lactose intolerance grp 7 E-1.ppt

7/27/2019 lactose intolerance grp 7 E-1.ppt

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LACTOSEINTOLERANCE

Section E-1 Group 7

SOLIS, Ianne RobinSONACO, Angela Baye B.

SUAREZ, Jaennes S.SUAYBAGUIO, Carl Angelo M.

SUING, Essel Marie L.


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Outline

Case Introduction

Definition of Lactose Intolerance and Lactase

Food Sources of Lactose

Normal Digestion and Utilization of Lactose

Definition and Differentiation of Lactoseand Lactase Deficiency

Distinct Clinical Syndromes of Lactase Deficiency

Characteristic Clinical Manifestations

of Lactose Intolerance

Laboratory Tests/Proceduresto Diagnose Lactose Intolerance

Therapy & Treatment for Lactose Intolerance

Case Discussion and Application


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Case Introduction

SALIENT FEATURES54 y/o, female Chief complaint:

Abdominal distension & bloating after meals Associated w/:

flatulenceEpisodic diarrhea (30mins-4hours after meals)Mild suprapubic cramping & urgency before BM relieved by defecating

(-) Nausea/Vomiting(-) Skin rash Past Medical History:

(-) DM(-) Prev GI surgery(-) History of foreign travel(-) Radiation exposure(+) Osteoporosis-15months ago

-

dietary calcium intake(3cups of milk/day) Physical examination:

-Unremarkable Stool examination:

- (-) for occult blood Flexible sigmoidoscopy

- normal


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Lab Tests:

Hemoglobin = 15 g/dL (normal = 14-16 g/dL)Hematocrit = 46% (normal = 44-50%)

Serum albumin = 4.5 g/dL (normal = 3.8-4.8g/dL)

Serum cholesterol = 210 mg/dL (normal =


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Lactose

Lactose (galactosyl-P- 1,4-glucose)in the milk of mammals (including humans)is the major dietary source of galactose.Lactose is hydrolyzed in the intestine bylactase. Galactose produced by hydrolysisof dietary lactose is mostly in the form of

the alpha-isomer.


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Lactase

Lactase is the enzyme needed todigest Lactose in the intestine, with the

absence of Lactase, the Lactose cannotbe digested and absorb in the body. Andif Lactose cant be digested LactoseIntolerance could happen to a person


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Food Sources of Lactose

Milk, Milk Products bread and other baked goods waffles, pancakes, biscuits, cookies, and mixes to

make them

processed breakfast foods such as doughnuts,frozen waffles and pancakes, toaster pastries, andsweet rolls

processed breakfast cereals potato chips, corn chips, and other processed

snacks margarine salad dressings


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Digestion of Lactose


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Lactose

Stomach

Small Intestines

(Brush border of Proximal Jejunum)

Beta-Glycosidase Complex


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Beta-Glycosidase Complex

Lactase Glucosyl Ceramidase

Split Glucose

and

Galactose from Ceramides

Cleaves via Beta 1,4 Glycosidic bond

Lactose to Glucose and Galactose

Active Secondary Simporter

Glucose and Galacose + SGLT1


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Absorption in the intestinal epithelium

Glucose and Galactose + GLUT 2

Exit to the blood capillaries

GLUT5


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Once broken down into the simple form of sugars, they are now

readily adsorbed. Gluco se and galactose are taken into theenterocyte by cotranspor t wi th sod ium using the same

transporter .

Lactase has two activities. It hydrolyzes phlorizin, a

disaccharide found in roots and bark of plants of the family

Rosaceae and some seaweeds andit also hydrolyzes -

galactoside or pu t simp ly, lactose.


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Lactase hydrolyses (binds water chemically H2O) the linkage. Once

lactose is hydrolysed by the interaction of the lactase enzyme, theenzyme then moves onto the next lactose molecule and does the

same each time.


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The result of the hydrolysed lactose disaccharide is the formation

of glucose and galactose as seen in the image above. These

monosaccharides are readily adsorbed by the transport

mechanism of the enterocytes in the small intestine.


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Transport Mechanism


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Lactose Intolerance


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Lactose

Stomach(Small Intestine)

Absence of Glycosidase Complex

Goes down to large intestine

Normal flora ferment the lactose to lactate

Producing gases and flatulence Attracts water to large intestine

causing osmotic Diarrhea and

bloating


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Differences of Lactose Intoleranceand Lactase Deficiency

Lactose IntoleranceIs usually a disease of adults and is

most often associated with an inadequateamount of an enzyme lactase in the small

intestines, which is essential to digestlactose. Without enough lactase, there islactose intolerance

Lactase DeficiencyNot enough of an enzyme calledlactase in the small intestine to digestlactose
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Lactoferrin

also known as lactotransferrin

Found in milk, saliva, tears, and nasalsecretion

Human Colostrum has the highestconcentration

Component of Immune system(antimicrobial)

Provide antibacterial activity to infant


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3 Distinct Clinical Syndromes of LactaseDeficiency:

Congenital Very rare inborn error of metabolism Autosomal recessive pattern Alactasia

Primary, adult lactase deficiency or hypolactasia Most common type Begins to fall after weaning Almost completely lost by late adolescence

Also called Late Onset Lactase DeficiencyOther type is Developmental Lactase Deficiency


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Secondary

Disease or damage to the small intestine villous structure orits function e.g.Celiac disease, Cystic Fibrosis, Short gut syndrome (smallbowel resection), Parasitic infection, - Gardia, Zollinger EllisonSyndrome, Whipples disease


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Clinical Manifestations of Lactose Intolerance:

Meteorism Borborygmi Flatulence Abdominal pain/Colicky pains Dyspepsia Bloating/Fullness

Nausea Diarrhea


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Diagnostic Tests


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Breath Hydrogen Test

After an overnight fast, patient exhales through a breathanalyzer

Water solution of 50 grams of lactose (32 oz of milk) is

then ingested

End-expiratory samples are taken at 30-minute intervalsand compared with zero-time level

Hydrogen breath >20 ppm above zero-time levelHypolactasia


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Oral Lactose Tolerance Test

Ethanol (300 mg/kg) is administered 15 minutes beforeoral lactose

40 minutes after lactose ingestion, blood sample istaken

Blood galactose level of


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Lactose-Ethanol Load TestIngestion of 50g lactose

Serum glucose is measured in fasting state, then every30 minutes thereafter 2 hours following lactose

ingestion

Blood glucose rise of less than 1.1 mmol/L (20mg/dL)

Hypolactasia

Blood glucose rise greater than 1.7 mmol/L (30 mg/dL) lactose persistence

Blood glucose incremental rise of 1.1 - 1.7 mmol/L

inconclusive


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Quantitation of Small Bowel

Lactase Activity

Tissue sample obtained from distalduodenum by endoscopy or jejuna biopsy

Most accurate, but also most invasivemethod

Seldom used clinically to make thediagnosis of lactase deficiency


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Therapy

Amount of lactose that can be tolerated

variesfrom person to persons

Complete lactose restriction to confirm all

symptoms are indeed related to the LactoseIntolerance

Dietary management

Avoiding lactose-containing products

Alternative products

Lactase supplementation

Division into several meal


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Treatment of lactose intolerance should not be aimed at reducing

malabsorption but rather at improving digestive symptoms. Reduction

of lactose intake rather than exclusion is recommended because

long-term effects of lactose restriction may help improvegastrointestinal complaints but can lead to other damages.

Long-term effects of a diet free of dairy products may be a concern as

you are significantly decreasing the amount of calcium. Low calcium

levels are leading to an increase in fractures and orthopaedic

problems.


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Age groupAmount of calcium to consume daily, Age

group in milligrams (mg)

06 months 210 mg

712 months 270 mg

13 years 500 mg

48 years 800 mg

9

18 years 1,300 mg

1950 years 1,000 mg

5170+ years 1,200 mg

Recommended calcium intake by age groupSource: Adapted from Dietary Reference Intakes, 2004, Institute of Medicine, National Academy of Sciences.


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To help in planning a high-calcium and low-lactose diet, the table that

follows lists some common foods that are good sources of dietary calcium

and shows how much lactose they contain.

Vegetables Calcium Content Lactose Content

Calcium-fortified orange

juice, 1 cup308-344 mg 0

Sardines, with edible

bones,

270 mg 0

3 oz.

Salmon, canned, with

edible bones, 3 oz.205 mg 0

Soymilk, fortified, 1 cup 200 mg 0

Broccoli (raw), 1 cup 90 mg 0

Orange, 1 medium 50 mg 0

Pinto beans, 1/2 cup 40 mg 0

Tuna, canned, 3 oz. 10 mg 0

Lettuce greens, 1/2 cup 10 mg 0


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Recent research shows that yogurt with active cultures may be a good

source of calcium for many people with lactose intolerance, even

though it is fairly high in lactose. Evidence shows that the bacterialcultures used to make yogurt produce some of the lactase enzyme

required for proper digestion.


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SUMMARY

Lactose intolerance is the inability or insufficient ability to digest

lactose, a sugar found in milk and milk products.

Lactose intolerance is caused by a deficiency of the enzymelactase, which is produced by the cells lining the small intestine.

Not all people with lactase deficiency have digestive symptoms,

but those who do may have lactose intolerance.

Most people with lactose intolerance can tolerate some amount of

lactose in their diet.

People with lactose intolerance may feel uncomfortable afterconsuming milk and milk products. Symptoms can include

abdominal pain, abdominal bloating, gas, diarrhea, and nausea.

The symptoms of lactose intolerance can be managed with dietary

changes.

Getting enough calcium and vitamin D is a concern for people with

lactose intolerance when the intake of milk and milk products islimited. Many foods can provide the calcium and other nutrients

the body needs.

Milk and milk products are often added to processed foods.

Checking the ingredients on food labels is helpful in finding

possible sources of lactose in food products.


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SALIENT FEATURES54 y/o, female Chief complaint:

Abdominal distension & bloating after meals

Associated w/: flatulenceEpisodic diarrhea (30mins-4hours after meals)Mild suprapubic cramping & urgency before BM relieved by defecating

(-) Nausea/Vomiting(-) Skin rash

Past Medical History:(-) DM(-) Prev GI surgery(-) History of foreign travel(-) Radiation exposure(+) Osteoporosis-15months ago

- dietary calcium intake(3cups of milk/day)

Physical examination:-Unremarkable

Stool examination:- (-) for occult blood

Flexible sigmoidoscopy-


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Lab Tests:

Hemoglobin = 15 g/dL (normal = 14-16 d/dL)

Hematocrit = 46% (normal = 44-50%)

Serum albumin = 4.5 g/dL (normal = 3.8-4.8g/dL)

Serum cholesterol = 210 mg/dL (normal =


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Sources:

Laboratory Manual and Conference GuideLecture Guide in Biochemistry, vol. 1Harpers Illustrated Biochemistry 28th edBiochemistry 5th ed, StryerBiochemistry 4th ed, LehningerLippincott Biochemistry 3rd edMedical Biochemistry: Human Metabolism in Health and Disease, 2009

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lactose intolerance grp 7 E-1.ppt