Steatorrhea Sprue

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. 

Malabsorption syndrome Steatorrhea Tropical sprue Idiopathic hypercalcemia... 

Effects in Patients with Idiopathic Steatorrhea and Tropical Sprue. 89... 

The main points of differentiation are summarized in Table 2. It will be seen that the group can be divided up into gluten-induced enteropathy, acute sprue, chronic sprue and idiopathic steatorrhea. As the cause of the sudden development of severe folic add deficiency... 

Gluten-induced enteropathy Acute sprue Chronic sprue Idiopathic steatorrhea... 

C14. Crismer, R., Dreze, C., and Demelenne-Jaminon, G., Neomycin cure of steatorrhea associated with Proteus hauseri enteritis relation of infectious steatorrhea to sprue nostras. Acta Gastroenterol. Belg. 22, 47-55 (1959). 

R6. Rodriguez-Molina, R., Cancio, M., and Asenjo, C. F., The effect of folic acid on the steatorrhea of tropical sprue and other tests for intestinal absorption. Am. J. Trop. Med. Hyg. 9, 308-314 (1960). 

Oral As a dietary supplement when calcium intake may be inadequate. Conditions that may be associated with calcium deficiency include the following Vitamin D deficiency, sprue, pregnancy and lactation, achlorhydria, chronic diarrhea, hypoparathyroidism, steatorrhea, menopause, renal failure, pancreatitis, hyperphosphatemia, and alkalosis. Some diuretics and anticonvulsants may precipitate hypocalcemia, which may validate calcium replacement therapy. Calcium salt therapy should not preclude the use of other corrective measures intended to treat the underlying cause of calcium depletion. 

Glucocorticoid antagonism Idiopathic hypercalcemia Malabsorption syndrome Sarcoidosis Steatorrhea Tropical sprue... 

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. 

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. 

Nontropical sprue (adult celiac disease) results from a reaction to gluten, a protein found in grains. Intestinal epithelial cells are damaged and malabsorption results. Common symptoms are steatorrhea, diarrhea, and weight loss. 

Carbohydrate Malabsorption 318 The Dumping Syndrome 318 Steatorrhea Idiopathic Steatorrhea Celiac Disease or Nontropical Sprue... 

Cooper and Castle have proposed a three-step sequence to explain the vitamin B12 absorption in the gastrointestinal tract. In the first step, vitamin B12 binds with the intrinsic factor in gastric juice. The affinity of the vitamin for the intrinsic factor is thought to be greater than its affinity for proteins in the intestinal content consequently, the intrinsic factor (IF) successfully displaces the vitamin from its weaker bonds with other proteins. Calcium facilitates and EDTA inhibits the absorption of vitamin B12 by the everted intestine. On the basis of these and related findings, workers proposed the second step in vitamin Bi2 absorption. At that stage it is assumed that the intrinsic factor-vitamin B12 complex is trapped in the intestinal wall by the intermediate of calcium bonds and absorbed by pinocytosis. This stage of the absorption process probably is interfered with in sprue and steatorrhea where calcicum soaps are formed in the intestinal lumen. 

Two diseases causing steatorrhea deserve further attention cystic fibrosis and sprue. Cystic fibrosis is a hereditary dysfunction of the mucous and serous exocrine glands (lung, pancreas, salivary gland, sweat glands, etc.) and is sometimes associated with cirrhosis of the liver. The disease has been described mainly in whites, rarely in Negroes. Cystic fibrosis is probably transmitted by an autosomal recessive mammalian gene. 

Primary steatorrhea is referred to as celiac disease in children and nontropical sprue in adults. In severe nontropical sprue, the delicate pattern designed by the slender villi is replaced by a flattened knobby epithelium [147-149]. Thus, the distended crypts open directly in the flat luminal surface. These changes result... 

When fat splitting and absorption is normal the ingestion of fats has in general been found to aid calcium absorption. In conditions in which there is excessive fat excretion, however, such as sprue or idiopathic steatorrhea, calcium is lost in the feces as calcium soaps. It has also been suggested... 

Absorption of fat is seriously impaired in man in the absence of bile from the intestinal tract, for example, in obstructive jaundice, although splitting of fat to fatty acids and glycerol proceeds normally. In sprue, idiopathic steatorrhea, and the celiac syndrome, fat is also poorly absorbed, although there is no decrease in available bile and the enzymatic breakdown to fatty acids is unimpaired. It has been suggested that a defective phosphorylating mechanism, due to deficiency of one or more vitamins of the B complex, may account for poor absorption in the sprue syndrome. Folic acid may be one of the factors involved. 

Calcium deficiency is manifested by tetany with characteristic carpopedal spasm and, at times, laryngospasm and convulsive seizures. When tetany is present, the concentration of serum calcium is usually less than 8 mg. per 100 ml. Tetany occurs in osteomalacia and often accompanies rickets, sprue, the celiac syndrome, and other steatorrheas. 

Absorption of vitamin A appears to be facilitated by the simultaneous absorption of fat. Poor absorption has been demonstrated in the steatorrheas, such as sprue and celiac disease, and in infectious hepatitis. Aqueous emulsions of vitamin A have been found to be more adequately absorbed than oily preparations, particularly in conditions associated with poor absorption of fat. Liquid petrolatum, administered with meals, interferes considerably with absorption of carotene and to a less extent with that of vitamin A. 

A difficult example is described by Nieweg (1953) in a girl aged 14 years. Free hydrochloric acid and intrinsic factor were absent from the gastric juice, but the response to vitamin Bj2 was poor, and although there was no steatorrhea, she had symptoms suggestive of sprue. 

In any event, this and related syndromes (celiac disease, also known as nontropical sprue or idiopathic steatorrhea), call attention to an almost completely neglected aspect of folic metabolism— the glutamyl chains in the native folic coenzymes. 

Excessive fat. Excessive levels of fat, especially those that are saturated, depress calcium absorption because the fats combine with calcium to form insoluble soaps, a process called saponification. These insoluble soaps are excreted in the feces, with consequent loss of the incorporated calcium. (They may also carry with them fat-soluble vitamin D.) This explains why patients with chronic intestinal disorders, such as sprue and celiac disease, leading to increased fat in the feces (steatorrhea) may develop osteomalacia in due time. 

A collective term for a group of nutritional deficiency diseases characterized by impaired absorption of nutrients from the small intestine, especially fats, glucose, and vitamins. Although all sprues exhibit the same general clinical manifestations of intestinal malabsorption and steatorrhea (fatty diarrhea), the following three etiologic classifications are presented in this book ... 

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