following factors results in growth retardation: insufficient food intake, malabsorption, increased catabolism, disease activity, disease extension, complications of disease and the side-effects of treatment., Conclusions: Failure of normal growth in a child with inflammatory bowel disease is an indicator of insufficient and unsuccessful therapy. The major causative factor is chronic anorexia because of chronic catabolic illness. Growth resumes to normal after effective control of the disease and nutritional intake. Regular follow-up of growth in these children is mandatory, and the measurement of both height and weight is an ideal indication of effective treatment. Failure of sustained growth in a child or adolescent with inflammatory bowel disease is a warning to consider a change of clinical strategy.

Background: The rapid growth of obesity rates has affected the practice of specialized nutrition support in various ways. One area that deserves special consideration is the impact that bariatric surgery, in particular complications resulting from bariatric surgery, has made on nutrition support practice. A descriptive survey was designed to evaluate this impact and to assess the various approaches to nutrition assessment and interventions in the postoperative bariatric surgery patient., Methods: A web-based survey consisting of 17 questions was administered in April 2006 to American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) members with available e-mail addresses. Participants were queried about professional background, primary practice setting, and various issues related to their involvement in the care of bariatric surgery patients., Results: There were 467 responses returned out of 3400 surveys delivered (14% response rate). Sixty percent of responders estimated they were consulted to see 1-10 patients requiring specialized nutrition support over the previous year as a result of complications of bariatric surgery. The most common indications for specialized nutrition support in these patients were anastomotic leak/fistula (49%) and chronic nausea/vomiting (27%). When estimating calorie goals, 62% used an adjusted body weight, 15% used ideal body weight, and 14% used actual weight. When estimating protein goals, 56% used an adjusted body weight, 29% used ideal body weight, and 8% used actual weight., Conclusion: These observations provide impetus for guideline development and highlight the priority for further research regarding the best practices to ensure that postoperative bariatric surgery patients receive safe and appropriate nutrition support.

Midgut volvulus presenting outside the neonatal period often manifests with less than classic findings. One must be ever vigilant for any deviation from normal when imaging the gastrointestinal tract in these patients. Plain films often are noncontributory, and gastrointestinal imaging findings frequently are subtle and not exactly the same as those seen in classic cases in the neonatal period. Cases are presented illustrating the following: abnormal but less than classic small bowel location and configuration, malabsorption and fortuitous spiraling of a nasogastric tube, viral gastroenteritis and pseudo intussusception, intractable vomiting and dehydration with abnormal cecal position, and duodenal obstruction: pseudo SMA syndrome. Fortunately, one now can confirm one's suspicions with computed tomography and ultrasound in terms of determining whether the superior mesenteric artery and superior mesenteric vein positions are normal or reversed.

Small bowel bacterial overgrowth historically has been associated with malabsorption syndrome attributed to deconjugation of bile acids in the upper small intestine. Recent reports raise the possibility that bacterial overgrowth may be a cause of watery diarrhea or irritable bowel syndrome. Quantitative culture of jejunal contents has been the gold standard for diagnosis, but a variety of indirect tests have been developed (and mostly discarded) over the years in an attempt to facilitate the diagnosis of small bowel bacterial overgrowth. These include breath tests and biochemical tests based on bacterial metabolism of various substrates. Problems with these indirect tests include rapid transit, which may cause substrate to reach the luxuriant bacterial flora in the colon, producing false positives and vagaries of the tests themselves, which may produce falsely negative results. The perfect test for small bowel bacterial overgrowth is yet to be devised.

Background/aims: In order to clarify vitamin E malabsorption after gastric surgery, we evaluated serum vitamin E level and neurological consequences in patients who had undergone gastrectomy for gastric cancer., Methodology: We studied forty-eight patients (30 men, 18 women) with a mean age of 68.0 years, who had previously undergone gastrectomy for gastric cancer and had no evidence of recurrence. The types of operation consisted of subtotal gastrectomy in 26 patients and total gastrectomy in 22 patients. We measured postoperative body weight, white blood cells, red blood cells, hemoglobin, hematocrit, platelets, and serum levels of vitamins E, vitamin B12, folic acid, total cholesterol, triglycerides, total protein, and albumin., Results: Serum vitamin E level was decreased in 7 (14.6%) of the 48 patients. The occurrence of low vitamin E level was significantly more frequent in the total gastrectomy group than in the subtotal gastrectomy group. In relation to reconstruction procedures, the incidence of low vitamin E level was significantly higher in patients without food passage through the duodenum. The low vitamin E level was significantly associated with low total cholesterol level. The incidence of neuropathy was significantly higher in patients with low vitamin E level., Conclusions: We assume that vitamin E deficiency more likely occurs after the reconstruction procedure in which food does not pass through the duodenum. Transport disturbance with loss of passage through the duodenum consequently may be the major cause of malabsorption. Differential diagnosis of neurological symptoms in post-gastrectomy patients should include hypovitaminosis E.

Patients with ileal continent urinary diversion may present some awkward challenges to internists which have a considerable role in their long-term management. The potential metabolic complications result from both unphysiological exposure of the ileum to urine and decrease in absorbitive bowel capacity. Moreover, a variety of histopathomorphosic changes have been reported in ileal segment because of chronic exposure to urine. The risk of malignancy, particularly at ureteroileal anastomosis, is well documented in several large series but the mechanisms of development tumor in intestinal segments used for urinary diversion remain uncertain. In order to avoid both metabolic and tumoral complications of ileal urinary diversion, research has been conducted into using tissues other than bowel for bladder augmentation or replacement. Tissue engineering technologies provide intriguing means for the development of tissue that can mimic the barrier properties of the urothelium together with functional aptitudes of the smooth muscle wall. Recent advances in biomaterial sciences pose significant challenges for tissue engineering.

A case is reported of a woman who developed untreatable diarrhea after a prior biliopancreatic diversion (BPD), attributed to the malabsorptive component. Abdominal ultrasound incidentally found focal liver lesions. On fine needle aspiration biopsy, atypia was found, and these hepatic lesions were resected with free margins. The specimen showed liver metastases of an aggressive malignant neuroendocrine neoplasm. The primary site was subsequently identified to be in the pancreas. The physician and surgeon must realize that non-related diseases can develop after bariatric surgery, as in the general population.

Background: Malabsorption syndrome often develops in patients with common variable immunodeficiency (CVID). Why structural damages appear in some CVID patients and not in others is not fully understood. Memory B cells (MBs) are responsible for the production of specific antibodies, and their defects have previously been related to autoimmune, granulomatous, and lymphoproliferative complications of CVID. The objective of this study was to ascertain whether a relationship exists between MB defects and the clinical outcome of respiratory and intestinal involvement in these patients., Methods: Forty-one CVID patients were grouped as follows, according to the quantification of peripheral MBs: the MB2 group (n = 7) included patients with normal MBs; the MB1 group (n = 16) included patients with low switched MBs; and the MB0 group (n = 18) included patients with absent/low MBs. The clinical outcome of respiratory and intestinal involvement of patients was then compared among the three groups., Results: In the MB0 group, chronic lung disease (ie, bronchiectasis and diminished FVC and/or FEV1) developed in 50% of patients vs 13% in the MB1 group and 0% in the MB2 group (p < 0.05). In the MB0 group, malabsorption syndrome or chronic noninfectious diarrhea developed in 50% of patients vs 19% in the MB1 group and 0% in the MB2 group (p < 0.05). No differences were found among the three groups for age at onset of symptoms, delay in diagnosis/treatment, months of follow-up/treatment, and prediagnostic serum IgG concentration., Conclusions: Alterations in MB count appear to be associated with a severe clinical outcome of respiratory and intestinal involvement in CVID. The MB count could be a useful laboratory parameter for orienting the prognosis and management of CVID patients.

Significant weight loss, a body mass index of less than 18.5, hypoalbuminemia, and a deficiency in specific nutrients are major criteria. Depending on the underlying diagnosis, maldigestion, malabsorption, catabolism, dysphagia, anorexia and intestinal obstruction are possible causes of malnutrition. In the majority of cases, malnutrition is associated with a poorer prognosis, a reduced general health status, and poorer quality of life. This means that in addition to treatment of the underlying disease, specific nutritional support, preferably by the enteral route, with the aim of providing an adequate supply of nutrients and improving the patient's general nutritional status is of importance.

Background: Duodenal switch (DS) operation combines both restrictive and malabsorptive components and has become an accepted operation in selected patients with morbid obesity. Complications develop in some patients, which are refractory to dietary supplementation. We report a series of 33 patients who required partial revision of the DS., Study Design: During the 10-year period after September 1992, 701 patients had DS operation performed; of these, 33 (5 men and 28 women) patients required revision. Revision was performed by side to side enteroenterostomy 100 cm proximal to the original anastamosis. Outcomes measures reviewed include postoperative complications, nutritional parameters, and weight change., Results: Revision was performed a median of 17 (range 7 to 63) months after DS. Indications for revision included protein malnutrition (n = 20), diarrhea (n = 9), metabolic abnormalities (n = 5), abdominal pain (n = 3), liver disease (n = 2), emesis (n = 2), and gastrointestinal bleed (n = 1). Median body mass index at the time of revision was 28. Median serum albumin was 3.6 g/dL and improved to 4.0 g/dL postoperatively (p = 0.01). Complications occurred in 5 of 32 patients (15%) and included wound infection (n = 2), respiratory failure (n = 1), gastrointestinal bleed (n = 1), and small bowel obstruction (n = 1). There was no perioperative mortality. During a median followup period after revision of 39 months, the median weight gain was 18 pounds. Three patients requested repeat operation because of weight regain., Conclusions: Patients requiring revision of DS for malnutrition can be corrected by a technically simple procedure, but they are at considerable risk for complications. Although many patients are anxious about regaining their weight after reversal, they can be reassured that substantial weight gain is unlikely.

Morbidly obese patients often have nutritional deficiencies, particularly in fat-soluble vitamins, folic acid and zinc. After bariatric surgery, these deficiencies may increase and others can appear, especially because of the limitation of food intake in gastric reduction surgery and of malabsorption in by-pass procedures. The latter result in more important weight loss but also increase the risk of more severe deficiencies. The protein deficiency associated with a decrease in the fat-free mass has been described in both procedures. It can sometimes require an enteral or parenteral support. Anemia can be secondary to iron deficiency, folic acid deficiency and even to vitamin B12 deficiency. Neurological disorders such as Gayet-Wernicke encephalopathy due to thiamine deficiency, or peripheral neuropathies may also be observed. Malabsorption of fat-soluble vitamins and other nutrients, especially if diagnosed after by-pass surgery, rarely cause clinical symptoms. However, some complications have been reported such as bone demineralization due to vitamin D deficiency, hair loss secondary to zinc deficiency or hemeralopia from vitamin A deficiency. A careful nutritional follow-up should be performed during pregnancy after obesity surgery, because possible deficiencies can affect the health of both the mother and child. In conclusion, increased awareness of the risk of deficiency and the systematic dosage of micronutrients are needed in the pre- and postoperative period in obese patients undergoing bariatric surgery. The case by case correction of these deficiencies is mandatory, and their systematic prevention should be evaluated.

Celiac disease is characterized by small bowel enteropathy, precipitated in genetically susceptible individuals by the ingestion of "gluten," which is a term used to encompass the storage proteins of wheat, rye, and barley. Although the intestine heals with removal of gluten from the diet, the intolerance is permanent and the damage recurs if gluten is reintroduced. This damage causes a wide variety of consequence including maldigestion and malabsorption, resulting in the characteristic, although not universal, features of malnutrition. This article examines recent advances in the understanding of the spectrum of celiac disease, illustrates the impact of celiac disease on nutrition, and describes approaches to the management of the disease.

Introduction: The neurological manifestations of Crohn's disease are rare, dominated by multiple mononeuropathies and the abnormalities of the white matter. Polyradiculoneurities remain exceptional., Observations: We report the case of a 33-year-old patient admitted for an ascending weakness of all four limbs. Eight years earlier he had presented a similar episode which had regressed spontaneously. The neurological examination revealed a tetraparesis with areflexia and hypotonia. These manifestations were concomitant with chronic diarrhea which had been neglected to date. The electrophysiological aspect was compatible with an acute polyradiculoneuritis. The analysis of the cerebrospinal fluid showed an albumino-cytological dissociation. The existence of the diarrhea directed the investigations towards an inflammatory enteropathy, which was attested later on by the endoscopic, radiologic and histological data leading to the diagnosis of active Crohn's disease. The diagnosis of a relapsing polyradiculoneuritis associated with Crohn's disease was retained. The patient was treated by salazopyrine-budesonide with improvement in the digestive and neurological manifestations after 3 years., Conclusion: The frequency of neurological features in Crohn's disease is not well documented. The incriminated mechanisms are either directly related to the disease (deficit in B12 vitamin or folic acid and/or by the means of an auto-immune vascularitis) or secondary to long-term treatment with metronidazole. The course of neurological manifestations is largely dependent on the course of the inflammatory disease.

In cystic fibrosis (CF), pancreatic insufficiency and a diminished bile acid pool cause malabsorption of important nutrients and dietary components leading to deficiency, poor nutritional status, and oxidative stress. Of particular significance is the malabsorption of fat-soluble nutrients and antioxidants, which are important for normal immune and neurologic function. Patients with CF often are deficient in these compounds despite supplementation with the current standard of care therapy. The objective was to compare the pharmacokinetic profile of this water-soluble vitamin E formulation (Aqua-E) with an oil-based softgel formulation in a malabsorbing patient population. Patients with CF who had documented malabsorption were recruited for participation in this pharmacokinetic study. Patients who met inclusion and exclusion criteria discontinued vitamin E supplementation, except for that in a multivitamin, for 7 to 21 days before the day of dosing. Patients were randomized to a single dose of 20 ml of Aqua-E or three oil-based softgels, which contained equivalent amounts of tocopherols. Blood was drawn from patients at time 0, 2, 4, 8, 24, 48, and 168 hr and analyzed for tocopherols. Eight patients were enrolled in the study and randomized to Aqua-E or softgels. The primary outcome, the absorption of gamma-tocopherol in Aqua-E (AUC=115 micro g/ml(*)hr), was significantly greater than that of oil-based softgels (AUC=25.3 micro g/ml(*)hr; P=0.013). Total-tocopherols (alpha+gamma+delta) in Aqua-E (AUC=294 micro g/ml(*)hr) showed a strong trend toward increased absorption compared with that of oil-based softgels (AUC=117 micro g/ml(*)hr; P=0.09). In conclusion, this novel, water-soluble formulation showed a marked and statistically significant increase in absorption of gamma-tocopherol in malabsorbing patients with CF compared with an oil-based formulation.

Anemia is common in patients following gastrectomy. The purpose of this study was to document causes of anemias developing during the post-gastrectomy period and to determine the importance of complete blood count parameters on types of anemia. A total of 72 patients (23 women and 49 men) who had previously undergone gastrectomy in the past and who were admitted for the evaluation of anemia were enrolled in study. The patients who were evaluated and treated for anemia in the post-gastrectomy period were excluded. Iron deficiency anemia was present in 68 (94.4%) of 72 gastrectomized patients with anemia. Deficiencies of vitamin B12 and folate were present in 57 (79.2%) and in three patients, respectively. The most common cause of anemia was the combination of iron and vitamin B12 deficiencies. Iron deficiency was present in the majority of patients, followed by vitamin B12 deficiency in frequency. In all combinations of iron deficiency, the values of mean cell hemoglobin and mean cell hemoglobin concentration were either normal or low. In cases who had low white blood cell and platelet counts vitamin B12 deficiency was frequent, while in cases who had high numbers of white cells or platelets iron deficiency was more frequent. In conclusion, gastrectomized patients should be followed for anemia and treated appropriately based on the cause of anemia.

Background: Biliopancreatic bypass with duodenal switch is a treatment for morbid obesity that combines restriction of dietary intake with a high degree of malabsorption. The operation involves the risk of losing important nutritional elements., Material and Methods: 64 women and 14 men who had a biliopancreatic bypass with duodenal switch performed in 2002 - 2005 and were followed up at least once, six months or later after surgery, were examined with 3 to 6-month intervals for the following; body weight, clinical status, haematological variables, ferritin, folate, albumin, creatinine, retinol, alpha-tocopherol/lipids, vitamin D metabolites, parathyroid hormone, vitamin B1, lipids, glucose and other clinical chemical variables., Results: Weight loss after surgery was substantial and rapid, from a mean of 153.8 kg (SD 30.2) to 92.7 kg (SD 21.6) after one year (n = 74). Low values of serum albumin, creatinine, retinol, 25-OH vitamin D and elevated parathyroid hormone were very common. Four women and three men (9 % of all) with common channels of < 100 cm, required a surgical revision mainly due to hypoalbuminemia. Two women became pregnant before the recommended 18 months after surgery., Interpretation: Biliopancreatic bypass with duodenal switch in patients with common channels < 100 cm, has a high rate of complications and nutritional deficiencies. This surgery should be used restrictively.

Background: Intestinal malabsorption in the elderly is infrequent, and clinical features are muted so that the diagnosis is often missed. Physiologic changes with aging are restricted to altered absorption of calcium and perhaps zinc and magnesium; however, achlorhydria can lead to impaired absorption of vitamin B(12), folic acid, and calcium., Methods and Results: Small bowel bacterial overgrowth occurs more commonly in elderly than in younger patients, accompanying gastric hypochlorhydria, altered intestinal motor activity, or diseases such as Parkinson's disease. Changes in pancreatic anatomy and secretion occur but are insufficient to produce macronutrient malabsorption. In addition to pancreatic cancer and pancreatic stones, older patients may present with severe pancreatic insufficiency of unknown etiology. Celiac disease is recognized as very common at all ages and may not become evident until late in life. Manifestations of celiac disease in the elderly are occult and the diagnosis often is not considered until serologic tests are performed and confirmed by upper small intestinal biopsy. Associated intestinal lymphoma, esophageal carcinoma, intestinal pseudo-obstruction, and splenic atrophy may be more common in the elderly. Treatment of older patients with celiac disease with a gluten-free diet may be difficult, and intensive vitamin and micronutrient replacement is mandatory. A pragmatic approach to the evaluation of malabsorption in elderly patients is discussed., (Copyright 2007 S. Karger AG, Basel.)

Pathological conditions, which are the reason of indigestive and resorption in small intestine are linked with nutrition and are so-called malabsorptions. The reason of these conditions is on one hand decreasing of production abilities and on the other hand bad prosperity of farm husbandry eventually domestic animals. Malabsorptions are classified from pathological point of view to secondary and primary. To the first category belong the postsurgical state of digestive organs, malfunction of digestive organs from the various reasons such as decreasing of bile activity, decreasing of pancreas activity or for the reason of the malignant changes in the digestive organs or as the consequence of antibiotic treatment or cytostatics. The second category represents endogenous malfunction of intestine enzymes, which are linking with hypersensitivity to some kinds of feed. However the secondary malabsorptions are epiphenomenon several diseases, are in text also cure method mentioned, respectively mark of cure in some stadium diagnosed malabsorption. This present study is particulary oriented to pathogenesis and characterisation of the primary and secondary malabsorptions in the veterinary theory and praxis.