Vitamin D: Dosing, levels, form, and route of administration: Does one approach fit all?

The 4th International Conference on Controversies in Vitamin D was held as a virtual meeting in September, 2020, gathering together leading international scientific and medical experts in vitamin D. Since vitamin D has a crucial role in skeletal and extra-skeletal systems, the aim of the Conference was to discuss improved management of vitamin D dosing, therapeutic levels and form or route of administration in the general population and in different clinical conditions. A tailored approach, based on the specific mechanisms underlying vitamin D deficiency in different diseases that were discussed, was recommended. Specifically, in comparison to healthy populations, higher levels of vitamin D and greater amounts of vitamin D were deemed necessary in osteoporosis, diabetes mellitus, obesity (particularly after bariatric surgery), and in those treated with glucocorticoids. Emerging and still open issues were related to target vitamin D levels and the role of vitamin D supplementation in COVID-19 since low vitamin D may predispose to SARS-CoV-2 infection and to worse COVID-19 outcomes. Finally, whereas oral daily cholecalciferol appears to be the preferred choice for vitamin D supplementation in the general population, and in most clinical conditions, active vitamin D analogs may be indicated in patients with hypoparathyroidism and severe kidney and liver insufficiency. Parenteral vitamin D administration could be helpful in malabsorption syndromes or in states of vitamin D resistance.Specific guidelines for desired levels of vitamin D should be tailored to the different conditions affecting vitamin D metabolism with the goal to define disease-specific normative values.

P-OGC33 Incidence, diagnosis and management of malabsorption following oesophagectomy: a systematic review

Background Survival following oesophagectomy for oesophageal cancer is increasing. This has resulted in increased focus on quality-of-life and improved survivorship. Weight loss and malnutrition occurs in 25-46% of patients after three years, with associated adverse gastrointestinal symptoms. Malabsorption syndrome is multifactorial and includes exocrine pancreatic insufficiency (EPI), small intestinal bacterial overgrowth (SIBO) and bile acid malabsorption (BAM), however there is little literature available in patients following oesophagectomy. The aim of this study was to evaluate the reported incidence and management of malabsorption syndromes post-oesophagectomy. Methods A systematic search of PubMed, EMBASE, MEDLINE, Scopus and the Cochrane Library evaluating incidence, diagnosis and management of malabsorption was performed for studies published until March 2021. Results Of 461 identified studies, seven studies (6/7 non-randomised observational studies) were included, with a combined population of 344 (range 7-87). Incidence of malabsorption syndromes including EPI, SIBO and BAM were 10.2-100%, 37.8-100% and 3.33-100% respectively. There was no consensus definition for EPI, SIBO or BAM; and there was variation in diagnostic methods. Diagnostic criteria varied from clinical (gastrointestinal symptoms or weight loss), or biochemical (faecal elastase, hydrogen breath test and Selenium-75-labelled synthetic bile acid measurements). Treatment modalities using pancreatic enzyme replacement, rifaximin and colesevelam showed improvement in symptoms and weight in all studies. Conclusions Malabsorption syndromes following oesophagectomy are likely to be severely underestimated. The resultant gastrointestinal symptoms have a negative effect on post-operative quality of life. Current literature suggests benefit with outlined therapies, however greater understanding of these conditions, their diagnosis, and management is required to further understand which patients will benefit from treatment.

Common malabsorption syndromes in different pediatrics age

The process of digestion involve many organs that include the small intestine, pancreas, gall bladder, related blood vessels and lymphatics. The small intestine which constitutes a large surface area of the gastrointestinal tract (GIT). The presence of the villi, absorptive spaces and enzymes directly contribute to the absorption of almost all elements. On the contrary, malabsorption syndromes is a condition that prevent the absorption of certain nutrients and fluids. Our present literature review mainly aimed to discuss the common malabsorption syndromes and their related etiologies in pediatric patients. We have classified our discussion based on the deficient nutrients for easy delivery and based on the specification of the etiology per each nutrient. Many studies have shown that some disease have been previously commonly reported with the development of different malabsorption syndromes such as inflammatory bowel diseases, celiac disease, autoimmune enteropathies and other congenital disorders. Furthermore, patients with malabsorption syndromes usually present with diarrhoea, steatorrhea and other GIT symptoms such as idiopathic pain and flatulence, but there are no specific symptoms associated with any of these syndromes. Efforts should be directed to understand more about the pathophysiology of some disorders, especially the congenital and idiopathic ones in order to achieve a better management and to enhance the prognosis of the affected patients.

Chronic giardiasis: a rare cause of exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is a major cause of maldigestion/malabsorption syndromes. It is routinely diagnosed in clinical practice with the use of faecal elastase 1 levels, and pancreatic enzyme replacement therapy continues to be the mainstay of treatment. Numerous primary pancreatic and extrapancreatic causes for EPI have been established. Chronic giardiasis is a common condition with symptoms similar to EPI; however, it has also been described as an infrequent cause of EPI. Much remains to be understood about the pathobiology of this association. Here, we present our experience of an intriguing case of severe pancreatic insufficiency in the setting of chronic giardiasis. The patient showed improvement in symptoms over weeks after completion of treatment for chronic giardiasis.

Differentiated approach to replacement therapy in exocrine pancreatic insufficiency

The article is an overview of current ideas about indications and features of various enzyme preparations (EP). The following requirements are applied for all EP: nontoxicity, resistance to hydrochloric acid and pepsin, good tolerance by patients, no significant side effects, optimal effect at pH≈6.0, rapid release of enzymatic activity in the small intestine at pH≈6.0, while maintaining this activity no less than 2 hours, high enzyme activity, compliance with the composition stated on the label, high serial homogeneity of the preparation, no unpleasant odor and taste. Considering the variety of pathogenetic mechanisms and nosological units that occur with maldigestion and malabsorption syndromes, the spectrum of indications for EP is rather wide: pancreatic, liver, gall bladder diseases, preparation for instrumental studies, etc. The authors present a modern algorithm (“steps”) of enzyme therapy. A differentiated approach to the choice of EP is developed depending on the pathology that the patient suffers from, EP composition, and features of its action. Attention is drawn to the possible reasons for the lack of effectiveness of replacement therapy, general contraindications to the prescription of EP (acute pancreatitis, severe exacerbation of chronic pancreatitis, hypersensitivity to the drug components) and their individual components (bile acids, nicotinamide, activated charcoal). Complications of enzyme replacement therapy are indicated, namely: pain in the oral cavity; skin irritation in the perianal region; abdominal discomfort; nausea; fibrosing colopathy; allergic reactions; sometimes hyperuricosuria; pancreatin shaping complexes with folic acid, disrupting its absorption.

Malabsorption syndromes in the tropics

Causes of secondary malabsorption that are most common in the tropics include (1) progressive wasting in people infected with HIV, which is known as ‘slim disease’; (2) various infections—protozoal (e.g. Giardia lamblia, Cryptosporidium parvum), helminthic (e.g. Capillaria philippinensis, Strongyloides stercoralis), and bacterial (Mycobacterium tuberculosis); (3) immunoproliferative small intestinal disease; and (4) hypolactasia. Coeliac disease and Crohn’s disease also occur. When patients with conditions that can cause secondary malabsorption are excluded, a group remains who have chronic diarrhoea, malabsorption, and its nutritional sequelae. This primary or idiopathic malabsorption syndrome is called ‘tropical sprue’, which occurs against the background of tropical enteropathy (describing the fact that the morphology of the mucosa of normal gut is different in tropical preindustrialized countries from that in temperate-zone industrialized countries). The aetiology of tropical sprue is not known: epidemiological data suggests an infective cause, but no causal agent has been identified. Presentation is typically with loose or watery stools lasting for several weeks or months, and with symptoms and signs of nutritional deficiency. Management involves symptomatic relief from diarrhoea, and correction of fluid and electrolyte abnormalities and nutritional deficiencies. Attempts at specific curative measures—folic acid and tetracyclines—are usually given for up to 6 months.

Persistent Diarrhea: Possible Risk Factors in Indonesia

From the management point of view, acute diarrhea in Indonesian children is not a big problem anymore. Persistent diarrhea, although the prevalence is less than 10% of acute diarrhea, hut the case fatality rate is about 5-7 times higher which is account for 30-50% of total diarrhea deaths. There are many factors which may contribute to the etiologies of persistent diarrheas. They are among others the specific agents mainly the invasive bacterias (Galmonella spp, Shigella spp, Campylobacter spp, Enteroinvasive E. coli, etc.), Giardia Lamblia and E. histolytica; malnutrition, malabsorption syndromes, systemic infections mainly measles; and last but not least the missmanagement of acute diarrhea, particularly the abundance use of antibiotics and antidiarrheal agents, the late of giving food to the patients and the too early giving semisolid food in normal young baby less than 4-6 month of age.