Important INFO on deficiencies and malabsorption...LONG

Clinical signs and symptoms of malabsorption and maldigestion Clinical sign or symptom Deficient nutrient General Weight lossLoss of appetite, amenorrhea, decreased libido CalorieProtein energy Skin Psoriasiform rash, eczematous scalingPallorFollicular hyperkeratosisPerifollicular petechiaeFlaking dermatitisBruisingPigmentation changesScrotal dermatosisThickening and dryness of skin ZincFolate, iron, vitamin B12Vitamin AVitamin CProtein energy, niacin, riboflavin, zincVitamin KNiacin, protein energyRiboflavinLinoleic acid Head Temporal muscle wasting Protein energy Hair Sparse and thin, dyspigmentationEasy to pull out Protein Eyes History of night blindnessPhotophobia, blurring, conjunctival inflammationCorneal vascularizationXerosis, Bitot's spots, keratomalacia Vitamin ARiboflavin, vitamin ARiboflavinVitamin A Mouth GlossitisBleeding gumsCheilosisAngular stomatitisHypogeusiaTongue fissuringTongue atrophyScarlet and raw tongueNasolabial seborrhea Riboflavin, niacin, folic acidVitamin C, riboflavinRiboflavinRiboflavin, ironZincNiacinRiboflavin, niacin, ironNiacinPyridoxine Neck GoiterParotid enlargement IodineProtein Thorax Thoracic 'rosary' Vitamin D Abdomen DiarrheaDistentionHepatomegaly Niacin, folate, vitamin B12Protein energyProtein energy Extremities EdemaSoftening of boneBone tendernessBone ache, joint painMuscle wasting and weaknessMuscle tenderness, muscle painHyporeflexia Protein, thiamineVitamin D, calcium, phosphorusVitamin DVitamin CProtein, caloriesThiamineThiamine Nails Flattening, brittleness, luster loss, spooningTransverse lines IronProtein Neurologic TetanyParesthesiasLoss of reflexes, wrist drop, foot dropLoss of vibratory and position sense, ataxiaDementia, disorientation Calcium, magnesiumThiamine, vitamin B12ThiamineVitamin B12Niacin Blood AnemiaHemolysis Iron, vitamin B12, folatePhosphorus The patient who gives a history of progressive weight loss, polyphagia, excessive flatus, diarrhea, bulky and foul-smelling stools, food particles or fat in the stool, abdominal distention, muscle wasting, bone pain, bleeding, weakness, tetany, paresthesia, glossitis, cheilosis or dermatitis is giving you the "classical" history of severe intestinal malassimilation. Specific vitamin and mineral deficiencies Vitamin/mineral Clinical manifestation Vitamin A Eyes Night blindnessXerosis (dry bulbar conjunctiva)Bitot's spots (conjunctiva plaques)Keratomalacia (corneal ulceration) Skin Hyperkeratosis Vitamin B12 Hematologic, neurologic systems AnemiaNonreversible loss of vibratory and position senseParesthesia Gastrointestinal Diarrhea Vitamin C Skin Perifollicular papules (brittle hair)Perifollicular hemorrhagesGum bleedingSkin purpura, ecchymosis Vitamin D Bone Bone pain and softeningJoint painRicketsProximal myopathy Vitamin K BruisingBleeding Vitamin B6(Pyridoxine) Skin Seborrheic dermatitisCheilosisGlossitis Niacin DermatitisDiarrheaDementia Thiamine CVSCNS Congestive heart failureWernicke's encephalopathyWernicke-Korsakoff syndrome Zinc Skin Acrodermatitis enteropathicaAlopecia Taste Hypogeusia Folate Hematologic, neurologic systems AnemiaReversible loss of position and vibratory sense CVS = cardiovascular system; CNS = central nervous system It is not uncommon for the patient to think the toilet is malfunctioning because several flushings are needed to remove the stool. A greasy character and truly rancid odor are indicative of increased stool fat, but are often absent until late. These complaints are often readily passed over by the busy physician. At such time, physical findings are usually absent, but hyperactive bowel sounds may be noted, especially in small intestinal disease. If symptoms are intermittent or if they progress slowly over many years, patients may exhibit vague, seemingly unrelated symptoms such as chronic fatigue and depression, long before the physician considers the possibility of serious organic disease. Carbohydrate malabsorption will result in symptoms of diarrhea and excessive flatus (gas). Malabsorbed carbohydrates that enter the colon are fermented by colon bacteria into gases. Stools seem to float on the water because of their increased gas content (not because of their fat content). This often happens when the gastric bypass patient begins to eat more carbohydrates, instead of protein. Given sufficient time, fat and muscle will be catabolized. Physical examination may reveal signs of weight loss from both fat stores and lean body mass. The patient will be weak and will easily develop fatigue. Fat loss will generally be noted as sunken cheeks and flat buttocks, with wrinkled or loose skin indicative of loss of subcutaneous fat stores. There may be direct evidence of a reduced metabolic rate. The patient will often be mentally slowed. Fat malabsorption Failure to digest or absorb fats results in a variety of clinical symptoms and laboratory abnormalities. These manifestations are the result of both fat malabsorption per se and a deficiency of the fat-soluble vitamins. In general, loss of fat in the stool deprives the body of calories and contributes to weight loss and malnutrition. Failure to absorb the fat-soluble vitamins A, D, E and K also results in a variety of symptoms. Vitamin K deficiency presents as subcutaneous, urinary, nasal, vaginal and gastrointestinal bleeding. Deficiencies in factors II, VII, IX and X produce defective coagulation. Vitamin A deficiency results in follicular hyperkeratosis. Vitamin E deficiency is destructive to the central nervous system. Malabsorption of vitamin D causes rickets, osteopenia and osteoporosis. Protein malabsorption Severe loss of body protein may occur before the development of laboratory abnormalities. Clinically, protein deficiency results in edema and diminished muscle mass. Since the immune system is dependent upon adequate proteins, protein deficiency can manifest as recurrent or severe infections. Protein deficiency in children results in growth retardation, mental apathy and irritability, weakness and muscle atrophy, edema, hair loss, deformity of skeletal bone, anorexia, vomiting and diarrhea. Protein-calorie malnutrition is known as marasmus, whereas protein malnutrition by itself is known as kwashiorkor. Protein/Energy Malnutrition Attempts have been made to classify malnutrition into a predominantly protein-depleted (i.e., kwashiorkor) or calorie- (energy-) starved (i.e., marasmus) state. In kwashiorkor, the subject ingests a moderate number of calories, usually as complex carbohydrate (e.g., rice), but very little protein. The liver is therefore supplied with inadequate amino acids. The liver becomes fatty and enlarged. Furthermore, other proteins, including albumin, are inadequately produced by the liver in kwashiorkor, and serum albumin falls, with resulting peripheral edema. With marasmus the subject takes inadequate amounts of protein and calories. The low caloric intake means that only small amounts of carbohydrate are taken; with adequate delivery of amino acids from muscle to the liver for protein production. Fatty liver does not occur, and serum albumin levels tend to be normal, with no peripheral edema. Often patients fall between these two extremes of nutritional states, but there are examples of kwashiorkor and marasmus in Western clinical practice. Anorexia nervosa is a classic example of marasmus. Marked muscle wasting and loss of subcutaneous tissue (adipose tissue****ur with normal-sized nonfatty livers and no peripheral edema. In contrast, the intensive care unit patient who has received intravenous dextrose (glucose) without amino acids for a prolonged period will often show a fatty liver and marked hypoalbuminemia (low albumin levels) and edema. Clinical features of protein-energy malnutrition vary depending on the severity and duration of nutrient deficiency, age at onset and the presence or absence of other contributing or conditioning factors. With minimal deficiency, abnormalities may be subtle - particularly in adults, in whom there are no growth requirements. In these patients muscle wasting and loss of subcutaneous fat may be present. Weakness and minimal changes in psychomotor function may develop. Nontender parotid enlargement (glands in the face and neck) may occur, sometimes bilaterally. Patchy brown pigmentation, particularly over the malar eminences of the face, may occur. A lackluster appearance with thinning and increased shedding of hair from the sides of the head, particularly on combing or brushing, may develop. Bradycardia may occur. Variable degrees of hepatomegaly may result, sometimes with steatosis. In patients with protein-energy malnutrition following jejunoileal bypass a wide spectrum of histopathologic change has been observed, similar to findings frequently associated with alcoholic liver disease. In adults with severe protein-energy malnutrition and in growing children, clinical features may be even more significant. Muscle wasting, subcutaneous fat loss, dependent edema and weight loss may be marked. Severe mental apathy and reduced physical activity may occur. Abnormalities in the hair, particularly of children, may be striking. Severe dyspigmentation may develop, especially distally; rarely, alternating strands of light and dark hair are observed. Hair may be removed without pain. Nails may become brittle, with horizontal grooves. An asymmetrical confluent pattern of skin hyperpigmentation may be seen, particularly over perineal and exposed areas, such as the face. Extensive desquamation may occur, leaving depigmented areas of superficial ulcers, particularly on the buttocks and backs of the thighs. Gastrointestinal symptoms are common but variable. These include marked constipation, diarrhea, anorexia or hyperphagia, nausea, vomiting and dehydration. Laboratory features are also variable. Serum proteins may be substantially reduced, including serum albumin and some higher-molecular-weight transfer proteins, such as transferrin, ceruloplasmin, lipoproteins, thyroxin and cortisol binding proteins. Serum amino acid analysis may show a decrease in essential amino acids (i.e., leucine, isoleucine, valine, methionine), and either normal or depressed levels of nonessentials (i.e., glycine, serine, glutamine). The urinary excretion of urea, creatinine and hydroxyproline may decrease. Severe electrolyte abnormalities develop, although serum levels may be normal. Symptoms of Iron deficiency Anemia Sometimes accompanying iron deficiency and subsequent anemia may be symptoms of pica and dysphagia. Pica originally referred to the eating of clay or soil; however the commonest "Pica" in North America is the eating of ice. Dysphagia: sores on the tongue and esophagus and/or reddened lips with sores. Weakness, fatigue, and edema also can occur. Physical examination often reveals pallor, and brittle, flat or spoon-shaped fingernails. Calcium, Vitamin D and Magnesium malabsorption May lead to bone pain, fractures, paresthesias, tetany, Chvostek's sign and Trousseau's sign. Vitamin D deficiency principally affects the spine, rib cage and long bones with or without fractures, and may cause extreme pain, particularly in the spine, pelvis and leg bones. Insufficient magnesium may cause seizures and symptoms identical to those of insufficient calcium. Malabsorption of B-12 The daily requirement for Vitamin B-12 (cobalamin) is 1 mg. The human liver can store approximately 5 mg of B-12 (cobalamin). These large stores account for the delay of several years in the clinical appearance of deficiency after B-12 (cobalamin) malabsorption begins. Electrolyte and water absorption Although water and electrolytes are also absorbed in the large intestine, much of this absorbtion and secretion is done in the small intestine. Since the gastric bypass patient has much of the small intestine bypassed, this overall balance is shifted toward secretion. Therefore, dehydration is more prominent in gastric bypass patients, requiring a higher than average intake of water per day. Short Bowel Syndrome The severity of symptoms following resections of large segments of the small bowel relates to the extent of the resection, to the specific level of the resected small bowel and to the reason for which the resection was undertaken. The level of resection is important because absorption of nutrients is most effective in the proximal small bowel (iron, folate and calcium). This section is bypassed in gastric bypass surgery. Resection of up to 40% of the intestine is usually tolerated provided the duodenum (bypassed in gastric bypass) and proximal jejunum (bypassed in gastric bypass) and distal half of the ileum and ileocecal valve are spared. Resection of 50% of the small intestine results in significant malabsorption, and resection of 70% or more of the small intestine will result in severe malnutrition sufficient to cause death unless the patient's malnutrition is aggressively treated. Where, exactly, each gastric bypass patients fits in this, is dependant on the type of surgery, and the length of bypass, but all result in a significant amount of malabsorption. Postgastrectomy Malabsorption Postgastrectomy malabsorption frequently follows gastric surgery. The small size of the gastric remnant (pouch) causes inadequate mixing of food with digestive juices. With the loss of the pylorus, there may be rapid gastric emptying, poor mixing of bile and pancreatic secretions, and rapid transit down the small intestine. Incoordinated secretion and poor mixing of bile and pancreatic juice leads to fat maldigestion. Gastric surgery that allows food to enter into the upper small intestine without dilution and with minimal digestion may "unmask" mild and subclinical celiac disease, lactase deficiency or pancreatic insufficiency.

If you are interested in having a better copy of this, I can email it to you! It looks much better than this and easier to follow! Hugz Dawn OR I also posted this on the mainboard to someones post- Can someone refresh my memory please!

Dawn, Would you email it to me? There's a few things that I'd like to read a little bit more about...did this come from a website? If so, please post the URL so I can go there and investigate the symptoms of my interest. Thanks! Sherri