9/7/2012 Nutritional Pathology Topics • Nutritional deficiencies – Protein – Energy Malnutrition – Anorexia Nervosa and Bulimia – Vitamin Deficiencies – Mineral Deficiencies • Obesity นายแพทย ดร.ณตพล ศุภณัฐเศรษฐกุล • Diet and Systemic Diseases ภาควิชาพยาธิวิทยา คณะแพทยศาสตร มหาวิทยาลัยนเรศวร 12 กันยายน พ.ศ. 2555 Nutritional deficiencies An aequate diet should provide: 1. Energy, in the form of carbohydrates, fats, proteins 2. Essential (as well as nonessential) amino acids and fatty acids as building blocks 3. Vitamins and minerals function as coenzymes and hormones in vital metabolic pathways http://www.easy-weightloss-tips.com/images/diabetic-food-pyramid.jpg 1 9/7/2012 ภาวะทุพโภชนาการ (Malnutrition) Common Causes Primary malnutrition : missing from the diet • Poverty (homeless, aged, children) • Ignorance Secondary malnutrition : adequate nutrients (infants, adolescents, pregnant women) supply, but malnutrition may result from - Malabsorption • Chronic alcoholism - Impaired nutrient use or storage • Acute and chronic illnesses - Excess nutrient losses (trauma, burn, cancer, etc.) - Increased need for nutrients • Self-imposed dietary restriction (GI diseases, chronic wasting diseases, acute critical illness) Protein - Energy malnutrition (PEM) - PEM refers to a range of clinical syndrome characterized by an inadequate dietary intake of protein and calories to meet the body’s needs. - Primary (children) and Secondary (illness) PEM - Two polar forms: - Marasmus, - Kwashiorkor A B 2 9/7/2012 1. Marasmus. - Severe reduction in caloric intake - Greater than 60% reduction in body weight - Most common during the first year of life - Use somatic protein component & subcutaneous fat as a source of energy - Serum albumin levels are either normal or only slightly reduced - Growth retardation, multivitamin deficiencies, Marasmus anemia, immune deficiency 2. Kwashiorkor - More severe form of malnutrition than marasmus - Mainly occur in children 6 months to 3 years of age - Occurs when protein deprivation is relatively greater than the reduction in total calories - Loss of visceral protein component - Hypoalbuminemia → generalized edema - Fatty change of liver - Skin lesion : hypo-and hyperpigmentation, desquamation - Hair change : overall loss of color or alternating band (flag sign), straightening, loss of firm attachment to the scalp - Multivitamin deficiencies, anemia, immune deficiency 3 9/7/2012 Secondary PEM. Syndrome Clinical Time Clinical features Laboratory Prognosis setting course findings 1. marasmus- Chronic Months History of weight Normal or Variable; like PEM illness (e.g., loss, muscle mildly depends chronic lung wasting, absent reduced on disease, subcutaneous fat serum underlying cancer) “Cachexia” proteins disease 2. kwashiorkor- Acute, Weeks Normal fat and Serum poor like PEM catabolic muscle , edema, albumin Kwashiorkor illness (e.g., easily pluckable 2.8 gm/dl severe hair trauma, burn, sepsis) Topics Anorexia Nervosa • Nutritional deficiencies • Self-induced starvation, resulting in marked weight loss – Protein – Energy Malnutrition – Anorexia Nervosa and Bulimia • Manifested as severe PEM with endocrine – Vitamin Deficiencies abnormalities – Mineral Deficiencies – Amenorrhea (GnRH, LH, FSH) – Decreased bone density (low estrogen level) • Obesity – Decreased thyroid hormone release (cold intolerance, bradycardia, constipation) • Diet and Systemic Diseases • Increased susceptibility to cardiac arrhythmia and sudden death 4 9/7/2012 http://www.funatiq.com/images/anorexia-nervosa-model.jpg Anorexia Nervosa http://www.womenshealthzone.net/eating-disorders/anorexia-nervosa/effects/img/1287.gif http://1.bp.blogspot.com/_cBDzDLF1zns/SE_ELpvdbjI/AAAAAAAAACk/92KsZWfMR8M/S740/normal_00031778.jpg Bulimia • A condition in which the patient binges on food and then induces vomiting • Amenorrhea occurs in less than 50% of Pt., Wt. and gonadotropin levels are near normal • Major medical complications: – Electrolyte imbalances (Hypokalemia) and cardiac arrhythmia – Pulmonary aspiration of gastric content – Esophageal and cardiac rupture http://www.netscool.com/elrio/daniela/bulimia.jpg 5 9/7/2012 Topics • Nutritional deficiencies – Protein – Energy Malnutrition – Anorexia Nervosa and Bulimia – Vitamin Deficiencies Bulimia – Mineral Deficiencies • Obesity • Diet and Systemic Diseases http://internationalteenlife.pbworks.com/f/bulimia.gif http://purgingpoet.today.com/files/2009/04/effects_of_bulimia.jpg http://www.topnews.in/files/Bulimia.jpg http://4.bp.blogspot.com/_zRiLerjhL2c/Rh8dELoSWOI/AAAAAAAAAVM/BoGHNraqwwQ/s400/bulimia.bmp Vitamin Deficiencies • Ascorbic acid C and Toxicities • Niacin B3 • Fat soluble vitamins • Pyridoxine B6 – A, D, E, K • Cobalamin B12 – Deficiency due to abnormal fat • Retinoic acid A absorption • Thiamine B1 – Accumulate and toxicity • Riboflavin B2 • Tocopherol E • Water soluble vitamins • Calciferol D – B1, B2, B3, B6, B12, C, Folate • Other names, Source 6 9/7/2012 Vitamin A Deficiency Bitot’s spot Xerophthalmia with corneal ulcer : night blindness : Bitot’s spot (small plaques of keratin debris), keratomalacia (corneal ulcer and destruction), xerophthalmia (dry eye), total blindness : Squamous metaplasia 2o pulmonary infection, KUB stone (keratin debris) : vulnerability to infection (measle, pneumonia, diarrhea) Corneal scaring Corneal ulcer towards keratomalacia http://www.cehjournal.org/images/ts040006.jpg Vitamin D 1, 25 (OH)2 D is the active form of vitamin D (synthesis from kidney by 1-hydroxylase) Function : stimulate intestinal absorption of Ca and P. : collaborates with PTH in the mobilization of Ca from bone. : stimulate the PTH-dependent reabsorption of Ca in the distal renal tubules 7 9/7/2012 Rickets Vitamin D - an excess of unmineralized matrix (osteoid) Deficiency : Rickets (children) - Intramembranous bone formation : Osteomalacia (adult) (direct ossification of embryonic connective : Hypocalcemia tetany tissue ; membrane bone of skull) - Endochondral bone formation (Intracartilaginous replacement of hyaline cartilage; bone of trunk and extremities cartilage) 8 9/7/2012 During nonambulatory stage of infancy: - Head : ศีรษะแบน เปนสี่เหลี่ยม หนาผากนูน (craniotabes, frontal bossing, squared appearance) - Chest : rachitic rosary at costochondral Rachitic rosary junction, pigeon breast deformity, Harrison’s groove. During ambulatory stage of infancy : Pelvis deformity, lumbar lordosis, bowing legs. 9 9/7/2012 Pectus excavatum (Funnel chest) Pectus carinatum (Pigeon chest) http://www.patient.co.uk/doctor/Chest-Deformity.htm http://www.respir.com/images/SemeioPectusExt.jpg http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9583.jpg Osteomalacia - Vitamin D deficiency in adult - Contour of the bone are not affected - Bone is weak and vulnerable to fracture due to osteopenia Bowing legs 10 9/7/2012 Vitamin E (a-tocopheral) Vitamin E Deficiency : Poor nerve conduction,axon degeneration - serves as a scavenger of free radicals, the on the posterior columns of the spinal antioxidant effect cord, loss of nerve cells in the dorsal - may reduce mutagenesis root ganglia, and degenerative changes in the spinocerebellar tracts - Cause of deficiency : deficient diet is uncommon : occurs in association with : The neurologic manifestations are malabsorption syndromes, infants of low birth ataxia, dysarthria, absent tendon weight, developmental defects in the GI tract, or reflexes, and loss of position sense and lipoprotein disorders. pain sensation. Vitamin K Vitamin K Deficiency - Clotting factor 2, 7, 9, 10 : ภาวะเลือดออกงาย (bleeding diathesis) - Anticoagulant protein C and S : Intracranial hemorrhage of the - May favor calcification of bone newborn proteins and inhibit bone resorption prevent osteoporosis 11 9/7/2012 Cause of deficiency : Vitamin B1 (thiamine) –fat malabsorption syndromes Function : maintains neural membranes and (biliary tract disease) normal nerve conduction, especially peripheral –destruction of the endogenous nerve vitamin Deficiency : most common in chronic alcoholism, –synthesizing flora (ingestion of result in syndromes of broad-spectrum antibiotics) - dry beriberi (polyneuropathy) –neonatal period - wet beriberi (heart failure, peripheral edema) –Diffuse liver disease - Wernicke – Korsakoff Syndrome –Drug (e.g., warfarin) (irriversible) Wernicke – Korsakoff Syndrome • Lesions in the CNS : hemorrhage and degeneration of mammillarv bodies, periventicular region of thalamus, floor of forth ventricle, anterior region of cerebellum • Wernicke encephalopathy is marked by ophthalmoplegia, nystagmus, ataxia of gait and confusion • Korsakoff psychosis consists of impairment of remote, recall, confabulation, and inability to acquire new information 12 9/7/2012 Vitamin B2 (Riboflovin) - cheilosis (cheilitis, angular stomatitis): first + most characteristic sign (crack + fissure at the angles) - Glossitis : tongue atrophy, red-blue discoloration - Eye change : interstitial keratitis, corneal vascularization, corneal ulcer - Scaling dermatitis : nasolabial folds and cheek (butterfly distribution), scrotal, vulva 13 9/7/2012 Vitamin B3 (Niacin) - an essential component of NAD+ and NADP - Pellagra (3 D’s): - Dermatitis sharply demarcated scaling and desquamation of exposure area, bilaterally symmetry - Diarrhea caused by atrophy of the gastrointestinal epithelium - Dementia results from neuron degeneration in the brain, and in the spinal cord Vitamin B6 (Pyridoxine) Vitamin B12 (Cobalamin) Deficiency state - Coenzyme in the DNA synthetic pathway - Most common in chronic alcoholism