Malabsorption Syndrome - Nursing Case Study

Pathophysiology

• Primary mechanism: Digestive enzyme deficiency - Malabsorption Syndrome often results from insufficient production/release of enzymes from the pancreas and small intestine, critical for breaking down food into absorbable nutrients. Reduced function hampers nutrient absorption, leading to malnutrition.

• Secondary mechanism: Damage to intestinal lining - Conditions like Celiac disease or Crohn’s disease cause inflammation and damage to the intestinal lining. This disrupts the absorptive villi and microvilli function, leading to impaired nutrient absorption.

• Key complication: Nutrient malabsorption - Insufficient absorption of proteins, carbohydrates, fats, vitamins, and minerals leads to deficiency-related conditions such as anemia, osteoporosis, weight loss, and malnutrition, causing significant morbidity and mortality.

Patient Profile

Demographics:

45-year-old male, works as a chef.

History:

• Key past medical history: Diagnosed with Crohn's disease 10 years ago, chronic gastritis

• Current medications: Crohn's disease medication, proton pump inhibitors for gastritis

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent diarrhea, weight loss, fatigue

• Key symptoms: Abdominal pain, bloating, gas, muscle weakness

• Vital signs: Blood pressure 110/70 mmHg, heart rate 92 beats per minute, respiratory rate 16 breaths per minute, temperature 37.2°C (99°F), BMI 18.5 (previously 24) indicating significant weight loss.

Section 1

Change in Patient Status:

Over the next few days, the patient's condition deteriorated. He reported increased frequency of diarrhea and complained about a loss of appetite. The patient also experienced episodes of dizziness, which he attributed to his ongoing fatigue. On further examination, the patient's BMI dropped to 17.5 and he appeared pale and lethargic. His vital signs were mildly unstable with a decreased blood pressure of 100/60 mmHg and an increased heart rate of 100 beats per minute, suggesting possible dehydration due to the persistent diarrhea. The patient also complained of bone pain and muscle weakness, indicating a possible deficiency of vitamin D and calcium.

Initial Assessment Findings:

Upon physical examination, the patient exhibited signs of peripheral edema, indicating possible protein malnutrition. His tongue appeared red and swollen, suggesting vitamin B deficiencies. Blood tests were initiated to assess the patient's nutritional status and revealed a decreased hemoglobin level of 10 g/dL, indicative of anemia. Serum albumin was low at 2.5 g/dL (normal range 3.5-5.5 g/dL) reflecting a state of malnutrition. The patient's electrolyte panel showed hypocalcemia with a calcium level of 7.8 mg/dL (normal range 8.6-10.2 mg/dL) and hypokalemia with a potassium level of 2.8 mEq/L (normal range 3.5-5.0 mEq/L), both likely due to malabsorption and diarrhea. These findings have triggered the need for further diagnostic tests and a review of the patient's current treatment plan.

Section 2

New Diagnostic Results:

The team requested a stool sample to assess for fat malabsorption, which returned positive for steatorrhea, indicating that the patient is not properly absorbing fat from his diet. Additionally, an abdominal CT scan revealed a thickening and inflammation of the small bowel wall, suggestive of an underlying inflammatory condition contributing to the malabsorption. A subsequent endoscopy with biopsy was performed to further investigate. The histopathological results showed villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes, which are characteristic findings of celiac disease.

The patient was also evaluated for vitamin and mineral deficiencies. His serum ferritin was low at 15 ng/mL (normal range 30-400 ng/mL), indicative of iron deficiency. Vitamin B12 levels were decreased to 180 pg/mL (normal range 200-900 pg/mL), and the vitamin D level was also critically low at 10 ng/mL (normal range 30-100 ng/mL). These results, along with the clinical findings, affirm the suspicion of malabsorption syndrome possibly secondary to celiac disease. It also highlights the need for a comprehensive nutritional intervention and possibly a gluten-free diet to manage the patient's condition.

These diagnostic results provide valuable insights about the patient's condition, requiring the healthcare team to make connections and inferences from the results to guide the next steps in the patient's care plan. It allows for further clinical reasoning, as the team needs to determine the most effective interventions based on these findings.

Section 3

Two weeks after initiating a gluten-free diet and supplementation with iron, Vitamin B12, and Vitamin D, the patient returned for a follow-up visit. He reported improvement in his symptoms, with less abdominal pain and bloating, and increased energy levels. However, he expressed difficulty adhering to the gluten-free diet due to limited food options and increased grocery expenses. His weight was 65 kg, showing no significant change from his previous weight of 65.5 kg.

A repeat analysis of iron and vitamin levels showed slight improvements. His serum ferritin increased to 20 ng/mL, Vitamin B12 to 200 pg/mL, and Vitamin D to 15 ng/mL. However, these levels remain below the normal range, suggesting that the patient may not be adequately absorbing these supplements, or his nutritional intake is still deficient. A repeat stool test showed persistent steatorrhea, indicating ongoing fat malabsorption. These results highlight the need for further intervention, including possible adjustments to his dietary plan or supplement regimen, and ongoing education and support for managing celiac disease. It also raises the possibility of other contributing factors to malabsorption, which may need to be explored.

Section 4

During the next visit, the patient reported increased lethargy, intermittent bouts of diarrhoea and a new onset of tingling sensations in his extremities. His weight had further reduced to 63 kg, indicating a concerning trend of weight loss. A physical examination revealed pallor and glossitis. His vital signs were within normal range; however, his heart rate was slightly elevated at 96 beats per minute. These symptoms, along with the continued presence of steatorrhea and persistent low vitamin levels, raised concerns for worsening malabsorption and possible peripheral neuropathy secondary to vitamin B12 deficiency.

New laboratory tests showed a slight decrease in hemoglobin to 11 g/dL, indicating mild anemia. Folate levels were also tested and found to be within the normal range, eliminating folate deficiency as a cause for the anemia. An intrinsic factor antibody test was positive, suggestive of pernicious anemia, which could be contributing to the vitamin B12 deficiency and malabsorption. A nerve conduction study was recommended to evaluate the tingling sensations in his extremities.

These new findings indicate that while the patient is partially responsive to the gluten-free diet and supplementation, he may have an additional condition causing malabsorption and contributing to his symptoms. It suggests the need for further investigation into his B12 absorption and potential neurological implications. The patient's ongoing struggles with adhering to the gluten-free diet also underscore the need for ongoing education and support to manage his condition effectively.

Section 5

During a follow-up visit, the patient described worsening of the tingling sensations and the development of a burning sensation in his extremities. He also reported experiencing dizziness, especially upon standing, and occasional shortness of breath. On physical examination, the patient's weight had decreased further to 60 kg, and his pallor had increased. His heart rate was now elevated to 100 beats per minute, and he had a new onset of postural hypotension with blood pressures of 110/70 mmHg when supine and 90/60 mmHg upon standing.

New laboratory tests showed a further decrease in hemoglobin to 9 g/dL, indicating moderate anemia. His vitamin B12 levels were significantly below the normal range, despite ongoing supplementation. The nerve conduction study confirmed peripheral neuropathy. In addition, an upper endoscopy was performed, which showed atrophic gastritis, a condition often associated with pernicious anemia. These findings suggest the patient's malabsorption syndrome is worsening, with the anemia and peripheral neuropathy likely linked to the vitamin B12 deficiency. They also underline the potential presence of an autoimmune condition, such as pernicious anemia, which could be exacerbating the malabsorption. The patient's new symptoms of dizziness and shortness of breath may be related to the anemia and should be further investigated.