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Morphological aspects of the duodenojejunal
mucosa in protein-calorie malnourished children
and during recovery”2’3
Roberto E. Schneider,4 M.D., and Fernando E. Viteri,5 M.D., D.Sc.
Protein-calorie malnutrition (PCM) is as- The morphological investigations consisted of
sociated with various degrees of intestinal the stereoscopical and light microscopy study of
the duodenojejunal mucosa obtained by suction bi-
malabsorption (1, 2). Morphological altera-
opsies. At the same time, different studies were
tions in the intestinal mucosa are also present, performed to measure and characterize the mal-
but their relationship to PCM has not beenabsorption present in these children. The micellar
elucidated as yet (3-5). Previous work of the capacity and the bile salts composition of the duo-
and denal content during fat stimulation were studied;
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Institute of Nutrition of Central America
stool-fat balances, d-xylose absorption, and Schill-
Panama (INCAP) has shown that, in general,
ing tests were also done. The results of these stud-
the malabsorptive state disappears as the will be reported
ies elsewhere.
child recovers (6), but some of the morpho- The children were investigated at different
logical changes persist despite improved stages of recovery
nu- as follows:
tritional status (7). 1) On admission, any time between admission
and the 4th hospital day.
A longitudinal study was carried out in 11 2) During stabilization, between the 9th and 12th
children with severe PCM from admission to
days of hospitalization. From admission until that
full recovery, in order to obtain information time, the children were placed on a therapeutic
on the role that malnutrition, infection, regimen,
and which improved their protein and calorie
diarrhea play in the pathogenesis of some nutrition
of only slightly, but water and electrolyte
disturbances were corrected. Antibiotics were used
the gastrointestinal alterations observed. The
when indicated. Any child requiring antimicrobial
present paper covers the morphological stud- therapy was excluded from the microbiological
ies of the duodenojejunal mucosa of these study. The diet contained 0.7 high
g quality pro-
patients. The microbiological alterations tein
ob- and 70 kcal/kg body wt; 20 to 30% of the
served in their GI tract are presented in totala calories were derived from fat. The children
also received vitamins andminerals in amounts
separate communication (8). adequate to fulfill daily recommended allowances.
After the studies were completed, intake of protein
Material and methods and calories was raised progressively to reach, in
6 to 8 days, 3 to 4 g protein/kg per day and 120 to
Besides the 11 malnourished subjects previously 150 kcal/kg per day, 30% of which came from fat.
mentioned, four clinically healthy children with
normal growth patterns, whohad been followed in Paper presented at the National Academy of
well baby clinics and who had always been well- Science Workshop on Malabsorption and Nutrition
nourished, were also studied. held in Washington, D.C., April 29-30, 1971.
The age of the malnourished children varied Funds 2from the National Institutes of Health
from 23 to 61 months. They were kept under close(NIH) of the U. S. Public HealthService (Grant
observation at the Clinical Center of INCAP dur-No. 5R22 AM 12105-03), through the U. S. Japan
ing the full duration of the study. All had severe Cooperative Medical Science Program.
PCM of the edematous type; none presented evi- Publication 1-594 of the Institute of Nutrition
dence of gluten enteropathy. of Central America and Panama, Guatemala, C.A.
The degree of malnutrition and of recovery was Research Associate, Biomedical Division, In-
assessed clinically, and by means of serial meas- stitute of Nutrition of Central America and Pan-
urements of weight for height, height for age, ama; Associate Professor of Medicine, University
creatinine/height index (CHI) (9), total serum pro-of San Carlos School of Medicine, Guatemala,
tein, and serum albumin concentrations. Some of
C.A., and Chief of the Research Division, Insti-
the characteristics of the children at the different tute of Social Security of Guatemala. Chief, 6
stages when the morphological and functional Biomedical Division, Institute of Nutrition of Cen-
studies were performed are shown in Table 1. tral America and Panama.
1092 The American Journal of Clinical Nutrition 25:
OCTOBER 1972, pp. 1092-1102. Printed in U.S.A.
MORPHOLOGY OF DUODENOJEJTJNAL MUCOSA IN PCM 1093
TABLE 1
Characteristics of the PCM children on admission and at different periods of study
Diarrhea
Hospital Percent of Serum
Child’s name months Period of study CHI5 protein, Indez of diarrhea
days wt/ht6 g/100 ml At the
time of
study
Partial Cumulative
NG 37 Adc 2 84 0.41 3.8 0
Stab’ 10 84 0.57 4.5 + 25
R±e 34 81 0.79 7.0 0 8
Rec1 118 105 1.10 6.5 0 19 17
GZ 41 Ad 2 74 0.47 5.6 +
Stab 13 74 0.56 4.8 0 70
Rec 161 110 1.10 7.1 0 17 2
RS 42 Ad 4 84 0.58 4.0 +
Stab 13 84 0.58 4.1 0 0
R± 41 88 0.78 6.3 0 11
Rec 75 98 0.90 7.0 0 9 8
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LC 19 Ad 2 67 0.57 4.0 0
Stab 14 67 0.57 4.0 0 46
R± 62 75 0.69 6.0 0 8
Rec 156 94 0.90 6.2 0 18 18
EP 26 Ad 4 85 0.59 4.5 0
R± 39 90 0.80 7.0 0 29
Rec 121 100 1.05 7.0 0 9 13
BM 23 Stab 9 72 0.46 3.5 0 80
Rec 105 100 1.04 7.2 0 5 8
VB 69 Stab 12 82 0.53 4.8 0 0
Rec 67 90 0.97 7.0 0 5 4
DM 35 Stab 10 72 0.44 3.5 0 40
Rec 107 99 1.04 7.0 0 5 8
DS 34 Stab 9 82 0.56 3.3 + 100
Rec 147 110 1.06 7.5 + 41 44
AC 26 Ad 4 70 0.58 4.8 +
R± 39 65 0.63 6.8 + 79
Rec 107 92 0.96 7.0 + 86 83
AS 24 Ad 4 98 0.52 4.5 +
R± 42 79 0.80 6.8 + 96
Rec 82 100 1.02 7.1 + 93 94
Percent wt/ht = percent of weight for height (on admission and at stabilization, edema was pres-
ent). b CHI = creatinine height index. c Ad = admission. d Stab = stabilization period. R±
#{149}
= during recovery. / Rec = full recovery.
This intake was maintained until nutritional carefully
full screened for thepresence of Giardia
recovery was attained. The protein sources usedlamblia. Stool cultures for enteropathogens were
were Incaparina (10) and casein; adequate nutri-made in the majority of children who presented
tional recovery was attained with either source. diarrhea. The degree of intestinal parasite infec-
3) During recovery, when the CHI was be- tion and protozoa present in the children on ad-
tween 0.65 and 0.80, which was usually achieved mission and their evolution during the of
period
around the 35th to 60th day of hospitalization. study are presented in Table 2; the number of
4) After full recovery, when all the measure- treatments administered during this period of time
ments used to evaluate recovery were within is
nor- also stated.
mal limits; this usually occurred between 75 and
150 days after admission. Characterization of diarrhea
Direct fresh stool examinations for ova and Diarrhea was defined by the number, weight,
parasites, as well as for ova counts (Stoll’s concen- and consistency of the stools every 24 hr. The
tration method), were done periodically. Freshnumber was considered abnormal when the child
stool examinations were also performed for the had four or more bowel movements; when stool
detection of protozoa, and the histological sections weight was greater than 150 g; and consistency of
of all duodenojejunal mucosa biopsies taken were the stools was considered abnormal if more than
1094 SCHNEIDER AND VITERI
TABLE 2 areas of the sections showing muscularis mucosa
Estimates of expected errors in counting different were favored for this study. A coefficient of varia-
types of nuclear cells in the lamina propria of Lion of 6% was obtained when the results were
duodenojejunal biopsies evaluated by analysis of variance techniques with
appropriate variance component models.
Ex- The following aspects were specifically evalu-
Mean pected ated:
Item count error Coeffici ent of variability
(n 3S4) (no. of Mucosa thickness, expressed as the average of
cells) 10 random measurements performed at a magnifi-
cation of 125 (12).
Plasma cells 24.36 1.62 6.65 Epit/ielial cell and brush border height, and
Lympho. 6.22 1.07 17.20 nuclear size, expressed as the mean value of 10 dif-
cytes ferent random measurements done at a magnifica-
1
PMN 4.60 1.15 25.00 EE X lion of 1,250. The nuclear size is determined by
Otherb 40.36 2.63 6.52 multiplying the longitudinal axis by the transverse
Total 75.34 2.99 3.97 axis of one randomly chosen epithelial cell nuclei.
The approximate thickness of the brush border was
a PMN = polymorphonuclear cell. b Other =
measured in PAS-stained sections; at the magnifica-
all cells not specifically defined. lion used, a minimal difference of 0.3 could be
consistently differentiated.
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50% were liquid, semiliquid, or contained mucus Mitotic figures present in well-oriented crypts
were counted in every 10th section of each biopsy
or blood. Diarrhea was diagnosed when least
at
taken. The mitotic activity is expressed as the num-
two of the above-mentioned criteria were present.
The incidence was calculated using an index ber of mitoses
of present in 100 crypts. This method
(to be published) has a correlation coefficient of
diarrhea, in percent, resulting from dividing the
0.957 with the usual mitotic index.
number of days that the child had diarrhea by the
Nuclear cell counts of the infiltrate present in
days of hospitalization. In this way, both cumula-
the epithelium. All nuclei clearly different from
live and partial diarrhea! indices were calculated.
The former assessed the overall incidence of diar- those of the epithelial cells were counted in two
areas of 700- to 900-p length. These nuclei were
rhea during the whole hospitalization, whereas the
latter was calculated for each period between not identified further, and thealues v reported rep-
studies. It was considered that a child had chronic resent the average of the two counts, expressed as
the number of nuclei in l00-j length.
diarrhea when the cumulative index was above
Nuclear cell counts in the lamina propria,
50%.
counted in two areas of 0.06 mm2 each. Depending
Morphological studies on nuclear characteristics, the cells were classified
as: 1) lymphoplasmocytic cells (lymphocytes and
Suction biopsies of the duodenojejunal mucosa plasma cells); 2) polymorphonuclear cells, and 3)
were obtained after 6 hr of fasting. A modified other cells.
suction tube and a capsule (1 1), which can be in- To estimate the contribution of varioussources
troduced following nasogastric intubation, was error,
of repeated counts of all groups of cells con-
used for this purpose, and two specimens weresidered were carried out in randomly selected slides
obtained in each session. Failure to obtain ade-
on two different occasions one month apart. A
quate specimens with this capsule was . 21% No total of 308 counts were performed. A summary
bleeding or other complications have occurred. The of the net expected error of the different items
capsule was located fluoroscopically, and the biop-counted is presented in Table 2. Although the
sies were taken at the level of the angle of Treitz.coefficient of variation is elevated in some of the
The properly oriented specimens were placed on
cell groups counted, it actually varies around the
a Marlex mesh and immediately fixed in Bouin’s minimal expected error of one cell.
solution. After 6 to 8 hr the secretions and mucus
that clouded the appearance of the mucosa were
rinsed. The biopsies were photographed at Results
15.6
magnifications and all the viii present in the two
specimens were counted. The former were classi-Morphology
fied into three groups: a) finger-like, b) leaf-shaped,
Table 3 shows the degree and type of
and c) ridged.
Serial 5-is sections, stained with hematoxylin- parasite
load and protozoa found in these
eosin and with Schiff’s periodic acid were used children
for upon admission, as well as their evo-
histological studies. Besides the general configura- lution during the study period. On admission
tion of the villi, several measurements, and cell was found that
it all patients had a moderate
counts were performed at random in a double-
degree of parasitic infection except for one
blind fashion using a Seitz ocular micrometer with
appropriate scales. Areas showing any degree who had 50,000
of eggs Ascaris of lu,nbricoides
trauma or other artifacts were avoided; the central per gram of feces. No correlation was found
MORPHOLOGY OF DUODENOJEJUNAL MUCOSA IN PCM 1095
TABLE 3
Intestinal parasite load, on admission and during treatment, of 11 PCM childrent
T.t. Al.
Xematodes5
, Na. S.s.
No. of
treat-
ments
E.h.
Protozoab
Stool biopsy
No. of
treat-
mta
Admission and sta- 5c 7 5 1 0 2 5 7 2
bilization 5 2,6001 5 2,000k fl,000 (14,000)
12,800J 5l,200j 4,000J
During recovery 4 3 1 1 10 2 0 3 4
I 800k f 2,000 (2,400) (10,000)
l2,400J 5l,200J
Fully recovered 4 2 1 1 12 0 0 4 1
f300 5 400 (200) (2,000)
400J l,000J
Studied longitudinally from admission to complete nutritional recovery.
b T.t. = Trichuris tric/liura; Al. = Ascaris lumbricoides; Na. = Necator americaizus; S.s.
E. h. = Eiztamoeba
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Strongyloides stercoralis; histolytica.
Number of children. Range of stool egg count in parentheses.
between the kind and degree of intestinal the viffi was noted within an area 52 to of
parasitic load and any of the morphological 100 j. It was not unusual to observe the
characteristics studied. This was also true presence of very long villi, some fused the at
when protozoa were present in stoolstips,
either giving origin to wider formations (Figs
or histological sections. 2A, 2B, 2C).
Practically all the children had experienced A significant and progressive increase in
frequent episodes of diarrhea for several the thickness of the duodenojejunal mucosa
months before admission; in many cases its
the epithelial cell height, and brush border
beginning could be traced back to the wean- thickness was observed in all children as nu-
ling period. During hospitalization diarrheal tritional recovery progressed (Fig. 3). Never-
episodes varied widely in frequency and theless,
se- in the two children with chronic diar-
verity. Even so, children AC and AS were rhea
the (circled points) these three measure-
only two patients who fulfilled the criteria ments
of were significantly smaller than in those
chronic diarrhea, with cumulative o
indices f without diarrhea.
84 and 96% , respectively. Information re- A close correlation was also observed be-
garding the severity of the diarrhea observed tween the increase in thickness of the du-
at the time of thestudy in each patient is odenojejunal mucosa and the creatinine/
given in Table 1. height index, the correlation coefficient being
The duodenojejunal mucosa of these pa-0.767. No significant changes were noted in
tients showed a homogeneously ridged the size of the epithelial
ap- cell nucleus through-
pearance on stereoscopy, irrespective of the out recovery.
degree of malnutrition present on admission Figure 4 shows the evolution of the mitotic
or the stage of nutritional recovery during activity. This is expressed as the number of
which the biopsy was taken (Figs. 1A, mitoses
1B). in 1 00 crypts of the duodenojejunal
Furthermore, its persistence in the recovered mucosa during different stages of nutritional
groups was not associated with any degree recovery, as well as with the presence and
of malabsorption, as a battery of tests degree
for of diarrhea, expressed by the partial
malabsorption revealed no abnormality. Be- index between biopsy periods. No change was
sides the marked predominance of ridged observed with nutritional recovery. However,
villi, the general distribution of the different children with a partial index higher than 20%
forms of villi observed remained unchanged had less mitotic activity than those a
with
during nutritional recovery (Table 4). Marked smaller partial index of diarrhea, regardless
variation in the length, shape, and contour of of the degree of nutritional recovery. Dc-
1096 SCHNEIDER AND VITERI
A
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B
FIG. IA, lB. Stereoscopical appearance of the duodenojejunal mucosa from patient NG on admission (A),
and fully recovered (B). X75.
MORPHOLOGY OF DUODENOJEJUNAL MUCOSA IN PCM 1097
TABLE 4
Average mucosal thickness and villi configuration (%) of the duodenojejunal mucosa
of PCM children at different stages of nutritional recovery
Villi configuration, %
Average mucosal
Nutritional status Percent wt/ht#{176} CHI
Convoluted Leaves Fingers
Admission 80.0 #{216}53c 380.7c 63.8c 29.0c 73c
(n = 7) 10.7 0.07 30.0 8.8 7.7 5.2
Stabilization 77.1 0.50 392.2 61.5 29.8 8.8
(n = 8) 6.6 0.05 40.0 8.2 6.0 4.3
Recovery 82.2 0.80 429.5 59.2 33.3 7.5
(n = 6) 5.7 0.08 23.2 6.0 5.4 5.1
Full recovery 102.1 1.00 487.1 66.9 25.6 7.5
(n = 11) 7.9 0.07 27.1 2.7 3.5 4.3
Control 100.4 472.3 60.0 31.6 8.4
(n = 4) 2.4 26.2 5.7 2.8 2.3
Percent of weight for height index (edema was present on admission and during stabilization).
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The average mucosal thickness of children without chronic nonspecific diarrhea 495.9
was 20.8.
±
The average mucosal thickness of children with chronic nonspecific diarrhea 447.5 was ± 4.9. The
difference is statistically significant (t = 2.95; P < 0.05). ± SD.
pressed mitotic activity was also wheninteraction
noted between PCM and diarrhea was
diarrhea was present at the of biopsy observed.
time
(mean ± SD mitotic activity 30.50 ± 6.54, The evolution of the morphological altera-
and 5 1.87 ± respectively).
8.24, tions determined in our patients led to the
Although the epithelial infiltrate (Table 5) definition of three categories. a) Those that
tended to be higher in children upon admis- persisted unchanged even when full nutri-
sion and during the stabilization period thantional recovery was attained, and were unre-
at other stages of recovery, significant differ- lated to diarrhea; these include the stereo-
ences (P < 0.001) were obtained between scopical appearance of the mucosa, the
the children with and without diarrhea, andpopulation of cells present in the lamina
between children with PCM and normal con-propria, and the size of the epithelial cell
trols. nuclei. b) Those that improved with nutri-
Finally (Fig. 5), the number of cells pres- tional recovery but which were adversely
ent in the lamina propria remained un-
affected by chronic diarrhea; these include
changed throughout recovery, whether diar-the mucosal thickness and the epithelial cell
rhea existed or not. and brush border heights. c) Lastly, those
It is important to note that the only
that were more related to the presence of
morphological difference between the biop- diarrhea than to nutritional status; these in-
sies from the four healthy children and thosedude the mitotic activity of the epithelium
recovering or fully recovered from malnutri- and its degree of cellular infiltrate. None of
tion was the degree of cellular infiltrate at the the morphological alterations could be related
epithelium. to the presence or degree of intestinal para-
sitic infection.
Discussion
For many years malnutrition was consid-
From the previous data it is evident thatered responsible for the morphological
protein-calorie malnutrition cannot be con- changes observed in the proximal small in-
sidered the only cause for the morphological testinal mucosa of children and adults with
alterations observed in the intestine. protein-calorie
The malnutrition. Nevertheless,
presence and frequency of “nonspecific diar-many ofthese changes, especially the pres-
rhea” seems to be more closely associated ence of leaf and ridged villi, mild alterations
with many of these changes, and often afrank of the epithelial cell, and the presence of
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00
C,)
C)
x
0
0
0
(j
C)
00
C)
0
a
.=
00
>
0
0
r
-
-
MORPHOLOGY OF DUODENOJEJUNAL MUCOSA IN PCM 1099
.UCCSOL THICKI453 propria in our normal controls coming from
poor environments further point to the non-
specificity of these alterations. They also
suggest that they are very common mdi-in
viduals living in poor hygienic conditions,
and that malnutrition is not directly responsi-
450
A
ble for them. Ther presence in normal adult
populations from developing countries (16)
400
50
with otherwise normal absorptive capacity
( 1 7) corroborates this possibility. A geneti-
cally induced change is unlikely, as the im-
5)
mediate postmortem examination of the small
EPITHELIAL CELL HEIGHT intestinal mucosa of fetuses and stillborns of
similar background to that of patients
our
revealed predominantly finger-like villi.
Finally, the presence of these changes in bi-
opsy specimens of adults from developed
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countries, obtained after they had lived for a
few months in Pakistan (18) and Viet Nam
A
60 .
0
0
:: ; . ‘
.
30 .
B
20
IC
B
z - - -
0
ADMI55IO STABILIZATION RECOVERY RECOVERED
ON
a S3 CC
A
. Re:c
C C = Pa?eC? cO=: CCOeC ‘S C’CC’ ‘CC ctde ?i’ CCO LOIChCS
6 N’ -
FIG. 3. Mucosal thickness, epithelial cell and
brush border heights of duodenojejunal mucosa 70 B
from 11 children with PCM followed from admis-
60
sion to complete nutritional recovery. Circled points
=
= patients with chronic diarrhea; stars normal - Sc’
children.
S 40 A
a #{149} a *
_: 3c
cellular infiltrate in the lamina propria, are
not specific and probably reflect the limited
ways in which the small intestinal mucosa re- 10
acts to different noxae. The above-mentioned
alterations have been observed not only in
PCM but in association with certain intestinal CIARPHEA INDEX
parasites and protozoa (13, 14), after the
FIG. 4. Number of mitoses of the duodenojeju-
administration of certain drugs and
(15), in
nal mucosa of 1 1 children with PCM followed lon-
many other conditions. The presence of thegitudinally, from admission to complete nutritional
same stereoscopical alterations and the de- recovery. (A) Changes observed with nutritional
gree of cellular population in the lamina status, and (B) with diarrhea index.
TABLE 5
Intestinal epithelial infiltrate in PCM children on admission and at different stages of recovery
I)iarrhea
All cases
Present Absent
On admission and stabilization 5.95 ± 0.42a 7.00 ± 0.37 4.81 ± 0.43
(n = 15) (n = 6 (ii = 9)
During recovery and recovered 5.18 ± 0.41 6.63 ± 0.23 4.73 ± 0.46
(n = 17) (n = 4 (n = 13)
Normal children 1.78 ± 0.23
(n = 4)
a Number of cells in100 , of epithelium (mean ± SE).
I ()n ad- ssion N
240 II StoHlzoon 0
#{149}N\
III Durrq rccoerv N
230 Iv F51l recovered N 11
Normal’ N= 4
220
210
1T1 1 S.D. I1
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200
190
130
170
160
150
140
130
.( 120
110
- 100
90
70 #{149}
60
50
40
30
10
I II I
Ii I’J #{149}‘N#{149}#{149} II
rFw III l’’ #{149}l’’ I II I’EJ I
-
II ill \‘ r
LYmphoplasma. Poly’orplonu. Other T’: Ces
cvtic CellS dect ce1is
FIG. 5. Number of cells in the lamina propria of I I children with ICM followed longitudinally from ad-
mission to complete nutritional recovery.
1100
MORPHOLOGY OF DUODENOJEJUNAL MUCOSA IN PCM 1101
(19), and the tendency for lesions to regress the mucosa and the cell population of the
when these individuals returned to their origi- lamina propria, remained unchanged and
nal environment (19) suggest that “nonspe- showed no relation to nutrition or diarrhea.
cific” or “tropical jejunitis,” as it is called, is The morphological characteristics of the
conditioned by ecological factors. A common upper GI mucosa of normal, well-nourished
denominator in the majority of these entities children, were no different from those ob-
is the presence of variable degrees of nonspe- served in the recovered patients.
cific diarrhea. PCM cannot be considered the only cause
The increase in mucosal thickness and for the alterations
in found, as the presence and
cell and brush border heights probably re-
frequency of nonspecific diarrhea were also
flects protein repletion, which also correlates associated with several of those alterations; a
with improvement in mucosal function. The frank interaction between PCM and diarrhea
epithelium of the proximal small intestinal was frequently observed. It appears that the
mucosa is one of the most active tissues in
ecological situation characteristic of environ-
the body (20); for this reason, the nutritional ments where poor hygienic conditions and
status of the patient is expected to affect diarrhea
it. prevail plays an important role in
Nonspecific diarrhea is associated with the genesis
a and persistency of the GI altera-
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decrease in mucosal thickness and in mitotic tions observed in children with and without
activity, as well as with an increase in epithe- clinically evident PCM. [
hal cell infiltrate. Alterations of the small in-
testinal fluxes of water, electrolytes, and nutri- References
ents resulting in decrease absorption, and low-
1. Vrrniu, F. E., M.BHAR, G. ARROYAVE AND
ered energy and protein availability (21) have
N. S. SCRIMSHAW. Clinical aspects of protein
been noticed also in nonspecific diarrhea. The malnutrition. In: Mammalian Protei,z Metabo-
mechanisms involved in the genesis of all of lism, edited by H. N. Munro J
and. B. Allison.
these changes remain unknown. New York: Academic, 1964, vol. chapt.
II, 22,
p. 523.
2. G6MEz, F., R. Rio GALvAN, J. CRAVIOTO,
Summary S. FRENK, J. VELAZQUEZ AND C. PEtA. Fat ab-
sorption in chronic severe malnutrition in chil-
The characteristics and evolution of differ- dren. Lancet 2: 121, 1956.
ent morphological and functional alterations 3. STANFIELD, J. P., M. S. R. Hurr AND R. TuN-
present in the proximal small intestine of I 1 NICLIFFE. Intestinal biopsy in kwashiorkor.
Lancet 2: 519, 1965.
severely protein-calorie malnourished chil-
4. BuRMAN, D. The jejunal mucosa in kwashiorkor.
dren were studied in relation to nutritional Arch. Disease Childhood 40: 526, 1965.
status, diarrhea, and intestinal parasitic infec- 5. BRUNSER, 0., A. Riom, F. M6NCKEBERG, A.
tion. Four healthy, not previously malnour- MAccIONI AND I. CONTRERA5. Jejunal mucosa
ished children whose background was simi- in infant malnutrition. Am. J. Clin. Nutr. 21:
976, 1968.
lar to that of the PCM subjects, were also
6. VITERI, F. E., J. M. FLORES AND M. B/CHAR.
studied. None of the morphological charac- Intestinal absorption inprotein-calorie malnu-
teristics examined correlated with either the trition. In: Proc. VlItlz Intern. Congr. Nutr.
presence or degree of intestinal parasitic or Hamburg, August 1966, p. 46.
protozoa infection. 7. SCHNEIDER, R. E., F. E. VITERI AND J. ALVA-
RADO. Histopathological study of the intestinal
Morphologically, the thickness of the du-
mucosa in malnutrition. A preliminary report.
odenojejunal mucosa of the PCM patients as In: Pediatrics in Latin A nzerica. (Report of a
well as the heights of the epithelial cell and Macy Conference.) Santiago, Chile, March
its brush border increased with nutritional re- 1969, p. 34.
8. MATA, L. J., F. JIMfNEZ, M. CORD6N, R.
covery. Nevertheless, the presence of diarrhea SCHNEIDER, F. VITERI, R. ROSALES AND E.
adversely affected improvement and was as- PRERA. Gastrointestinal floraof children with
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Discussion
Dr. Lindenbaum: Dr. Schneider, did you say dude the data in the paper presented here, the
that increased or decreased crypt a
mitotic c- study of rectal biopsies obtained simultaneously
tivity was noted during diarrhea? with the upper intestinal biopsies revealed that
the mitotic activity of the rectal mucosa also de-
Dr. Schneider: Decreased. Although I did not in- creased during diarrhea.
