European Consensus on Malabsorption-UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN: Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Abstract

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Keywords: breath test; coeliac disease; diarrhoea; enteropathy; nutrition; pancreatitis; weight loss.

FIGURE 1

(A) Schematic algorithm for the diagnosis of malabsorption in adults. (B) Schematic algorithm for the diagnosis of malabsorption in children and adolescents. The algorithm should be considered as expert‐based, and the order of the examinations may vary depending on specific clinical situations and local test availability. Indeed, if a specific cause of malabsorption is highly likely depending on patient's history, the order of testing will depend on this. For example, overt malabsorption in a patient with a first‐degree family history of coeliac disease (CD) should prompt further testing for CD, while leaving other tests as a second line in case CD is not confirmed. Similarly, in a patient with a single nutrient deficiency, such as vitamin B12 with pernicious anaemia, autoimmune gastritis would be the most likely diagnosis. The initial assessment, both in adults and children, should be made by any physician, while second‐level testing should be recommended by specialist physicians. For adults, three different illustrative clinical examples are provided based on the presenting features. Indeed, not all examinations are necessary in every case, and the order may vary, as previously mentioned. A universal algorithm that fits every clinical picture dominated by malabsorption does not exist; specific guidelines should be followed for individual diseases. The same principle is applied to the paeditric setting. a1‐AT, alpha 1‐anti‐trypsin; CT, computer tomography; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; FOBT, faecal occult blood test; INR, international normalized ratio; MR, magnetic resonance; PET, positron emission tomography; US, ultrasound.

FIGURE 2

Schematic algorithm for the first assessment of a patient with malabsorption in a primary care setting. This algorithm should be considered as expert‐based, and the number and type of examinations may vary depending on specific clinical situations and local tests availability. In the primary care setting, the most important thing is to recognise signs and symptoms related to malabsorption as early as possible, as well as other differential diagnoses. According to the local test availability and to specific clinical situations, a series of first‐line tests should be performed. For example, among other laboratory tests, iron, vitamin B12, albumin, and folic acid may be useful as well in addressing the diagnosis, depending on the specific clinical setting. Coeliac disease is certainly one of the most common malabsorptive disorders, and therefore serology should always be performed. Faecal calprotectin is useful for differential diagnosis with inflammatory disorders of the colon. The availability of these tests may widely vary across different countries. The referral to a specialist physician shound be made within 1 month (or earlier if needed), depending on the clinical picture and the results of the first‐line tests, so to avoid treatment delay.