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Aktuelle Ernährungsmedizin 2005; 30(2): 75-87
DOI: 10.1055/s-2004-834735
Originalbeitrag
© Georg Thieme Verlag KG Stuttgart · New York

Diätetische Therapie bei Kohlenhydratmalabsorption und Laktoseintoleranz

Dietary Management of Carbohydrate Malabsorption and Lactose IntoleranceO.  Leiß1
  • 1Gastroenterologische Gemeinschaftspraxis Prof. Dr. O. Leiß et al., Mainz
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Publication History

Publication Date:
14 April 2005 (online)

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Zusammenfassung

Physiologie der Kohlenhydratverdauung, Pathophysiologie und Symptomatik der Kohlenhydratmalabsorption, beeinflussende Faktoren und die unter dem Begriff „physiologische Kohlenhydratmalabsorption” zusammengefasste Beschwerdesymptomatik werden erörtert. Nach kurzer Darstellung von Monosaccharidintoleranzen wird ausführlich auf die häufigste Disaccharidintoleranz Laktoseintoleranz eingegangen. Die Häufigkeit der Laktoseintoleranz, Formen des Laktasemangels und diagnostische und differenzialdiagnostische Probleme werden diskutiert. Die diätetischen Maßnahmen wie Meidung von laktosehaltigen Nahrungsmitteln, partielle Zufuhr von Joghurt und Verwendung von laktosefreier Milch werden ausführlich erörtert, auf die Enzymsubstitution mit laktasehaltigen Enzympräparaten wird eingegangen. Die Überlappung mit der Symptomatik bei Colon irritabile und die Bedeutung einer differenzierten Diagnostik werden betont.

Abstract

The physiology of carbohydrate digestion, pathophysiology and symptom pattern of carbohydrate malabsorption, factors influencing the severity of symptoms and the so-called physiological carbohydrate malabsorption are discussed. Both monosaccharide intolerances as well as disaccharide intolerances are mentioned. The incidence of lactose intolerance, primary and secondary types of lactase deficiency, diagnostic approach and differential diagnosis are presented. Dietary management including avoidance of lactose-containing nutrients, consumption of yogurt and lactose free milk and therapy with lactase enzymes are discussed in detail. The overlap of colon irritabile symptoms with symptoms from lactose intolerance is underlined; a clear diagnostic work up is important.

Schlüsselwörter

Kohlenhydratmalabsorption - Disaccharidintoleranz - Laktoseintoleranz - laktosefreie Ernährung - laktasehaltige Enzympräparate

Key words

Carbohydrate malabsorption - disaccharide intolerance - lactose intolerance - lactose free diet - lactase enzymes

Literatur

  • 1 Klein S, Jeejeebhoy K N. The malnutrished patient: nutritional assessment and management. In: Feldman M, Friedman LS, Sleisenger MH, Saunders WB (eds) Sleisenger & Fordtran's Gastrointestinal and Liver Disease - Pathophysiology/Diagnosis/Management. 7th edition. Philadelphia, London, New York; Edited by Company 2002: 265-285
    Google Scholar
  • 2 Hammond J B, Littmann A. Disaccharide malabsorption. In: Berk JE, Haubrich WS, Kalser MH, Roth JLA, Schaffner F (eds) Bockus Gastroenterology, fourth edition. Philadelphia, London, Toronto; W. B. Saunders Company 1985: 1703-1718
    Google Scholar
  • 3 Olsen W A, Lloyd M L. Carbohydrate assimilation. In: Yamada T, Alpers DH, Owyang C, Powell DW, Silverstein FE (eds) Textbook of Gastroenterology. Philadelphia; Lippincott Company 1991: 334-353
    Google Scholar
  • 4 Suarez F L, Levitt M D. Intestinal gas. In: Feldman M, Friedman LS, Sleisenger MH (eds) Sleisenger & Fordtran's Gastrointestinal and Liver Disease - Pathophysiology/Diagnosis/Management. 7th edition. Philadelphia, London, New York; W. B. Saunders Company 2002: 155-163
    Google Scholar
  • 5 Högenauer C, Hammer H F. Maldigestion and malabsorption. In: Feldman M, Friedman LS, Sleisenger MH (eds) Sleisenger & Fordtran's Gastrointestinal and Liver Disease - Pathophysiology/Diagnosis/Management. 7th edition. Philadelphia, London, New York; W. B. Saunders Company 2002: 1751-1782
    Google Scholar
  • 6 Semenza G, Auriccio S. Small-intestinal disaccharidases. In: Scriver CR, Beaudet AL, Sly WS, Valle D (eds) The metabolic and molecular basis of inherited disease. New York; McGraw-Hill, Inc 1995: 4451-4480
    Google Scholar
  • 7 Duro D, Rising R, Cedillo M. et al . Association between infantile colic and carbo-hydrate malabsorption from fruit juices in infancy.  Pediatrics. 2002;  109 797-805
    CrossrefPubMedGoogle Scholar
  • 8 Rumessen J J, Gudmand-Hoyer E. Functional bowel diseases: malabsorption and abdominal distress after ingestion of fructose, sorbitol, and fructose-sorbitol mixtures.  Gastroenterology. 1988;  95 694-700
    PubMedGoogle Scholar
  • 9 Born P, Zech J, Lehn H, Classen M, Lorenz R. Colonic bacterial activity determines the symptoms in people with fructose-malabsorption.  Hepatogastroenterology. 1995;  42 778-785
    PubMedGoogle Scholar
  • 10 Mishkin D, Sablauskas L, Yalovsky M. et al . Fructose and sorbitol malabsorption in ambulatory patients with functional dyspepsia.  Dig Dis Sci. 1997;  42 2591
    CrossrefPubMedGoogle Scholar
  • 11 Evans P R, Piesse C, Bak Y T, Kellow J E. Fructose-sorbitol malabsorption and symptom provocation in irritable bowel syndrome: relationship to enteric hypersensitivity and dysmotility.  Scand J Gastroenterol. 1998;  33 1158-1163
    CrossrefPubMedGoogle Scholar
  • 12 Choi Y K, Johlin jr F C, Summers R W. et al . Fructose intolerance: an underrecognized problem.  Am J Gastroenterol. 2003;  98 1348-1353
    CrossrefPubMedGoogle Scholar
  • 13 Harms H K, Bertele-Harms R M, Bruer-Kleis D. Enzyme substitution therapy with the yeast Saccharomyces cerevesiae in congenital sucrase-isomaltase deficiency.  N Engl J Med. 1987;  316 1306-1309
    PubMedGoogle Scholar
  • 14 Treem W R, McAdams L, Stanford L. et al . Sacrosidase therapy for congenital sucrase-isomaltase deficiency.  JPGN J Ped Gastroenterol Nutr. 1999;  28 137-142
    PubMedGoogle Scholar
  • 15 Lembcke B. Kohlenhydratmalabsorption und funktionelle Darmstörungen. In: Hotz J, Rösch W (Hrsg) Funktionelle Störungen des Verdauungstraktes. Berlin, Heidelberg, New York; Springer-Verlag 1987: 35-57
    Google Scholar
  • 16 Levitt M D, Hirsh P, Fetzer C A. et al . H2 excretion after ingestion of complex carbohydrates.  Gastroenterology. 1987;  92 383-390
    PubMedGoogle Scholar
  • 17 Semenza G, Keller P, Zwicker E, Wacker H, Mantei N. Lactase-phlorizin hydrolase and sucrase-isomaltase along the small intestine. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 66-75
    Google Scholar
  • 18 Keller P, Wacker H, Semenza G, Mantei N. Structure of lactase-phlorizin hydrolase and ist gene. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia Dyn Nutr Res. Basel; Karger 1993 3: 76-84
    Google Scholar
  • 19 Swallow D M, Harvey C B. Genetics of adult-type hypolactasia. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger; 1993 3: 85-92
    Google Scholar
  • 20 Auricchio S, Maiuri L. Cellular basis of adult-type hypolactasia. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 93-101
    Google Scholar
  • 21 Naim H Y. In vivo and in vitro biosynthesis of lactase in animals and in humans. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 102-113
    Google Scholar
  • 22 Lloyd K L. The regulation of lactase expression in adult life in humans. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 124-131
    Google Scholar
  • 23 Flatz G. The genetic polymorphism of intestinal lactase activity in adult humans. In: Scriver CR, Beaudet AL, Sly WS, Valle D (eds) The metabolic and molecular basis of inherited disease. New York; McGraw-Hill, Inc 1995: 4441-4450
    Google Scholar
  • 24 Johnson J D, Kretchmer N, Simoons F J. Lactose malabsorption: its biology and history.  Advances in Pediatrics. 1974;  21 197-237
    PubMedGoogle Scholar
  • 25 Simoons J F. The geographic hypothesis and lactose malabsorption: weighing of the evidence.  Am J Dig Dis. 1978;  23 963-980
    CrossrefPubMedGoogle Scholar
  • 26 Scrimshaw N S, Murray E B. The acceptability of milk and milk products in populations with a high prevalence of lactose intolerance.  Am J Clin Nutr. 1988;  48 1080-1159
    PubMedGoogle Scholar
  • 27 Sahi T. Genetics and epidemiology of adult-type hypolactasia.  Scand J Gastroenterol. 1994;  29, Suppl 207 7-20
    PubMedGoogle Scholar
  • 28 Maiuri L, Rossi M, Raia V. et al . Mosaic regulation of lactase in human adult-type hypolactasia.  Gastroenterology. 1994;  107 54-60
    PubMedGoogle Scholar
  • 29 Harvey C B, Wang Y, Hughes L A. et al . Studies on the expression of intestinal lactase in different individuals.  Gut. 1995;  36 28-33
    PubMedGoogle Scholar
  • 30 Rossi M, Maiuri L, Fusco M I. et al . Lactase persistence versus decline in human adults: multifactorial events are involved in down-regulation after weaning.  Gastroenterology. 1997;  112 1506-1514
    PubMedGoogle Scholar
  • 31 Kuokkanen M, Enattah N S, Oksanen A. et al . Transcriptional regulation of the lactase-phlorizin hydrolase gene by polymorphisms associated with adult-type hypolactasia.  Gut. 2003;  52 647-652
    CrossrefPubMedGoogle Scholar
  • 32 Troelsen J T, Olsen J, Möller J, Sjöström H. An Upstream polymorphism associated with lactase persistence has increased enhancer activity.  Gastroenterology. 2003;  125 1686-1694
    PubMedGoogle Scholar
  • 33 Sahi T. Progress report: Dietary lactose and the aetiology of human small-intestinal hypolactasia.  Gut. 1978;  19 1074-1086
    PubMedGoogle Scholar
  • 34 Newcomer A D, McGill D B. Clinical importance of lactase deficiency.  N Engl J Med. 1984;  310 42-43
    PubMedGoogle Scholar
  • 35 Cooper B T. Lactase deficiency and lactose malabsorption.  Dig Dis. 1986;  4 72-82
    PubMedGoogle Scholar
  • 36 Enck P, Whitehead W E. Lactase deficiency and lactose malabsorption. A review.  Z Gastroenterol. 1986;  24 125-134
    PubMedGoogle Scholar
  • 37 Sahi T. Hypolactasia and lactase persistence. Historical review and the terminology.  Scand J Gastroenterol. 1994;  29, Suppl 202 1-6
    PubMedGoogle Scholar
  • 38 Arola H, Tamm A. Metabolism of lactose in the human body.  Scand J Gastroenterol. 1994;  29, Suppl 202 21-25
    PubMedGoogle Scholar
  • 39 Villako K, Maaroos H. Clinical picture of hypolactasia and lactose intolerance.  Scand J Gastroenterol. 1994;  29, Suppl 202 36-54
    PubMedGoogle Scholar
  • 40 Craper S. Milk is not for every body. Living with lactose intolerance. New York; Facts on File, Inc 1995
    Google Scholar
  • 41 Schleip T. Laktoseintoleranz. Wenn Milchzucker krank macht. Ratgeber Ehrenwirth, 3. Aufl. Verlagsgruppe Lübbe 2001
    Google Scholar
  • 42 Chanard J. Intestinal absorption of calcium, lactose malabsorption, and osteoporosis. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 31-39
    Google Scholar
  • 43 Stefano M Di, Veneto G, Malservisi S. et al . Lactose malabsorption and intolerance and peak bone mass.  Gastroenterology. 2002;  122 1793-1799
    PubMedGoogle Scholar
  • 44 Birlouez-Aragon I, Scalbert-Menanteau P, Ravelontseheno L, Cathelineau G, Abitbol G. Milk consumption and cataract formation. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 40-51
    Google Scholar
  • 45 Cramer D W. Lactase persistence, galactose metabolism, and milk consumption as risk factors for ovarian cancer. In: Auricchio S, Semenza G (eds) Common Food Intolerances 2: Milk in Human Nutrition and Adult-Type Hypolactasia. Dyn Nutr Res. Basel; Karger 1993 3: 52-60
    Google Scholar
  • 46 Arola H. Diagnosis of hypolactasia and lactose malabsorption.  Scand J Gastroenterol. 1994;  29, Suppl 202 26-35
    PubMedGoogle Scholar
  • 47 Brummer R JM, Karibe M, Stockbrügger R W. Lactose malabsorption. Optimalization of investigational methods.  Scand J Gastroenterol. 1993;  28, Suppl 200 65-69
    PubMedGoogle Scholar
  • 48 DiPalma J A, Narvaez R M. Prediction of lactose malabsorption in referral patients.  Dig Dis Sci. 1988;  33 303-309
    CrossrefPubMedGoogle Scholar
  • 49 Corazza G, Sorge M, Maurino E. et al . Methodology of the H2 breath test. I. Collection and storage for gas measurement.  Ital J Gastroenterol. 1990;  22 200-203
    PubMedGoogle Scholar
  • 50 Lorenzo C Di, Dooley C P, Valenzuela J E. Role of fasting gastrointestinal motility in the variability of gastrointestinal transit time assessed by hydrogen breath test.  Gut. 1991;  32 1127-1130
    PubMedGoogle Scholar
  • 51 Strocchi A, Corazza G, Ellis C J, Gasbarrini G, Levitt M D. Detection of malabsorption of low doses of carbohydrate: accuracy of various breath H2 criteria.  Gastroenterology. 1993;  105 1404-1410
    PubMedGoogle Scholar
  • 52 Rumessen J J, Nordgaard-Andersen I, Gudmand-Hoyer E. Carbohydrate malabsorption: quantification by methane and hydrogen breath tests.  Scand J Gastroenterol. 1994;  29 826-832
    PubMedGoogle Scholar
  • 53 Maiuri L, Rossi M, Raia V. et al . Morphological method for the diagnosis of human adult type hypolactasia.  Gut. 1994;  35 1042-1046
    PubMedGoogle Scholar
  • 54 Kuokkanan M, Myllyniemi M, Sipponen P. et al .A biopsy Quick Test for diagnosis of duodenal hypolactasia in upper GI endoscopy. Zur Publikation eingereicht. 
    Google Scholar
  • 55 Tamm A. Management of lactose intolerance.  Scand J Gastroenterol. 1994;  29, Suppl 202 55-63
    PubMedGoogle Scholar
  • 56 Kolars J C, Levitt M D, Aouji M, Savaiano D A. Yoghurt - an autodigesting source of lactose.  N Engl J Med. 1984;  310 1-5
    PubMedGoogle Scholar
  • 57 Lerebours E, Djitojap Ndam C N, Lavoine A. et al . Yogurt and fermented-then-pasteurized milk: effect of short-term and long-term ingestion on lactose absorption and mucosal lactase activity in lactase-deficient subjects.  Am J Clin Nutr. 1989;  49 823-827
    PubMedGoogle Scholar
  • 58 Onwulata C I, Rao D R, Vankineni P. Relative efficiency of yogurt, sweet acidophilus milk, hydrolized-lactose milk, and commercial lactase tablet in alleviating lactose maldigestion.  Am J Clin Nutr. 1989;  49 1233-1237
    PubMedGoogle Scholar
  • 59 Marteau P, Flourie B, Pochart P. et al . Effect of the microbial lactase activity in yoghurt on the intestinal absorption of lactose: an in vivo study in lactase-deficient humans.  Br J Nutr. 1990;  64 71-79
    PubMedGoogle Scholar
  • 60 Fioramonti J, Theodorou V, Bueno L. Probiotics: What are they? What are their effects on gut physiology?.  Best Practice & Research Clinical Gastroenterology. 2003;  17 711-724
    PubMedGoogle Scholar
  • 61 Marteau P, Shanahan F. Basis aspects and pharmacology of probiotics: an overview of pharmacokinetics, mechanisms of action and side-effects.  Best Practice & Research Clinical Gastroenterology. 2003;  17 725-740
    CrossrefPubMedGoogle Scholar
  • 62 Servin A L, Coconnier M H. Adhesion of probiotic strains to the intestinal mucosa and interaction with pathogens.  Best Practice & Research Clinical Gastroenterology. 2003;  17 741-754
    PubMedGoogle Scholar
  • 63 Briet F, Pochart P, Marteau P. et al . Improved clinical tolerance to chronic lactose ingestion in subjects with lactose-intolerance: a placebo effect?.  Gut. 1997;  41 632-635
    PubMedGoogle Scholar
  • 64 Souci S W, Fachmann W, Kraut H. Die Zusammensetzung der Lebensmittel - Nährwerttabellen. Herausgegeben von der Deutschen Forschungsanstalt für Lebenmittelchemie, Garching. Bearbeitet von H. Scherz und F. Senser. 6. revidierte und ergänzte Auflage. Medpharm Scientific Publishers,. Stuttgart, Boca Raton, London, New York; Stuttgart und CRC Press 2000
    Google Scholar
  • 65 Kocian J, Skala I, Bakos K. Calcium absorption from milk and lactose-free milk in healthy subjects and patients with lactose intolerance.  Digestion. 1973;  9 317-324
    PubMedGoogle Scholar
  • 66 Smith T M, Kolars J C, Savaiano D A, Levitt M D. Absorption of calcium from milk and yogurt.  Am J Clin Nutr. 1985;  42 1197-1200
    PubMedGoogle Scholar
  • 67 Tremaine W J, Newcomer A D, Riggs B L, McGill D B. Calcium absorption from milk in lactase-deficient and lactase-sufficient adults.  Dig Dis Sci. 1986;  31 376-378
    CrossrefPubMedGoogle Scholar
  • 68 Schuette S A, Knowles J B, Ford H E. Effect of lactose or its component sugars on jejunal calcium absorption in adult man.  Am J Clin Nutr. 1989;  50 1084-1087
    PubMedGoogle Scholar
  • 69 Wynckel A, Jaisser F, Wong T, Drücke T, Chanard J. Intestinal absorption of calcium from yogurt in lactose-deficient subjects.  Reprod Nutr Dev. 1991;  31 411-418
    PubMedGoogle Scholar
  • 70 Solomons N W, Guerrero A M, Torun B. Effective in vivo hydrolysis of milk lactose by beta-galactosidases in the presence of solid foods.  Am J Clin Nutr. 1985;  41 222-227
    PubMedGoogle Scholar
  • 71 Lin M Y. et al . Comparative effects of exogenous lactase (β-galactosidase) preparations on in vivo lactose digestion.  Dig Dis Sci. 1993;  38 2022-2027
    CrossrefPubMedGoogle Scholar
  • 72 Rosado J L, Solomons N W, Lisker R. Enzyme replacement therapy for primary adult lactase deficiency. Effective reduction of lactose malabsorption and milk intolerance by direct addidtion of β-galactosidase to milk at mealtime.  Gastroenterology. 1984;  87 1072-1082
    PubMedGoogle Scholar
  • 73 Ramirez F C. et al . All lactase preparations are not the same: results of a prospective, randomized, placebo-controlled trial.  Am J Gastroenterol. 1994;  89 566-570
    PubMedGoogle Scholar
  • 74 Bosch S, Kalde S, Kuhlbusch R, Söllenböhmer C, Lübke H J. Therapie der Laktoseintoleranz mit einem Aspergillus-Laktasepräparat.  Akt Ernähr-Med. 1995;  20 310-315
    PubMedGoogle Scholar
  • 75 Rask Peddersen E, Jensen B H, Jensen H J. et al . Lactose malabsorption and tolerance of lactose-hydrolyzed milk.  Scand J Gastroenterol. 1982;  17 861-864
    PubMedGoogle Scholar
  • 76 Pena A S, Truelove S C. Hypolactasia and the irritable bowel syndrome.  Scand J Gastroenterol. 1972;  7 433-438
    PubMedGoogle Scholar
  • 77 Newcomer A D, McGill D B. Irritable bowel syndrome. Role of lactase deficiency.  Mayo Clin Proc. 1983;  58 339-341
    PubMedGoogle Scholar
  • 78 Bianchi Porro G, Parente F, Saangaletti O. Lactose intolerance in adults with chronic unspecific abdominal complaints.  Hepatogastroenterol. 1983;  30 254-257
    PubMedGoogle Scholar
  • 79 Enck P, Kremer A, Kuhlbusch R. et al . Prevalence of lactose malabsorption among patients with functional bowel disorders.  Z Gastroenterol. 1990;  28 239-241
    PubMedGoogle Scholar
  • 80 Böhmer C JM, Tuynman H ARE. The clinical relevance of lactose malabsorption in irritable bowel syndrome.  Eur J Gastroenterol Hepatol. 1996;  8 1013-1016
    PubMedGoogle Scholar
  • 81 Cann P A, Read N W, Brown C, Hobson N, Holdsworth C D. Irritable bowel syndrome: relationship of disorders in the transit of a single solid meal to symptom patterns.  Gut. 1983;  24 405-411
    PubMedGoogle Scholar
  • 82 Sciaretta G, Giacobazzi G, Verdi A. et al . Hydrogen breath test quantification and clinical correlation of lactose malabsorption in adult irritable bowel syndrome and ulcerative colitis.  Dig Dis Sci. 1984;  29 1098-1104
    CrossrefPubMedGoogle Scholar

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