Sprue disease

Persons who have intestinal diseases, such as ulcerative colitis or sprue... 

Noninfectious causes of acute diarrhea include drugs and toxins (Table 18-3), laxative abuse, food intolerance, irritable bowel syndrome (IBS), inflammatory bowel disease, ischemic bowel disease, lactase deficiency, Whipple s disease, pernicious anemia, diabetes mellitus, malabsorption, fecal impaction, diverticulosis, and celiac sprue. 

Bile salt deficiency must also be directly studied. It may occur in the absence of obstruction or obvious liver disease (R7). The majority of patients with one form or another of the sprue syndrome will be found to have pancreatic enzymes and bile salts within the normal range. Pancreatic enzymes are absent or markedly deficient in patients with pancreatogenous malabsorption syndrome (B17, F13). It is surprising how frequently this necessary step in differential diagnosis is omitted. 

F14. Frazer, A. C., Disordered gastro-intestinal function and its relationship to tropical sprue, coeliac disease and idiopathic steatorrhoea. Trans. Boy. Soc. Trop. Med. Hyg. 46, 576 (1952). 

R8. Rubin, C. E., Brandborg, L. L., Phelps, P. C., and Taylor, H. C., Jr., Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue. Gastroenterology 38, 28-49 (1960). 

R12. Rubin, C. E., Celiac disease and idiopathic sprue. Some reflections on reversibility, gluten and the intestine. Gastroenterology 39, 260-261 (1960). 

Santini, R., Jr., Aviles, J., and Sheehy, T. W., Sucrase activity in the intestinal mucosa of patients with sprue and normal subjects. Am. J. Digest. Diseases 5, 1059-1062 (1960). 

Santini, R., Jr., Perez-Santiago, E., Martinez de Jesus, J., and Butterworth, C. E., Jr., Evidence of increased intestinal absorption of molecular sucrose in sprue. Am. ]. Digest. Diseases 2, 683-668 (1957). 

Parenteral Anticoagulant-induced prothrombin deficiency hypoprothrombinemia secondary to conditions limiting absorption or synthesis of vitamin K (eg, obstructive jaundice, biliary fistula, sprue, ulcerative colitis, celiac disease, intestinal resection, cystic fibrosis of the pancreas, regional enteritis) drug-induced hypoprothrombinemias due to interference with vitamin K metabolism (eg, antibiotics, salicylates) prophylaxis and therapy of hemorrhagic disease of the newborn. 

Since vitamin A is a fat-soluble vitamin, any disease that results in fat malabsorption and impaired liver storage brings with it the risk of vitamin A deficiency these conditions include biliary tract disease, pancreatic disease, sprue, and hepatic cirrhosis. One group at great risk are children from low-income families, who are likely to lack fresh vegetables (carotene) and dairy products (vitamin A) in the diet. 

Gastrointestinal diseases Inflammatory bowel disease, nontropical sprue, subacute hepatic necrosis... 

Calcium and phosphate enter the body from the intestine. The average American diet provides 600-1000 mg of calcium per day, of which approximately 100-250 mg is absorbed. This figure represents net absorption, because both absorption (principally in the duodenum and upper jejunum) and secretion (principally in the ileum) occur. The amount of phosphorus in the American diet is about the same as that of calcium. However, the efficiency of absorption (principally in the jejunum) is greater, ranging from 70% to 90%, depending on intake. In the steady state, renal excretion of calcium and phosphate balances intestinal absorption. In general, over 98% of filtered calcium and 85% of filtered phosphate is reabsorbed by the kidney. The movement of calcium and phosphate across the intestinal and renal epithelia is closely regulated. Intrinsic disease of the intestine (eg, nontropical sprue) or kidney (eg, chronic renal failure) disrupts bone mineral homeostasis. 

There are several forms of intolerance to lactose and galactose. Primary adult lactase deficiency is a normal age-related decrease in lactase activity seen in the majority of adults. Secondary lactase deficiency is a transient state of low enzyme activity following injury to the intestinal mucosa as a result of diseases such as celiac sprue, infectious gastroenteritis, and protein-calorie malnutrition. The last two states are common conditions (Dahlqvist 1983). 

Tissue reserves of retinoids in the healthy adult are sufficiently large to require long-term dietary deprivation to induce deficiency. Vitamin A deficiency occurs more commonly in chronic diseases affecting fat absorption, such as biliary tract or pancreatic insufficiency, sprue, Crohn s disease involving the terminal ileum, and portal cirrhosis deficiency may also occur following partial gastrectomy or during extreme, chronic dietary inadequacy. 

It should be noted that deficiency states for some vitamins (e.g., pantothenic acid) are practically unknown in human beings. In such cases, deficiency states may be simulated by feeding the subject an appropriate vitamin antagonist. In another series of situations, vitamin deficiencies can be brought about by interfering with their absorption intentionally or may be the result of a disease process. Thus, fat-soluble vitamin deficiency may develop in cases of fat malabsorption syndromes (steatorrhea) sprue, pancreatic insufficiency, and bile duct obstruction. 

Normally there is very little fat in the feces. However, fat content in stools may increase because of various fat malabsorption syndromes. Such increased fat excretion is steatorrhea. Decreased fat absorption may be the result of failure to emulsify food contents because of a deficiency in bile salts, as in liver disease or bile duct obstruction (stone or tumor). Pancreatic insufficiency may result in an inadequate pancreatic lipase supply. Finally, absorption itself may be faulty because of damage to intestinal mucosal cells through allergy or infection. An example of allergy-based malabsorption is celiac disease, which is usually associated with gluten intolerance. Gluten is a wheat protein. An example of intestinal infection is tropical sprue, which is often curable with tetracycline. Various vitamin deficiencies may accompany fat malabsorption syndromes. 

The Lundh test also includes intestinal intubation and direct measurement of enzyme output in duodenal juice but uses a standardized test meal as a pancreatic stimulus. Because this test requires release of physiological regulatory mediators from the duodenal mucosa, it is less specific than the SC test and may render falsepositive results in intestinal diseases such as celiac sprue. 

Measurement of stool weight and quantitative fecal fat excretion on three consecutive days during a balanced diet are common screening tests for both pancreatic insufficiency and other pathologies that result in malabsorption. However, these tests are insensitive and nonspecific for pancreatic malfunction Steatorrhea occurs only after loss of more than 90% of exocrine parenchyma, and other causes of malabsorption (e.g., celiac sprue or Crohn s disease) may also induce abnormal fecal fat excretion of more than 7 g/day or more than 5 g/100 g. 

Diseases of ileal mucosa (Crohn s or Bechet s disease,TB, actinomycosis, lymphoma, ulcerative ileo-jejunitis [due to sprue], radiation enteritis, HIV enteropathy, Yersinia enteritis)... 

Chronically abnormal epithelium Amyloidosis Coeliac disease Crohn s disease Ischaemia Radiation enteritis Tropical sprue Whipple s disease... 

DEFICIENCY Pernicious anemia. Conceivably, one could get Bi2 deficiency on a purely vegetarian diet, but this is rare. Deficiency is more likely with diseases of the intestine that impede absorption (e.g., tropical sprue, regional enteritis). The tapeworm Diphyllobothrium latum may deplete Bi2 stores. A deficiency of gastric intrinsic factor (a glycoprotein) may result in Bj2 deficiency, as intrinsic factor is important in facilitating Bj2 absorption in the bowel. Intrinsic factor deficiency may occur following gastrectomy or as an entity in itself, in pernicious anemia. Intrinsic factor deficiency sometimes results from an autoimmune disease. 

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