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Archives of Disease in Childhood 1997;76:236-241; doi:10.1136/adc.76.3.236
Copyright © 1997 BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health.
Arch Dis Child 1997;76:236-241 ( March )

Intestinal permeability in kwashiorkor

D R Brewster,a M J Manary,b I S Menzies,c E V O'Loughlin,d R L Henrye

a College of Medicine, University of Malawi, Blantyre, Malawi, b Washington University School of Medicine, St Louis, USA, c Department of Clinical Biochemistry, King's College Medical School, London, d New Children's Hospital, University of Sydney, Westmead, Australia, e Faculty of Medicine and Health Sciences, University of Newcastle, Australia

Correspondence to: Dr David Brewster, Flinders University and Maternal and Child Health, Royal Darwin Hospital, PO Box 41326, Casuarina, NT 0811, Australia.

Accepted 16 September 1996

Intestinal permeability can be assessed non-invasively using the lactulose-rhamnose (L-R) test, which is a reliable measure of small intestinal integrity.
AIMS---To determine risk factors for abnormal intestinal permeability in kwashiorkor, and to measure changes in L-R ratios with inpatient rehabilitation.
DESIGN---A case-control study of 149 kwashiorkor cases and 45 hospital controls. The L-R test was adapted to study kwashiorkor in Malawi, with testing at weekly intervals during nutritional rehabilitation. Urine sugars were measured by thin layer chromatography in London.
RESULTS---The initial geometric mean L-R ratios (×100) (with 95% confidence interval) in kwashiorkor were 17.3 (15.0 to 19.8) compared with 7.0 (5.6 to 8.7) for controls. Normal ratios are <5, so the high ratios in controls indicate tropical enteropathy syndrome. Abnormal permeability in kwashiorkor was associated with death, oliguria, sepsis, diarrhoea, wasting and young age. Diarrhoea and death were associated with both decreased L-rhamnose absorption (diminished absorptive surface area) and increased lactulose permeation (impaired barrier function) whereas nutritional wasting affected only L-rhamnose absorption. Despite clinical recovery, mean L-R ratios improved little on treatment, with mean weekly ratios of 16.3 (14.0 to 19.0), 13.3 (11.1 to 15.9) and 14.4 (11.0 to 18.8).
CONCLUSION---Abnormal intestinal permeability in kwashiorkor correlates with disease severity, and improves only slowly with nutritional rehabilitation.


Key messages

  • Kwashiorkor still has a 30% case fatality rate at urban hospitals in Malawi
  • Intestinal permeability can be measured non-invasively by the lactulose-rhamnose test as an indicator of gut damage
  • The degree of abnormal permeability in kwashiorkor reflects the severity of illness and improves only slowly with nutritional rehabilitation
  • Changes in intestinal permeability can be used to evaluate treatment interventions



Keywords: kwashiorkor; intestinal permeability; Africa.

© 1997 by Archives of Disease in Childhood
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