Best Practice & Research Clinical Gastroenterology 23 (2009) 395–406

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Gastroenterology

Disorders of intestinal secretion and absorption

Jörg-Dieter Schulzke, MD, Chair, Professor a, b, *,
Hanno Tröger, MD, Researcher a,1, Maren Amasheh, MD, Researcher a,1
a
Department of Gastroenterology, Infectiology, and Rheumatology, Hindenburgdamm 30, 12203 Berlin, Germany
b
Department of General Medicine, Charité Berlin; Berlin, Germany

Keywords:
The gastrointestinal tract possesses a huge epithelial surface area
alpha-1-Antitrypsin-clearance and performs many different tasks. Amongst them are the
bacterial overgrowth digestive and absorptive functions. Disorders of intestinal
blind loop syndrome absorption and secretion comprise a variety of different diseases,
coeliac disease e.g. coeliac disease, lactase deficiency or Whipple’s disease. In
duodenal biopsy principle, impaired small intestinal function can occur with or
exsudative enteropathy without morphological alterations of the intestinal mucosa.
fructose intolerance
Therefore, in the work up of a malabsorptive syndrome an early
giardia lamblia
small intestinal biopsy is encouraged in conjunction with breath
lactase deficiency
malabsorption tests and stool analysis to guide further management. In addition,
protein-losing enteropathy there is an array of functional tests, the clinical availability of
short bowel syndrome which becomes more and more limited. In any case, early diag-
whipple’s disease nosis of the underlying pathophysiology is most important, in
order to initiate proper therapy. In this chapter, diagnostic
procedure of malabsorption is discussed with special attention to
specific disease like coeliac disease, Whipple’s disease, giardiasis
and short bowel syndrome. Furthermore, bacterial overgrowth,
carbohydrate malabsorption and specific nutrient malabsorption
(e.g. for iron or vitamins) and protein-losing enteropathy are
presented with obligatory and optional tests as used in the clinical
setting.
Ó 2009 Elsevier Ltd. All rights reserved.

* Corresponding author: Department of General Medicine, Hindenburgdamm 30, 12203 Berlin, Germany. Tel.: þ49 30 8445
2666; Fax: þ49 30 8445 4493.
E-mail addresses: joerg.schulzke@charite.de (J.-D. Schulzke), hanno.troeger@charite.de (H. Tröger), maren.amasheh@
charite.de (M. Amasheh).
1
Tel.: þ49 30 8445 2537; Fax: þ49 30 8445 4493.

1521-6918/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpg.2009.04.005
396 J.-D. Schulzke et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 395–406

Generalized malabsorption, e.g. coeliac disease, short bowel syndrome

Malabsorption indicates impaired uptake of nutrients, ions or water along the gastrointestinal
tract which can occur with and without morphological changes of the small intestinal mucosa.
Thereby, disturbed digestion (maldigestion) and absorption (malabsorption) can work alone or
together (malassimilation). Malabsorption occurs when a primary transport disorder (without
morphological changes) or a secondary transport defect due to morphological changes arises, when
the absorptive area is reduced or the transport of absorbed ingesta from the intestine is affected
(Table 1). Depending on localization and extent of the disturbance the functional impairment is
either global, partial or compensated. Since effective therapy strategies require identification of the
underlying mechanisms, standardized diagnostic procedures have been developed. At first, malab-
sorption has to be confirmed by setting the patients for 24–48 h on total parenteral nutrition. Stool
volume is reduced in case of malabsorptive diarrhoea. In contrast, no change in stool volume points
to a secretory or leak-flux mechanism. Rarely, hormone release from neuroendocrine tumours can be
triggered by food intake and miscellaneous responses are seen [1]. More specific evidence can be
obtained from diagnostic procedures such as endoscopy, diagnostic imaging and laboratory tests.
Duodenal biopsy should be taken early in the diagnostic setup (Fig. 1). From the result of this upper
GI endoscopy and histology the subsequent diagnostic concept has to be defined and distinct tests
are proposed which are described in the context of the respective underlying diseases (see below).
Generally, upper GI endoscopy can identify coeliac disease, Whipple’s disease and several other
small intestinal disorders, whereas the colonoscopy can detect Crohn’s disease or amyloidosis.
Laboratory tests include tests for chronic pancreatic disease (elastase-1 test), neuroendocrine
tumours (ELISA for gastrin and VIP), aids (HIV test) and cobalamin deficiency (Schilling test).
Diagnostic procedures should be completed by the hydrogen breath tests using lactose (lactase
deficiency), lactulose (intestinal transit time and identification of non-responders) and glucose
(bacterial overgrowth syndrome). Microbiological testing for chronic infectious agents, e.g. Giardia
lamblia (direct immunofluorescence in stool), Mycobacterium tuberculosis, Yersinia enterocolitica
(serologic testing) and Strongyloides stercoralis (stool examination) completes the diagnostic
program.

Table 1
Malabsorption syndromes.

Disease
Whipple’s disease
Intestinal lymphoma
Intestinal lymphangiectasia
Eosinophilic gastroenteritis
Amyloidosis
Crohn’s disease
Infectious diseases
Mastocytosis
Coeliac disease
Giardia lamblia infection
Blind loop syndrome
Vitamin-B12 deficiency
Radiation enteritis
Zollinger–Ellison syndrome
Starvation, malnutrition
or parenteral nutrition
Lamina propria macrophages with PAS-positive material Biopsy, PCR, EM
Lymphoma cells in the lamina propria and submucosa Biopsy, T-cell receptor clonality
Dilated lymphatic ducts with partial villus atrophy Biopsy
Eosinophilic infiltrates Biopsy
Amyloidal deposits Biopsy
Skip lesions with detection of granuloma Biopsy
Detection of microorganisms Stool microbiology, serum
titre and PCR
Mast cell infiltrates Biopsy, IgE
Villus reduction, crypt hyperplasia, increased Biopsy, tissue transglutaminase
intraepithelial lymphocytes antibodies, HLA-DQ2
Partial villus atrophy Stool ELISA, indirect
immunofluorescence
Partial villus atrophy and increased intraepithelial H2-test (glucose), quantitative culture
lymphocyte count from small intestinal mucus
Macrocytotic anaemia, ileal inflammation, gastric Serum vitamin B12, parietal cell
resection or atrophic gastritis antibodies, Schilling test, gastric pH
Inflammation of the intestine Endoscopy
Ulcers and erosions of gastric mucosa and small Serum gastrin, endoscopic
intestinal partial villus atrophy ultrasound, CT
Mucosal hypotrophy (villus and crypt reduction) Biopsy
 J.-D. Schulzke et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 395–406 397

chronic diarrhea / malabsorption

immune competent patients immune deficient

humoral cellular

inflamed-ENDOSCOPY-normal
Giardia
lamblia

Crohn celiac disease macroscopy Kaposi

disease whipple‘s disease CMV
lymphangiectasia histology cryptosporidia
amyloidosis microsporidia
mastocytosis microbiology MAI complex

Fig. 1. Diagnostic setup for malabsorptive diarrhoea.

Coeliac disease

Coeliac disease is a common cause of malabsorption in Caucasians, especially those of European

descent. Coeliac disease has variable manifestations, almost all of which are secondary to nutrient
malabsorption, and a varied natural history, with the onset of symptoms occurring at all ages.
There is no functional test to diagnose coeliac disease. Therefore as indicated in the Introduction, an
early duodenal biopsy in combination with specific antibodies (anti-gliadin, anti-endomysial, anti-
tissue transglutaminase) is the diagnostic test of choice. Furthermore, almost all patients with coeliac
sprue express a distinct HLA-DQ2 allele (DQA1*0501þDQB1*0201). Therefore, absence of this DQ2
allele virtually excludes the diagnosis. The gold standard of coeliac disease diagnosis is the presence of
an abnormal small intestinal biopsy and the clinical and histopathological response to the elimination
of gluten from the diet.
Since the diarrhoea in coeliac disease has several pathogenetic mechanisms, tests for (secondary)
lactase deficiency, fructose intolerance and rarely bile acid malabsorption are encouraged to guide the
patient and counsel him regarding the diet of choice or medical therapy. Some patients may obtain
temporary improvement with dietary lactose, fructose or fat restriction, while awaiting the full effects
of total gluten restriction. In some patients a therapeutic trial with cholestyramine with/without prior
SeHCAT test and/or stool fat test can be helpful when ileal involvement with bile acid diarrhoea is
suspected.

Giardia lamblia infection

In the Western world chronic infection with Giardia lamblia is probably the most important
infectious agent causing malabsorption in the immunocompetent as well as in immunocompromised
people (mainly humoral defect of the immune system). Diarrhoea is thought to result mainly from
malabsorption due to a partial villous atrophy and reduced disaccharidase activity, although there is
also a leak-flux and secretory component to this type of diarrhoea [2,3]. Diagnosis is made by stool
ELISA or direct immunfluorescence staining in stool samples resulting in higher sensitivity than
conventional staining for ova, cysts and parasites. With a lower sensitivity compared to the stool
analysis, parasites can also be detected in duodenal fluid or in the histological section of a small
intestinal biopsy [4].
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Whipple’s disease

Whipple’s disease is characterized by diarrhoea, steatorrhea, weight loss, arthropathy and fever. It is
caused by the ubiquitous bacterium Tropheryma whipplei. New experimental approaches point to
defects in T-cell and macrophage immunity in these patients. The steatorrhea is generally considered to
be secondary to small intestinal mucosal injury and lymphatic obstruction due to the massive infil-
tration of PAS-positive macrophages in the lamina propria.
The diagnosis of Whipple’s disease is made from tissue biopsies from the small intestine or other
organs involved. The hallmark of Whipple’s disease had been the presence of PAS-positive macro-
phages in the small intestine. Besides these typical histomorphological changes the detection of the
bacteria by polymerase chain reaction (PCR) has become important in diagnostic setup and in
the course of the disease. Analysis of cerebral fluid is mandatory to detect a possible involvement of the
central nervous system [5].

Short bowel syndrome

The short bowel syndrome (SBS) can appear clinically as a partial or global malabsorption
syndrome. The incidence of symptoms is variable. The exact definition of resection extent and the
length of the remaining small intestinal segment with or without colon are essential for the under-
standing of the symptoms and therapy planning. A specified step-by-step diagnostics oriented on the
anatomy helps to analyse the specific intestinal failure and enables initiation of therapy.
The degree of intestinal dysfunction in SBS is difficult to objectively quantify. All SBS patients should
undergo detailed anatomical assessment either by a detailed surgically resection analysis or by oral and
enema contrast studies. Ultrasound examination can demonstrate liver and intestinal morphology. Besides
anthropometric parameters, serological and faeces diagnostics are necessary in SBS patients (see below).
Non-invasive measurement of intestinal transit time is difficult to achieve. The usage of blue food
colour in water serves as a rapid non-invasive visual measure of transit time in short gut patients with
ostomy. Breath hydrogen testing (with lactulose) may yield transit time information in patients with
SBS and an intact ileocaecal valve [6].
Fat malabsorption is detected on the basis of the beta carotene level in the serum. Further functional
tests are available for the detection of pancreatic insufficiency, such as the determination of faecal
pancreatic elastase. Particularly with regard to the degree and localization of malabsorption, proximal
D-xylose test (carbohydrate absorption) and ileal Schilling test (cobalamin absorption) as well as the
bile acid absorption test (SeHCAT) are relevant.
Plasma parameters include blood and lymphocyte count, glucose, electrolytes, albumin, folic acid,
Fe2þ, ferritin, Cu2þ, Zn2þ, Ca2þ, Mg2þ, phosphate and liver enzymes [7]. Additionally, reduced plasma
citrulline levels are an innovative quantitative biomarker of significantly reduced enterocyte mass and
function. Circulating citrulline is mainly produced by enterocytes of the small bowel independently of
nutritional status. Citrulline levels can be used as a prognostic marker for parenteral nutrition weaning
(citrullin >20 mmol/l) [8].
The supportive therapy of generalized malabsorption including short bowel syndrome comprises of
a fibre and lactose reduced diet (multiple small meals) enriched in MCT (medium chain fatty acids)
containing fat. Loperamide, a m-opiate agonist, inhibits propulsion and in this manner increases the
contact time. Cholestyramine, a bile acid chelator, is helpful when bile acid diarrhoea is suspected.
Proton pump inhibitors are used to reduce gastric acid secretion for reduction of intestinal fluid load
and optimal pH environment for digestive enzymes. As a last resort home parenteral nutrition may be
initiated and can be maintained for many years. As a possible alternative in chronic irreversible
‘‘intestinal failure’’ small intestinal transplantation is becoming established in special centres, espe-
cially if parenteral nutrition is limited by liver injury.

Bacterial overgrowth

Small bowel bacterial overgrowth (SBO) syndrome is characterized by diarrhoea, weight loss,
bloating and macrocytic anaemia and is caused by an increased number of colonic-type bacteria in the
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small intestine. Physiologically, the number of bacteria in the small intestine is reduced by several
mechanisms. Most importantly, antegrade peristalsis prevents attachment of ingested microorganisms
and an intact ileocoecal valve inhibits retrograde ascension of bacteria into the small bowel from the
colon with its high bacterial content. Furthermore, gastric acid, bile and proteolytic enzymes destroy
many microorganisms or prevent them from entering the small intestine from the stomach. In addi-
tion, the mucosal barrier with its mucus layer and anti-bacterial factors including the innate (e.g.
defensins) and acquired immune system (e.g. immunoglobulins) inhibit bacteria from overgrowth.
The pathopysiological basis for this syndrome can be any disturbance in the factors mentioned
above. In most cases, an intestinal stasis caused either by impaired peristalsis (functional stasis, e.g.
scleroderma, amyloidosis, diabetes) or by changes in intestinal anatomy (anatomic stasis, e.g. stricture,
blind loop, diverticula) predispose to bacterial overgrowth syndrome. However, several other disorders
have been associated with this syndrome. Predisposing disorders for bacterial overgrowth syndrome
are listed in Table 2.
The increased number of bacteria in the small intestine can cause several changes in small intestinal
function. First, bacteria deconjugate bile acids in the proximal small intestine which are then not re-
absorbed anymore leading to a decrease in the bile acid pool and a lack of intraluminal bile acids. This
leads to fat malabsorption with consequent steatorrhoe. Furthermore, a variable degree of non-specific
inflammation or epithelial defects are sometimes noted due to bacterial proteases, exotoxins or
invasive strains [9]. However, it should be noted that small intestinal histology is not specific in this
disease and rather useful to exclude alternative diagnosis (see below). As most bacteria require
cobalamin for growth, increased concentrations of bacteria can lead to cobalamin deficiency with
megaloblastic anaemia and potentially neurologic changes. That is why a typical laboratory feature is
the combination of a low serum cobalamin level with an elevated serum folate level, since bacteria
frequently produce folate compounds that are then absorbed.
An imaging modality of the small bowel is indicated preferably in Sellink technique (conventional
x-ray, CT or MRT scan) when bacterial overgrowth is suspected, in order to detect underlying
anatomical problems. A small bowel biopsy, while not diagnostic of bacterial overgrowth, is useful for
identifying inflammation associated with overgrowth and helps to exclude other causes of
malabsorption.

Table 2
Disorders associated with bacterial overgrowth.

Small intestinal stasis

Anatomic abnormalities
Small intestinal diverticula
Surgically created blind loops
Strictures (Crohn’s disease, radiation, surgery, neoplasia)
Dilatation of a previous intestinal anastomosis

Functional abnormalities
Diabetes mellitus
Scleroderma
Idiopathic intestinal pseudoobstruction
Radiation enteritis
Amyloidosis
Motility-inhibiting drugs

Abnormal intestinal communication

Gastrocolic or jejunocolic fistula or surgical bypass
Resection of the ileocaecal valve

Other causes
Gastric hypochlorhydria
Immunodeficiency
Chronic pancreatitis
Liver cirrhosis
Alcoholism
End stage renal disease
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Some clinicians advocate empiric treatment as a diagnostic test for SBO. But overall the available
tests for the diagnosis of small intestinal overgrowth syndrome have to be interpreted carefully (for
review, see [10,11]). However, the gold standard is the direct quantification of bacteria in a jejunal
aspirate, usually obtained by upper gastrointestinal endoscopy. Using this technique a bacterial content
of >105 CFU/ml is recognized as diagnostic [12] but some authors advocate even lower levels of
bacteria with regard to the colonic type of microflora in the jejunum [13]. There are several drawbacks
to this invasive test mostly due to the difficulties in culturing the bacteria, since only very few species
are readily cultured at all and this test requires careful microbiological techniques. Furthermore,
contamination by the oropharyngeal flora may occur. At last, bacterial overgrowth can be only a focal
phenomenon and missed by a single culture or it is located at a site that is difficult to access. Moreover,
it is unclear whether or not disinfection procedures for endoscopy may hamper diagnosis of bacterial
overgrowth, which on the other hand is a prerequisite for a safe diagnostic procedure.
Breath hydrogen testing is the non-invasive approach of choice and is performed by adminis-
tering a test dose of carbohydrate (usually D-glucose), which in patients with bacterial overgrowth is
associated with a rise in breath hydrogen levels. Lactulose is normally metabolized in the colon and
is used for diagnosing a reduction in transit time. In small bowel bacterial overgrowth, however, an
early rise in hydrogen production followed by the later colonic hydrogen peak suggests bacterial
overgrowth in more proximal segments of the GI tract. D-glucose is used as a substrate, since it may
be metabolized to hydrogen by bacteria in the small bowel prior to complete absorption. False-
positive results can be obtained by rapid intestinal transit, e.g. in short bowel syndrome. Further-
more, in the case of lactulose the early rise in hydrogen can sometimes be difficult to distinguish
from the colonic peak. Furthermore, one has to remember that 15–20% of the patients are non-
hydrogen producers. Therefore a glucose hydrogen breath test should always be combined with
a lactulose test to exclude this.
The 14C-D-xylose breath test is advocated for use in routine clinical practice by the Clinical Efficacy
Committee of the American College of Physicians. D-Xylose is a pentose sugar that is catabolized by
gram-negative aerobes of the microflora releasing the radioactive isotope 14CO2which is detectable in
breath samples. Like the lactulose hydrogen breath test normal 14CO2 release peaks in the colon,
whereas early peaks indicate the presence of small intestinal overgrowth. Despite the recommenda-
tion, it is not commonly performed in clinical practice, since it is not widely available. It is not approved
world wide and due to radiation not recommended for fertile women and children.
The diagnostic accuracy of the D-glucose hydrogen breath test was compared to the D-xylose test
with culture of the small bowel aspirate as gold standard. There was no statistically significant
difference found in the accuracy between the studies [14]. Another yet rarely available test for diag-
nosis of bacterial overgrowth is an abnormal Schilling test which should return to normal following the
administration of an adequate antibiotic therapy.
Primary treatment should be directed, if at all possible, to the correction of the underlying problem
leading to SBO including surgical and medical (e.g. pro-kinetic) therapy. Patients with symptomatic
bacterial overgrowth are treated with broad-spectrum antibiotics for about 1–3 weeks. Traditionally,
tetracycline (250 mg p.o. qid) have been advocated as first line therapy. However, there are several
other at least equally effective antibiotics, e.g. ciprofloxacin, norfloxacin, amoxicllin/clavulansäure,
metronidazole and others [15]. So far, there is no convincing evidence for the role of probiotics in
bacterial overgrowth syndrome [16].

Carbohydrate malabsorption

Carbohydrates represent the main source of energy in the diet and are present mainly in the form of
starch, disaccharides (saccharose and lactose) and glucose. Carbohydrates are absorbed in the small
intestine as monosaccharides. Therefore, carbohydrates must be digested by salivary and pancreatic
amylase, gastric acid and by the intestinal brush border disaccharidases (maltase, isomaltase, lactase,
saccharase) to monosaccharides (glucose, fructose and galactose). Absorption of glucose and galactose
occurs via the transport protein SGLT1. The intestinal Naþ-glucose cotransporter SGLT1 uses sodium
and electrical gradients across the apical enterocyte membrane to drive sugar and water against their
concentration gradients. Glucose and galactose are both handled by SGLT1, whereas fructose is
 J.-D. Schulzke et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 395–406 401

transported across the brush border by its own carrier, the facilitated fructose transporter GLUT5. All
three monosaccharides share a common exit on the basolateral membrane of the enterocyte through
another facilitated sugar transporter (GLUT2) into the portal blood. Furthermore, GLUT2 can also be
inserted apically and then represent a very dynamic high capacity low affinity pathway for mono-
saccharides [17].
Malabsorbed monosaccharides generate an osmotic load that draws water and electrolytes into the
lumen leading to osmotic diarrhoea. In addition, non-absorbed sugars are a substrate for the intestinal
microflora which produce fatty acids and gases (methane, hydrogen, carbon dioxide) leading to
bloating and flatulence. The increase in luminal fatty acids leads to a lowered faecal pH which can be
measured in infants in whom carbohydrate malabsorption is suspected.

Lactose intolerance

Clinically the most important disorder of carbohydrate absorption is lactose malabsorption. As

mentioned above, lactose is broken down by the brush border lactase into glucose and galactose. The
enzyme lactase is invariably present in humans (as well as in other mammalians) in the postnatal
period but then physiologically disappears in many populations, except for most of the Caucasians
where lactase activity persists by about 80% throughout life.
Clinically three different types of lactase intolerance syndromes can be distinguished, namely
congenital, primary and secondary lactase deficiency. The congenital lactase deficiency is an
extremely rare autosomal-dominant inherited disease with a complete absence of lactase activity
immediately after birth. Primary lactase deficiency is a genetically determined relative or absolute
absence of lactase which progressively develops in childhood at various ages in different ethnic
groups and is the most common type of lactose intolerance. Secondary lactase deficiency occurs in
association with small-intestinal mucosal disease (e.g. infectious diarrhoea, coeliac disease,
Crohn’s disease) with structural and consequently functional changes of the small intestinal
mucosa.
Individuals with symptomatic lactose malabsorption develop one or more of the following symp-
toms after ingestion of lactose-containing food: abdominal pain, diarrhoea, nausea, bloating, and/or
flatulence. Development of symptoms of lactose intolerance is related to the amount of lactose
appearing in the small intestine and the activity of mucosal lactase. Besides the amount of ingested
lactose several other factors, e.g. rate of gastric emptying, intestinal transit time and composition of
microflora can influence the onset and severity of symptoms.
A precise clinical history remains the most important approach to a patient with suspected
lactase deficiency and often reveals a correlation between lactose ingestion and onset of symp-
toms. If lactose malabsorption is suspected, a 2-week trial of lactose-free diet is reasonable, under
which the symptoms should ameliorate or disappear. Then, the re-introduction of lactose into the
diet with recurrence of symptoms is considered diagnostic. Alternatively or in more subtle cases
the hydrogen breath test is the least invasive and best diagnostic tool for the diagnosis of lactose
malabsorption [18].
The older lactose tolerance test which was based on the onset of typical symptoms after
ingestion of a standardized amount of lactose and measurement of the maximum increase in blood
glucose levels should not be used any more due to the high rate of false-negative and false-positive
results.
If secondary lactase deficiency is suspected, various other gastrointestinal examinations including
stool culture for diarrhoeal agents (e.g. rotavirus, Giardia lamblia), blood tests for coeliac disease and/or
intestinal biopsies should be considered. In intestinal biopsies, lactase activity (and also the activity of
other brush border enzymes) can be quantified directly by histochemistry.
To improve the accuracy of the hydrogen breath test, various other tests have been advocated to be
superior, like a 13C breath test with/without a combination with the established hydrogen breath test,
or a 13C-glucose blood test after 13C-lactose ingestion [19,20]. Furthermore, the routine use of genetic
testing prior to a breath test seems another although yet more experimental approach [21]. However,
all of these tests have not been introduced widely in routine clinical use and await acceptance by the
community.
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Glucose–galactose malabsorption

Glucose–galactose malabsorption (GGM) is a very rare disease and is due to a mutation in the SGLT1
[22]. The disease is characterized by severe diarrhoea in newborns when individuals ingest carbohy-
drates that contain actively transported monosaccharides (e.g. glucose or galactose) but not mono-
saccharides that are not actively transported (e.g. fructose). The most reliable diagnostic test for GGM is
the hydrogen breath test. The H2 breath test for glucose or galactose results in a great elevation in
patients with GGM, while no such increase is noted in controls or patients who eat fructose. Children
with GGM normalize on fructose-containing diets, but symptoms promptly return even in adulthood
after glucose provocation and the H2 breath test remains positive.

Fructose intolerance

Fructose is taken up by the brush border transport protein GLUT 5 and as shown recently also by
GLUT2. Since fructose is rapidly cleared from the circulation, luminal uptake of fructose is guaranteed.
A true fructose malabsorption, as in lactase deficiency or in SGLT1 mutation, has not yet been
reported. Fructose intolerance is rather defined as ‘‘any situation in which free fructose is available to
fermentative metabolism by luminal bacteria before it can be absorbed across the small intestinal
mucosa’’ [23].
Fructose intolerance is not widely accepted as a disease and it rather represent intolerance to a wide
range of badly- or non-absorbed fermentable monosaccharides. Due to the increasing load of fructose-
containing solutions in the Western diet the capacity of the fructose absorption system may be
overloaded leading to symptoms of carbohydrate malabsorption. On the other hand in chronic intes-
tinal disease like irritable bowel disease, inflammatory bowel disease or coeliac disease fructose
malabsorption may play a role in maintaining gastrointestinal symptoms despite adequate therapy. In
this situation breath testing might be applicable. However, the high rate of non-responders and the
uncertainty of the loading dose hamper this diagnostic tool. Therapy should then be aimed at reducing
the fructose content in the diet.

Malabsorption of specific nutrients, e.g. iron, vitamins, bile acids

Oral iron absorption test

When iron deficiency with or without anaemia occurs a detailed work up following guidelines
should be performed including urine and faecal blood analysis, screening for coeliac disease and in
most cases endoscopy of the upper and lower GI tract (see also British Society of Gastroenterology:
guidelines for the management of iron deficiency anaemia).
In these circumstances an oral iron absorption test may help to exclude a malabsorptive component
to this symptom directing further management but has to be regarded as a semiquantitative and
facultative test. The test is easy to perform and even the serum iron increase after 1 h seems sufficient
[24]. Furthermore, this test is proposed in patients who are refractory to oral iron replacement therapy
[25]. These patients should receive parenteral iron therapy, but only if previous work up of an
underlying disease has already be done.

Bile acid absorption test

Bile acids are secreted with bile in the duodenum and are almost exclusively re-absorbed in
conjugated form in the distal ileum. Malabsorption of bile acids can be due to resection or mucosal
disease (e.g. ileitis terminalis) of this part of the small bowel. Bile acids entering the colon can lead to
the so called bile acid diarrhoea due to a direct action on colonocytes. The 75Se-HCAT test is the
functional test of choice when bile acid malabsorption is suspected. The test uses a radiolabelled
analogue of taurocholic acid which follows the physiological enterohepatic circulation and after
a period of time measures the retained fraction of the isotope with a gamma camera. A retained
fraction under 12–15% after 7 days suggests bile acid malabsorption. Some clinicians emphasize
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a therapeutic trial of cholestyramine – a bile acid chelator – that can ameliorate the bile acid diarrhoea
for the diagnosis of bile acid malabsorption. However, when de novo synthesis of bile acids cannot
compensate for the loss in bile acid malabsorption, then cholestyramine worsens the diarrhoea due to
the reduced intraluminal bile acid concentration with subsequent fat malabsorption (so called fatty
acid diarrhoea).

Vitamins and trace minerals

Vitamins and trace minerals are required constituents of the human diet, since they are either
inadequately synthesized or not synthesized at all in man. Deficiencies of vitamins and minerals may
be caused by disease states such as malabsorption. The micronutrient depletion most often includes
fat-soluble vitamins as well as folate and vitamin B12. Also, low serum iron or iron deficiency
anaemia is observed. The use of laboratory tests to confirm suspected micronutrient deficiencies is
important, because the physical findings for these are often equivocal or non-specific. Low blood
micronutrient levels can predate serious clinical manifestations and may also indicate drug–nutrient
interactions.
Vitamin B12 (cobalamin) absorption requires hydrolysis of food-bound vitamin B12 in the stomach and
binding of the released B12 to the gastric intrinsic factor. Absorption of the B12 intrinsic factor complex is
mediated by ileal receptors. Resection of the terminal ileum results in respective malabsorption. Due to
large vitamin B12 body stores vitamin B12 deficiency occurs after 2–3 years of B12 malabsorption. Vitamin
B12 deficiency may be associated with neurologic, psychologic and haematologic disorders.
The diagnostic utility of serum total vitamin B12 has been questioned, because total vitamin B12 in
blood may not accurately reflect intracellular vitamin B12 status in the different tissues. As a result of
the lack of specificity, the lower cut-off limits for serum vitamin B12 have been reduced at the expense
of sensitivity. Therefore, total vitamin B12 in serum is now considered an unreliable indicator of
functional vitamin B12 status.
The introduction of the metabolite assays, methylmalonylacid (MMA) and homocysteine, has rendered
it possible to diagnose vitamin B12 and folate deficiencies at an earlier stage. MMA is a specific marker for
vitamin B12 deficiency, while the homocysteine level is also increased in folate and vitamin B6 deficiencies.
Overall, the sensitivity of increased serum MMA in the diagnosis of vitamin B12 deficiency appears to be
higher than that of serum homocysteine. However, there are serious problems with the measurement of
MMA in terms of its application in clinical practice. Measurement methods (gas chromatography–mass
spectrometry and HPLC) are cumbersome and require expensive equipment [26].
Folic acid is absorbed mainly in the upper small intestine. Folic acid in food is present as a hepta-
peptide requiring hydrolysis by pancreatic enzymes. Folate body stores are limited and folic acid
deficiency may occur within weeks. Serum folate and erythrocyte folate are widely available param-
eters and most commonly used to assess the folate status. The red cell folate assay may be a more
accurate test to evaluate the folate stores, because it is not influenced by the dietary intake, but its
concentration is affected by the vitamin B12 status and the high variation coefficient of the assay. An
increased concentration of total homocysteine in plasma occurs with deficiency of both vitamin B12
and folate.
Mild zinc deficiency has been described in inflammatory bowel disease and malabsorption
syndromes. Mild chronic zinc deficiency can cause stunted growth in children, decreased taste
sensation (hypogeusia) and impaired immune function. Severe chronic zinc deficiency causes clinical
manifestations such as diarrhoea, alopecia, muscle wasting, depression, irritability and a rash involving
the extremities, face and perineum. The rash is characterized by vesicular and pustular crusting with
scaling and erythema. Acrodermatitis enteropathica is a rare autosomal-recessive disorder charac-
terized by abnormalities in zinc absorption.
Plasma zinc comprises only 0.1% of the total body zinc stores, therefore accurately measuring zinc
status is difficult. Nevertheless, the diagnosis of zinc deficiency is usually made by a serum zinc level of
<12 mmol/l (<70 mg/dl). Pregnancy and birth control pills may cause a slight depression in serum zinc
levels, and hypoalbuminaemia from any cause can result in hypozincaemia.
In addition to serum and plasma zinc levels, zinc concentrations in erythrocytes and hair can be
measured. This may be useful for establishing a diagnosis of zinc deficiency, but cut-off values to define
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the lower limits of normal have not been well standardized. A second approach to determining body
zinc status is to measure the activity or concentration of zinc-dependent enzymes, but here is no
consensus which zinc-dependent enzyme is most appropriate to measure [27].
Fat-soluble vitamin deficiency (A, D, E and K) is more common, because of steatorrhea and the
subsequent decrease in fat digestion. Vitamin A is an essential nutrient for epithelial cell maintenance
and repair. Deficiency may cause night blindness, conjunctival and corneal xerosis, dry thickened skin
and abnormalities of bronchial mucosal epithelialization. Vitamin A status is usually assessed by
measuring serum retinol or blood spot retinol or by tests of dark adaptation.
Deficiency of vitamin E may decrease nerve conduction velocity. Symptoms include absent deep
tendon reflexes, loss of position sense and vibration sense in the lower limbs, tremor, ataxia and
decreased visual activity. The laboratory diagnosis of vitamin E deficiency is made on the basis of low
blood levels of a-tocopherol.
Deficiency of vitamin D is associated with decreased bone mineral density and osteopenia,
demonstrating decreased calcium and phosphate levels. Vitamin D status is usually estimated by
measuring plasma 25-OH-D levels. The biologically most active vitamin D metabolite, 1,25(OH)2-D, is
inapplicable because plasma levels of 1,25(OH)2-D but not of 25OH-D are maintained normal or even
elevated in mild to moderate osteomalacia due to secondary hyperparathyroidism and most peripheral
tissues including bone cells have the capacity to convert circulating 25OH-D to 1,25(OH)2-D and
thereby cover local needs.
Vitamin K is synthesized mainly by colonic bacteria. Therefore, vitamin K deficiency is uncommon
in patients with intact colon. The diagnosis of vitamin K deficiency is usually made on the basis of an
elevated prothrombin time or reduced clotting factors, although vitamin K may also be measured
directly by HPLC [28].

Protein-losing enteropathy

Protein-losing enteropathy is not a specific disease but rather a syndrome that is characterized by
hypoproteinaemia and peripheral oedema in the absence of proteinuria, defects in protein synthesis or
protein malnutrition. It can occur in numerous gastrointestinal and non-gastrointestinal diseases.
These diseases causing protein-losing enteropathy can be classified into three groups according to the
mucosal alterations:

(1) mucosal ulceration, such that the protein loss primarily represents exudation across ulcerations,
e.g. ulcerative colitis, Crohn’s disease, gastrointestinal carcinomas or peptic ulcer.
(2) Non-ulcerated mucosa, but with evidence of mucosal changes so that the protein loss represents
loss across epithelia with altered permeability, e.g. coeliac disease, Ménétrier’s disease, collage-
nous colitis and Whipple’s disease.
(3) Lymphatic dysfunction, representing either primary lymphatic disease or secondary to partial
lymphatic obstruction that may occur as a result of enlarged lymph nodes or cardiac disease, e.g.
after paediatric heart surgery such as Fontan operation [29] or constrictive pericarditis.

The diagnosis of protein-losing enteropathy is suggested by the presence of peripheral oedema and
low serum albumin levels in the absence of protein malnutrition and renal or hepatic disease. The first
step in the diagnostic algorithm when exsudative enteropathy is suspected is to diagnose the under-
lying disorder rather than the protein loss via the gastrointestinal tract itself. Therefore, routine
gastrointestinal workup including endoscopy with histology should be started. Patients who appear to
have idiopathic protein-losing enteropathy without any evidence of gastrointestinal disease should be
examined for cardiac disease including an echocardiography.
The decision for a diagnostic test to demonstrate protein-losing enteropathy tends to depend rather
on the regional availability of the test. There are several established tests using radiolabelled proteins
(e.g. 131J-PVP (Gordon test) or 51Cr-albumin) which are quantified in the stool during a 24 or 48 h period
[30]. Unfortunately, hardly any of these radiolabelled proteins are available for routine clinical use.
Therefore, we emphasize the a1-antitrypsin clearance method, which is a reliable and simple test
without the need of an isotope [31]. a1-Antitrypsin is a 50 kDa protein that is synthesized in the liver
 J.-D. Schulzke et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 395–406 405

and accounts for approximately 4% of the total serum protein. Due to its antiproteolytic activity it is
resistant to degradation and is excreted almost unchanged with the faeces. Healthy controls have an
intestinal a1-antitrypsin clearance of <35 ml/day and values above 50 are usually assumed to be
pathologic, whereas in severe protein-losing enteropathy values up to and above 300–400 ml/day can
be measured. However, this test is less sensitive in protein-losing gastropathy, since a1-antitrypsin is
degraded in an acidic environment with pH-values below 3. When the site of protein loss is not known,
a scintigraphic approach e.g. with radiolabelled human serum albumin can be helpful in localizing the
intestinal region with the protein loss [32].

Main clinical practice points

 An early small intestinal biopsy is encouraged in malabsorptive diarrhoea to guide further

management.
 The exact definition of resection extent and the length of the remaining small intestinal segment
with or without colon are essential for understanding of the short bowel syndrome.
 Diagnosis of suspected Giardia lamblia infection is made by stool ELISA or immunofluorescence
staining.
 In Whipple’s disease the detection of a possible cerebral involvement is mandatory.
 Diagnosis of small intestinal bacterial overgrowth remains difficult and direct quantification of
bacteria in a jejunal aspirate remains gold standard.
 Fructose intolerance does not represent an abnormality but rather an intolerance to a wide
range of non-absorbed fermentable monosaccharides with symptoms of carbohydrate
malabsorption. Reduction of fructose content in the diet is sufficient e.g. by abandonment of
added sweetener.
 Alpha1-antitrypsin clearance is considered the test of choice for diagnosis of protein-losing
enteropathy.

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