Snapshot A 60-year-old man presents to his primary care physician for pale, foul-smelling stools. He has a history of alcoholism, though he has not had a drink in a few months. He also has a history of recurrent pancreatitis, requiring multiple admissions. Each episode was treated conservatively. He is scheduled for an abdominal computed tomography (CT), which shows inflammation and calcium deposits in the pancreas, suggesting chronic pancreatitis. He is started on enzyme replacement therapy for pancreatic insufficiency. Introduction Overview malabsorption syndromes inability to absorb macronutrients or micronutrients often associated with chronic diarrhea and result in nutritional deficiencies treatment is targeted at correcting the underlying disorder Epidemiology etiology fat malabsorption login to view 6 more bullets lactose intolerance bile salt deficiency short bowel syndrome Pathogenesis mechanism impairment in absorption of nutrients due to a variety of defects in intestinal mucosa malabsorption of fat-soluble vitamins login to view 1 more bullet vitamin B12 deficiency login to view 2 more bullets lactose intolerance login to view 2 more bullets Presentation History easy bruising Symptoms common symptoms frequent and loose watery stools login to view 1 more bullet pale, bulky, foul-smelling stools login to view 1 more bullet abdominal pain and flatus bloating and weight loss vitamin deficiencies Vitamin Deficiencies Vitamin A Deficiency Vitamin D Deficiency Vitamin E Deficiency Vitamin K Deficiency Night blindness Xeroderma Osteomalacia Rickets Hemolytic anemia Muscle weakness Paresthesias Bleeding Easy bruising Imaging Abdominal computed tomography indications evaluate for chronic pancreatitis Studies Serum labs hypocalcemia ↑ prothrombin time/INR vitamin K malabsorption autoantibodies for celiac disease anemia microcytic or macrocytic depending on etiology of malabsorption syndrome Invasive studies Sudan black stain of stool stains and detects fat 72-hour fecal fat test most sensitive small bowel biopsy indication login to view 1 more bullet findings login to view 8 more bullets lactose hydrogen breath test indication login to view 1 more bullet D-xylose absorption test indications login to view 2 more bullets findings login to view 1 more bullet Differential Fat Malabsorption Syndromes Celiac Disease Whipple Disease Pancreatic Insufficiency Tropical Sprue Fat malabsorption Pale, bulky, and foul-smelling stools Pale, bulky, and foul-smelling stools Pale, bulky, and foul-smelling stools Pale, bulky, and foul-smelling stools Unique clinical features Positive autoantibodies Dermatitis herpetiformis Triad cardiac symptoms arthralgia neurologic symptoms Caused by Tropheryma whipplei, a gram-positive rod History of alcoholism History of previous episodes of pancreatitis History of being in tropical regions Negative autoantibodies Megaloblastic anemia due to folate and vitamin B12 deficiences Diagnostic testing Small bowel biopsy Abnormal D-xylose test Autoantibodies Small bowel biopsy Polymerase chain reaction of stool showing T. whipplei Abnormal D-xylose test Abdominal CT scan Secretin stimulation testing Small bowel biopsy Abnormal D-xylose test Treatment Dietary restrictions avoid gluten Ceftriaxone Trimethoprim/sulfamethoxazole Tetracycline Enzyme replacement therapy Doxycycline Trimethoprim/sulfamethoxazole Treatment Lifestyle dietary restriction indication login to view 1 more bullet modality login to view 1 more bullet Medical treat underlying condition antibiotics indication login to view 2 more bullets drugs login to view 4 more bullets enzyme replacement therapy indication login to view 2 more bullets nutrition replacement therapy indication login to view 1 more bullet Surgical none Complications Malnutrition