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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Material and Methods
 ::  Results
 ::  Discussion
 ::  Acknowledgement
 ::  References
 ::  Article Tables

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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 3  |  Page : 112-117

Malabsorption in cirrhosis of the liver


Department of Medicine and Pharmacology, Seth G. S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012., India

Correspondence Address:
R V Patwardhan
Department of Medicine and Pharmacology, Seth G. S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012.
India
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PMID: 614424

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 :: Abstract 

Gastrointestinal function of absorption has been studied in twenty biopsy proved cases of cirrhosis of the liver. The gastro­intestinal function was assessed by means of glucose and lactose tolerance tests and by fecal fat, d-Xylose and Co 57 B 12 excretion tests. Steatorrhoea and lactose intolerance are common in cir­rhotics. The etiopathogenesis of this malabsorption in cirrhotics is discussed and appears multifactorial in origin.



How to cite this article:
Patwardhan R V, Pimparkar B D, Mehta J M, Sheth U K. Malabsorption in cirrhosis of the liver. J Postgrad Med 1977;23:112-7

How to cite this URL:
Patwardhan R V, Pimparkar B D, Mehta J M, Sheth U K. Malabsorption in cirrhosis of the liver. J Postgrad Med [serial online] 1977 [cited 2014 Oct 22];23:112-7. Available from: http://www.jpgmonline.com/text.asp?1977/23/3/112/42760



 :: Introduction Top


Although, Bright [3] in 1836 commented that "the evacuation of fatty matter, more or less mingled with feces accom­panied the complete retention of bile", it is not commonly realised that steator­rhoea is a common feature of chronic liver disease. Hence, we undertook a study to assess the gastrointestinal func­tion in biopsy proved cases of cirrhosis of liver.


 :: Material and Methods Top


Twenty biopsy proved cases of cir­rhosis of liver were studied. All were males, ranging in age from 19 to 60 years. A detailed history and a good clinical examination, with special em­phasis on symptoms suggestive of mal­absorption and liver cell dysfunction was recorded on a special proforma. Sixteen patients gave history of alcoholism while five patients had a history of jaundice. The duration of disease was more than 3 years in 75% of cases. Each subject had had routine investigations such as, hemogram, E.S.R., stool and urine analysis, estimation of blood urea nitro­gen, serum amylase, and serum elec­trolytes.

X-ray chest and plain X-ray abdomen, particularly to rule out either pulmonary tuberculosis and/or pancreatic calcifica­tion, and,/or calculus cholecystitis, were also taken.

Liver function was assessed by various biochemical liver function tests and by liver biopsy. Serum bilirubin was esti­mated by the method of Malloy and Evelyin, [13] serum alkaline phosphatase by the method of King and Armstrong, [9] S.G.O.T. and S.G.P.T. by the method of Reitman and Frankel, [17] and Prothrombin time by Quick's one stage method. Total serum proteins were estimated by the method of Phillips et al, [14] whereas electrophoretic pattern was done by the method of Koiw and Gronwall. [10] The results of gastric secretory function in chronic liver disease are published separately and hence are not included in this paper.

The intestinal absorption of carbo­hydrates was tested by lactose and glucose tolerance tests, the blood glucose being estimated by the method of Folin and Wu [6] and d-Xylose excretion test by the method of Roe and Rice, [18] as modified by Santini et al [20] Fecal fat was esti­mated by the method of Van de Kamer et a1 [24] and Co57 B 12 absorption by the method of Schilling. [21] The gastro­intestinal mucosal pattern and motility were studied by barium meal follow through X-rays, supplemented whenever necessary by barium enema X-rays.


 :: Results Top


[Table 1] shows the symptomatology. As expected, swelling of feet, distention of abdomen, weight loss, oedema, ascites, anaemia, muscle wasting, hepato­splenomegaly, and obvious venous col­laterals were the most common symp­toms and signs.

[Table 2] shows hemoglobin and serum protein values. The mean ± S.D. values for hemoglobin, and serum albumin were significantly lower while those for gamma globulins were significantly higher than those in normal controls. Serum bilirubin was elevated in 4 patients, serum alkaline phosphatase in 2; serum enzymes, (S.G.P.T. & S.G.O.T.), in 6; while prothrombin time was pro­longed in all cases. Patients who were icteric had no evidence of obstructive jaundice either clinically or radiologic­al ly.

All patients had had barium meal follow through X-rays, [Table 3]. These were normal in 8 patients. Somewhat delayed motility and coarsening of the mucosa were the most common findings. Less than 25% of the cases showed dilatation, fragmentation, or segmenta­tion. [Table 4] and [Table 5] show the results of absorption studies. All patients had nor­mal Co 57 B 12 absorption. Although two patients had abnormal d-Xylose excre­tion, the mean 5 hour urinary excretion of d-Xylose in cirrhotics was within nor­mal limits. Eighty per cent of patients with cirrhosis had flat lactose tolerance test, and the mean ± S.D., as well as the maximal rise over the fasting levels after a lactose load was also significantly lower in cirrhotics. Glucose tolerance test, on the other hand, was flat in only 2, (10%), diabetic in 8 (40%), while it was normal in 10 patients (50%). The mean maximum rise over the fasting level after a glucose load was within normal limits in cirrhotics. The mean daily fat excretion was significantly high and 65%, of cirrhotics had steatorrhoea.


 :: Discussion Top


Steatorrhoea in the presence of ob­structive or hepatocellular jaundice has been confirmed repeatedly. [1],[3] Some correlation has been demonstrated bet­ween the depth of jaundice and the degree of steatorrhoea by Gross et al [7],[8] .It would be reasonable to assume that the liver with its diverse functions in the metabolism of absorbed food-stuffs, when diseased would contribute to the deve­lopment of malabsorption. However, it is perhaps less widely recognised that steatorrhoea may be a feature of an unicteric liver disease where major ob­struction to the biliary tract can be excluded. [2],[4],[11],[12],[19],[22],[23] Earlier case reports included only those cases that had well marked malabsorption. Later unselected case series by many workers have reported an overall incidence of steatorrhoea in 50% of the patients with cirrhosis or chronic liver disease. This study reveals an incidence of 65%. The mechanism or etiopathogenesis of this steatorrhoea in liver disease is not cer­tain and is considered to be related to the associated mal- or under-nutrition, associated portal hypertension and ascites, decreased synthesis of bile acids by cirrhotic liver, or increased decon­jugation of bile acids in the intestine from bacterial overgrowth.

All subjects showed normal Co 57 B 12 absorption while only two patients (10%) had malabsorption of d-Xylose. Forty per cent of our cirrhotics showed diabetic glucose tolerance curve, where­as, it was flat in only 2, (10%). Thus, the findings of normal absorption of Co 57 B 12 d-Xylose and glucose with increas­ed incidence of diabetes in cirrhotics, and normal barium meal X-rays findings are similar to those reported by others.

Nearly 80% of our cirrhotics showed lactose intolerance. Lactose intolerance in cirrhotics has not been commonly reported. The etiopathogenesis of this in­tolerance is also not certain. It could probably be due to associated bacterial overgrowth. However, this needs to be confirmed by further studies which are n progress. Thus, the evidence from his and other studies suggests that mal-absorption in chronic liver disease is common and is multi-factorial in origin.


 :: Acknowledgement Top


We wish to thank the Dean, Seth G.S. Medical College and K.E.M. Hospital for allowing the facilities to carry out this research project and to publish the re­port.

 
 :: References Top

1.Atkinson, A., Nordin, B. E. C. and Sher lock, S.: Malabsorption and Bone Disease in Prolonged Obstructive Jaundice. Quart. J. Med. 25: 299-312, 1956.  Back to cited text no. 1    
2.Baraona, E., Orieqo, H. O., Fernandez E., Amenabar, E., Mandonado, F., Taq. F. and Salinas, A.: Absorptive Function of the Small Intestine in Liver Cirrhosis. Amer. J. Digest. Dis. 7: 318-330, 1962.  Back to cited text no. 2    
3.Bright, R.: Observations on Jaundice. Guy's Hospital Reports, 1: 614, 1836. Quoted by Losowsky and Walker, 1959.  Back to cited text no. 3    
4.Fast, B. R., Wolfe, S. J., Stormont, J. M. and Davidson, C. S.: Fat Absorption in Alccholics with Cirrhosis. Gastroentero­logy. 37: 321-324, 1959.  Back to cited text no. 4    
5.Foldes, Van. J., Magyar, I., Szucs, J. and Gyertyanffy, G.: Die Wirkung von bauch­specichelorusen extrakt auf die steator­rhoea bei leberzierrhoe and nach subtota­len gastrrectomie 2 Gastroenterologie. 4: 284-298, 1966. Quoted by Losowsky and Walker. [12]  Back to cited text no. 5    
6. Folin, •O. and Wu, H.: System of blood analysis; A Simplified and Improved Method for the Determination of Sugar J. Biol. Chem. 41: 367, 1920.  Back to cited text no. 6    
7.Gross, J. B., Comfort, M. W., Wallaeger, E. E. and Power, M. H.: Study of Fecal Excretion of Fat and Nitrogen and Exter. nal Pancreatic Function in Cases of Primary Parenchymatous Hepatic Disease, Proc. Mayo Clin. 26: 9-13, 1951.  Back to cited text no. 7    
8.Gross. J. B., Comfort, M. W.. Wallaeger E. E. and Power, M. H.: Total Solids, Fat, and Nitrogen in the feces. VA . Study of Patients with Primary Parenchymatous Hepatic Disease. Gastroenterology. 16: 140-150, 1950.  Back to cited text no. 8    
9.King, E. J. and Armstrong, A. R.: A con­venient method for determining serum and bile phosphatase activity. Canad. Med. Associ. J. 31: 376-381, 1934: Quoted from Practical Clinical Biochemistry bj' H. Varley, 2nd Ed., Interscience Publishers Inc., New York, 1958, p. 356-361.  Back to cited text no. 9    
10.Koiw, E. and Gronwall, A.: Staining of protein-bound carbohydrates after elec­trophoresis of serum on filter paper. Scand. J. Lab. Clin. Invest. 4: 244-246, 1952. Quoted from Varley, Practical Clinical Biochemistry, 2nd Ed. P. 194-203, Inter Science Publishers Inc. New York, 1958.  Back to cited text no. 10    
11.Linscheer, W. G., Patterson, J. F., Moore, E. Q., Robins, J. F. and Chalmers, T. C.: Medium and Long Chain, Fat Absorption in Patients with cirrhosis. J. Clin. Invest. 45: 1317-1325, 1966.  Back to cited text no. 11    
12.Losowsky, M. S. and Walker, B. E,: Liver Disease and Malabsorption. Gastroentero­logy. 56: 589-600, 1959.  Back to cited text no. 12    
13.Malloy, H. T. and Evelyn, K. A.: The Determination of Bilirubin with Photo­electric Calorimeter. J. Biol. Chem., 119: 481-490, 1937.  Back to cited text no. 13    
14.Phillips, R. A., Van Slyke, D. D., Hamil­ton, P. B., Dole, V. P., Emerson, K. (Jr.) and Archibald, R. M.: Measurement of Specific Gravities of Whole Blood and Plasma by Standard Copper Sulphate Solution. J. Biol. Chem. 183: 305-330, 1950.  Back to cited text no. 14    
15.Pimparkar, B. D., Tulsky, E. G., Kaiser. M, H. and Bockus, H. L.: Correlation of Radioactive and Chemical Faecal Fat in Various Malabsorption Syndromes. III. Studies in (A) (i) Non-specific Regional Enteritis (ii) Chronic Idiopathic Ulcera­tive Colitis (B) Hepatobiliary Disorders (C) Patients with Gastric Surgery. J. Postgard. Med• (Bombay). 10: 89-113, 1964.  Back to cited text no. 15    
16.Pimparkar, B. D., Basantani, G. K, Mehta, J. M., Bhalerao, R. A. and Donde, U. M.: Correlation Between Gastric Acid Output and Liver Function Tests in Human Cirrhosis of the liver. Ind. J. Med. Sci. 29: 1-4, 1975.   Back to cited text no. 16    
17. Reitman, S. A. and Frankel, S.: A Colori­meteric Method for the Determination of Serum Glutamic Oxalcacetic and Serum Glutamic Pyruvic Transaminases. Amer. J. Clin. Path. 28: 56-63, 1957.  Back to cited text no. 17    
18.Roe, J. H. and Rice, E. W.: A Photo-metric Method for the Determination of Free Pentoses in Animal Tissue. J. Biol. Chem. 173: 507-512, 1948.  Back to cited text no. 18    
19.Ruffin, J. M., Keever, I, C., Chears, C., Jr., Shingelton, W. W. , Baylin, G. J., Isley, J. K. and Sanders, A. P.: Further Observations on the Use of 1-131 Labelled Lipids in Study of Disease of the Gastrointestinal Tract, Gastroentero­logy. 34: 484-490, 1958.  Back to cited text no. 19    
20.Santini, H., Sheehy, T. W. and Martinez­de Jesus, J.: The Xylose Tolerance Test with a Five Gram Dose. Gastroentero­logy. 40: 772-774, 1961.  Back to cited text no. 20    
21.Schilling, R. R.: Intrinsic Factor Studies. The Effect of Gastric Juice on the Urinary Excretion of Radioactivity After the Oral Administration of Radioactive Vitamin B 1 . J. Lab. Clin. Med. 42: 860­866, 1953.  Back to cited text no. 21    
22.Siurala, M. Machela, T. E. and Hakikila, J.: Malabsorption in Chronic Parenchy­matous Liver Disease I. Studies with 1-131 labelled Triolein. Ann. Med Intern. Fenn. 49: 93-104, 1960.  Back to cited text no. 22    
23.Sun, D. C. H., Albacete, R. A. and Chen, J, K.: Malabsorption Studies in Cirrhosis of the Liver. Arch. Intern, Med. (Chicago), 119: 567-572, 1967.  Back to cited text no. 23    
24.Van de Kamer, J. H., ten Bolckel Huinick, H. and Weyers, H. A.: Rapid Method for the Determination of Fat in the Faeces. J. Biol. Chem. 177: 347-355, 1949.  Back to cited text no. 24    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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