Disorders of digestion, absorption of

carbohydrates

DR. S.S. WALVEKAR

Carbohydrate malabsorption
• Carbohydrate malabsorption, sometimes also known as “carbohydrate
intolerance.

• Carbohydrate malabsorption occurs when the main dietary carbohydrates,

sugars and starches, are not absorbed from the gastrointestinal (GI) tract.

• Malabsorption may result from congenital or acquired defects of single

transport systems. 

• Or from impairment of the epithelial surface of the small intestine.

How to handle the situation.

•  Rather than completely restricting carbohydrate intake, it's better to

incorporate lean proteins, healthy fats, and fruits and vegetables with
lots of dietary fiber on a daily basis.

• The intestinal diseases such as celiac disease or Crohn's disease may

delay or prevent the absorption of the carbohydrates.
Celiac disease

•Celiac disease is an autoimmune condition that involves the immune system

reacting to gluten.

•Gluten is a general name for a group of proteins in cereals such as wheat, barley.

•Symptoms are:

•abdominal pain, bloating

•Gas, chronic diarrhea.

•Nausea, vomiting

•pale stool with a foul smell

Crohn's disease

• Crohn's disease is a type of an auto-immune mediated inflammatory

bowel disease (IBD).

• It causes inflammation of the digestive tract, which can lead to

abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition.

• Crohn’s disease can be painful, and sometimes life threatening.

Disorders of digestion absorption of carbohydrate.

• The carbohydrate malabsorptive syndromes are frequently seen by

pediatricians.

• The congenital deficiency states are quite rare but adult type
hypolactasia and lactose intolerance following rotavirus infection are
recognized with increasing frequency by primary care physicians.

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Clinical significance of Digestion
• Lactose intolerance is the inability to digest lactose due to the
deficiency of Lactase enzyme.
• Causes
• Congenital Acquired during lifetime.
1) Primary
2) Secondary

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Congenital Lactose intolerance
• It is a congenital disorder

• There is complete absence or deficiency of lactase enzyme.

• The child develops intolerance to lactose immediately after birth.

• It is diagnosed in early infancy.

• Milk feed precipitates symptoms.

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Primary Lactase deficiency
• Primary lactase deficiency develops over time

• There is no congenital absence of lactase but the deficiency is precipitated during adulthood.

• The gene for lactose is normally expressed upto RNA level but it is not translated to form
enzyme.

• It is very common in Asian population. Lactose intolerance is also very common in

people of West African, Arab, Jewish, Greek, and Italian population.  

• There is intolerance to milk + dairy products.

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Secondary lactase deficiency
• It may develop in a person with a healthy small intestine during
episodes of acute illness.
• This occurs because of mucosal damage or from medications
resulting from certain gastrointestinal diseases, including exposure to
intestinal parasites such as Giardia lamblia.
• In such cases the production of lactase may be permanently
disrupted.
• A very common cause of temporary lactose intolerance is
gastroenteritis, particularly when the gastroenteritis is caused by
rotavirus.
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• Giardiasis  is an infection of the small intestine that is caused by the
parasite, Giardia duodenalis.

• Giardia is found on surfaces or in soil, food, or water that has

been contaminated with faeces from infected people or animals.

• If left untreated, Giardia will eventually lead to more acute symptoms,

including bloody diarrhea, weight loss, and dehydration. 

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• Another form of temporary lactose intolerance is lactose overload in
infants.

• Secondary lactase deficiency also results from injury to the small

intestine that occurs with celiac disease, Crohn’s disease, or
chemotherapy.

• This type of lactase deficiency can occur at any age but is more common
in infancy.

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Biochemical basis.

• If an individual does not produce enough lactase (lactase deficient), then

undigested lactose passes through the small intestine to the large
intestine, where bacteria break it down, producing hydrogen gas and lactic
acid.

• This process can cause the affected person to experience abdominal pain
and bloating, flatulence (passing gas), and diarrhoea within 30 minutes to 2
hours of consuming milk or other dairy products.

• It results in In the form of abdominal cramps, distensions, diarrhoea,

constipation, flatulence upon ingestion of milk or dairy products.
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 Diagnosis

• Two tests are commonly used:

• - • Hydrogen Breath Test
• The person drinks a lactose loaded
beverage and then the breath is
analyzed at regular intervals to
measure the amount of hydrogen.
• Normally, very little hydrogen is
detectable in the breath, but
undigested lactose produces high
levels of hydrogen.
• The test takes about 2 to 3 hours

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• If average basal values of breath hydrogen is more than 16 parts per
million (ppm), it is generally considered as a high value.

• Positive diagnosis for a lactulose breath test – typically positive if the

patient produces approximately 20 ppm of hydrogen within the first
60–90 minutes (indicates bacteria in the small intestine).

•  The sensitivity and specificity of the lactulose hydrogen breath test

has been reported to be only 68% and 44%, 

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• Stool Acidity Test
• • The stool acidity test is used for infants and young children to
measure the amount of acid in the stool.
• Undigested lactose creates lactic acid and other short chain fatty acids
that can be detected in a stool sample.
• Glucose may also be present in the stool as a result of undigested
lactose.

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Methylamine test for lactose.

• Add 1.0 ml of a 0.2 % solution of methylamine hydrochloride ,

followed by 10 % sodium chloride to 5 ml of urine. Mix by inversion,
cover the tube with a glass bulb and heat at 560 C for 30 minutes.

• Remove from water bath and cool at room temperature.

• Urine containing much lactose shows red colour.

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Lactose tolerance tests
• Glucose blood test

• This is an alternate test sometimes used to detect and diagnose lactose intolerance.

• This test measures the glucose level in the blood samples taken immediately before
and after the lactose drink.

• Since lactose is normally broken down to glucose and galactose, taking the lactose
drink would normally lead to absorption of this glucose and result in an increase in
blood glucose.

• In persons with lactose intolerance, there is inadequate breakdown of lactose and

so this rise in blood glucose is not seen.
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• Besides these tests, urine shows positive test with Benedict’s test,.

• since lactose is a reducing sugar and a small amount of lactose is

absorbed in the intestinal cell by pinocytosis and is rapidly eliminated
through kidneys in to urine.(Lactosuria).

• Mucosal biopsy confirms the diagnosis

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• Avoidance of dairy products.
• One glass of milk contains 11 gm of lactose.
• Although the body’s ability to produce lactase cannot be changed,
the symptoms of lactose intolerance can be managed with dietary
changes.
• Most people with lactose intolerance can tolerate some amount of
lactose in their diet.
• Gradually introducing small amounts of milk or milk products may
help some people adapt to them with fewer symptoms.

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Lactose-free, lactose-reduced milk.

• Soy milk and other products may be recommended.

• Lactase enzyme drops or tablets can also be consumed.

• Getting enough calcium is important for people with lactose intolerance

when the intake of milk and milk products is limited.

• A balanced diet that provides an adequate amount of nutrients—

including calcium and vitamin D—and minimizes discomfort is to be
planned for the patients of lactose intolerance.
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Factors affecting rate of absorption of
Monosaccharides
• The absorption is faster through intact mucosa.

• The absorption is decreased if there is some inflammation or injury

to the mucosa.

• Thyroid hormones ↑ the rate of absorption of glucose.

• Mineralocorticoid,i.e Aldosterone ↑ the rate of absorption.

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• Vitamin B6,B12, pantothenic acid, folic acid are required for absorption
of glucose.

• With advancing age, rate of absorption declines.

• Insulin has no role in the absorption of monosaccharide like glucose

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2. Sucrase deficiency.

• The deficiency of the enzyme sucrase occurs along with that of

isomaltase because these two occur as a single enzyme complex.

• People with this condition cannot break down the sugars sucrose (a
sugar found in fruits, and also known as table sugar) and maltose (the
sugar found in grains).

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• The undigested sugar undergoes a process called “fermentation.”

• This fermentation results in increased gas production.

• When undigested substances are not absorbed in the colon, an osmotic

pull of water into the colon causes watery diarrhoea. 

• Symptoms are quite similar, such as diarrhoea and cramps, abdominal

pain, etc.
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