Lactose Intolerance


Article Author:
Talia Malik


Article Editor:
Kiran Panuganti


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
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Ahmad Malik
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James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/22/2019 6:27:25 PM

Introduction

Lactose intolerance is a clinical syndrome that manifests with characteristic signs and symptoms upon the consumption of food substances containing lactose, a disaccharide. Normally upon the consumption of lactose, it is hydrolyzed into glucose and galactose by lactase enzyme, which is found in the small intestinal brush border. Deficiency of lactase due to primary or secondary causes results in clinical symptoms. Disease severity varies among individuals. Lactose is present in dairy, milk products, and mammalian milk.[1] It is also sometimes referred to as lactose malabsorption.

Etiology

Lactase enzyme deficiency can occur in individuals, and they have lower levels of this enzyme which results in failure to hydrolyze lactose into absorbable glucose and galactose components. There are 4 main causes of lactase deficiency.

Primary Lactase Deficiency

It is the most common cause of lactase deficiency, also known as lactose non-persistence. There is a gradual decline in lactase enzyme activity with increasing age. Enzyme activity begins to decline in infancy and symptoms manifest in adolescence or early adulthood. It is a hereditary cause of lactase deficiency.

Secondary Lactase Deficiency

Injury to intestinal mucosa due to several infectious, inflammatory or other diseases can cause secondary lactase deficiency. Common causes include:

  • Gastroenteritis
  • Celiac disease
  • Crohn disease
  • Ulcerative colitis
  • Chemotherapy
  • Antibiotics

Congenital Lactase Deficiency

There is a decrease or absence of lactase enzyme activity since birth due to autosomal recessive inheritance. It manifests in the newborn after ingestion of milk. It is a rare cause of the deficiency. 

Developmental Lactase Deficiency

It is seen in premature infants born at 28 to 37 weeks of gestation.[2] The intestine of the infant is underdeveloped resulting in an inability to hydrolyze lactose. This condition improves with increasing age due to the maturation of intestine, which results in adequate lactase activity.

Epidemiology

Lactose intolerance is a common disease; however, it is rare in children younger than 5 years of age. It is most often seen in adolescents and young adults. On average, 65% of the world's population is lactose intolerant.[3] The prevalence of lactose intolerance is variable among different ethnicities. It is most common in African Americans, Hispanics/Latinos, and Asians, while least prevalent in people of European descent.[4] Ethnic groups with a higher prevalence of lactose intolerance also are more likely to have lactose non-persistence.[5][6]

Pathophysiology

Lactase enzyme is located in the brush border of the small intestinal mucosa.  Deficiency of lactase results in presence of unabsorbed lactose within the bowel. This results in an influx of fluid into the bowel lumen resulting in osmotic diarrhea. Colonic bacteria ferment the unabsorbed lactose producing gas(hydrogen, carbon dioxide, and methane) which hydrolyzes lactose into monosaccharides. This results in an additional influx of fluid within the lumen. The overall effect of these mechanisms results in various abdominal signs and symptoms.

Histopathology

Microscopic findings of the small intestine vary depending on the cause of lactase deficiency. In primary lactase deficiency, the mucosa appears normal. Lactase activity can be measured to assess the severity of the disease. In secondary lactase deficiency, the mucosa may be abnormal depending upon the underlying cause. It is helpful in determining the secondary causes of disease such as celiac disease.

History and Physical

Signs and symptoms of lactose intolerance manifest 30 minutes to 1 to 2 hours after ingestion of milk containing (dairy) products. The severity of symptoms depends upon the amount of lactose consumed and the severity of the disease. Common signs and symptoms may include:

  • Diarrhea
  • Abdominal bloating
  • Abdominal Pain
  • Nausea and vomiting
  • Fullness
  • Flatulence

Less commonly it can present with headache, muscle pain,  joint pain, mouth ulcers, urinary symptoms and loss of concentration.[7][8]

Evaluation

Lactose intolerance is evaluated by getting a careful history, performing the physical exam and medical tests.

History

It is important to take a past medical, family and dietary history to determine the cause of lactose intolerance and exclude secondary causes.

Physical Exam

Assess for presence of abdominal bloating, tenderness, and pain.

Medical Tests

  1. Hydrogen breath test: This test measures the hydrogen content of breath after ingestion of lactose. The test is positive for lactose malabsorption if post lactose breath hydrogen value rises >20ppm compared with baseline. 
  2. Stool acidity test: Unabsorbed lactose is fermented by colonic bacteria into lactic acid which lowers the stool pH.
  3. Lactose tolerance test: This test determines the absorption of lactose after ingestion of a lactose-containing liquid. Blood samples are obtained every 2 hours to check for blood glucose levels. Failure of blood glucose levels to rise may indicate lactose intolerance.
  4. Small bowel biopsy: This test is rarely performed as it is invasive. It is only indicated to rule out secondary causes of lactose intolerance.

Treatment / Management

Management of lactose intolerance consists of dietary modification, lactase supplementation and the treatment of an underlying condition in people with secondary lactase deficiency.

Dietary Modification

Lactase containing milk products and calcium supplements are recommended. Limiting dietary intake of lactose by avoiding intake of lactose-containing products improves the symptoms of the disease. Following products contain lactose and therefore must be avoided:

  • Soft and processed cheese
  • Buttermilk
  • Cream
  • Milk
  • Ice cream
  • Sour cream
  • Whey
  • Yogurt
  • Pancakes and waffles
  • Mashed potatoes
  • Butter
  • Margarine
  • Custard and pudding

 Lactase Supplements

Lactase enzyme supplements contain lactase which breaks down lactose in milk and milk containing products. They are available as lactase enzyme tablets or drops.

Differential Diagnosis

  • Irritable bowel syndrome
  • Celiac disease
  • Tropical sprue
  • Cystic fibrosis
  • Ulcerative colitis
  • Diverticular disease
  • Intestinal Neoplasm or polyp
  • Excessive ingestion of laxatives
  • Viral gastroenteritis
  • Bacterial infection
  • Giardiasis

Prognosis

Lactose intolerance has an excellent prognosis. Most patients have a considerable improvement in signs and symptoms with dietary modification alone.

Complications

  • Osteopenia
  • Osteoporosis
  • Malnutrition
  • Weight loss

Consultations

Once a diagnosis of lactose intolerance is made, consult with a gastroenterologist and dietician. 

Pearls and Other Issues

People with lactose intolerance can check the ingredients on food labels for lactose on food products to avoid their use.

Some people with lactose intolerance can tolerate some amounts of milk and milk containing products and may not need to avoid them completely.

Lactose intolerance is commonly confused with milk allergy. Lactose intolerance is a gastrointestinal disorder while milk allergy is an autoimmune reaction against certain milk proteins. Milk allergy is life-threatening and presents early in infancy while Lactose intolerance usually presents in adolescence or early adulthood. 

Milk is rich in calcium, and vitamin D. Prolong avoidance of milk in people with lactose intolerance can result in calcium and vitamin D deficiency.

Enhancing Healthcare Team Outcomes

The diagnosis and management of lactose intolerance is with a multidisciplinary team that includes a nurse practitioner, primary care provider, pediatrician, gastroenterologist and an allergist. Lactose intolerance is commonly confused with milk allergy. Lactose intolerance is a gastrointestinal disorder while milk allergy is an autoimmune reaction against certain milk proteins. Milk allergy is life-threatening and presents early in infancy while Lactose intolerance usually presents in adolescence or early adulthood. It is important to educate the patient that when they have lactose intolerance, they should always check the ingredients on food labels for lactose on food products to avoid their use. However, some people with lactose intolerance can tolerate some amounts of milk and milk containing products and may not need to avoid them completely. Prolong avoidance of milk in people with lactose intolerance can result in calcium and vitamin D deficiency.[9] (level V)


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Lactose Intolerance - Questions

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In a patient suspected of lactose intolerance, which of the following test will be abnormal if you drink milk?



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A 14-year-old male develops increased flatulence and bloating after drinking cow's milk. The symptoms improve after restricting cow's milk from his diet. The boy is otherwise healthy. What is the most likely cause of his symptoms?



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Prevalence of lactose intolerance varies among certain ethnic groups. Which group is most likely to have the highest number of individuals with lactose intolerance?



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A 12-year-old boy developed increased flatulence and bloating when he began drinking cow's milk. What is the most likely cause of his symptoms?



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A 17-year-old African American reports diarrhea and bloating after ingesting milk or ice cream. Her parents have similar issues. She has no other complaints or past medical history. The exam is normal. What medication should be advised?



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A 24-year-old Asian male presents to the clinic with symptoms of nausea, bloating, and abdominal cramps after ingesting milk. The provider makes a preliminary diagnosis of lactose intolerance. Which of the following investigations is not indicated in patients with lactose intolerance?



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A female patient complains of abdominal cramping and bloating after consuming dairy products. She is diagnosed with lactose intolerance, a condition in which insufficient amounts of lactase are produced. What is the function of lactase?



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Which of the following is an indication for the use of soy-based formulas for infants?



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A previously healthy 15-year-old female complains of crampy abdominal pain, flatulence, and bloating for about two months. Her menses are regular, she has not lost weight, and she is not sexually active. She has started drinking milk twice a day as she read that she should increase her calcium intake. Select the most appropriate first step in management.



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A 17-year old female presents with complaints of abdominal fullness and bloating every time she consumes dairy products. Sometimes she has diarrhea with flatulence. However, these symptoms do not occur every time she consumes these foods. Which is the best test to make a diagnosis of her symptoms?



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An infant is brought to the clinic with a rotavirus infection. Which of the following is most likely to be seen in this patient?



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A 15-year-old Asian boy presents to the clinic with complaints of watery diarrhea, abdominal pain and cramps a few hours after consuming milk. The boy had no symptoms during infancy and is otherwise healthy. A small intestinal biopsy in this patient is most likely reveal which of the following?



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Lactose Intolerance - References

References

Mattar R,de Campos Mazo DF,Carrilho FJ, Lactose intolerance: diagnosis, genetic, and clinical factors. Clinical and experimental gastroenterology. 2012     [PubMed]
Mobassaleh M,Montgomery RK,Biller JA,Grand RJ, Development of carbohydrate absorption in the fetus and neonate. Pediatrics. 1985 Jan     [PubMed]
Suchy FJ,Brannon PM,Carpenter TO,Fernandez JR,Gilsanz V,Gould JB,Hall K,Hui SL,Lupton J,Mennella J,Miller NJ,Osganian SK,Sellmeyer DE,Wolf MA, National Institutes of Health Consensus Development Conference: lactose intolerance and health. Annals of internal medicine. 2010 Jun 15     [PubMed]
Suchy FJ,Brannon PM,Carpenter TO,Fernandez JR,Gilsanz V,Gould JB,Hall K,Hui SL,Lupton J,Mennella J,Miller NJ,Osganian SK,Sellmeyer DE,Wolf MA, NIH consensus development conference statement: Lactose intolerance and health. NIH consensus and state-of-the-science statements. 2010 Feb 24     [PubMed]
Bailey RK,Fileti CP,Keith J,Tropez-Sims S,Price W,Allison-Ottey SD, Lactose intolerance and health disparities among African Americans and Hispanic Americans: an updated consensus statement. Journal of the National Medical Association. 2013 Summer     [PubMed]
Campbell AK,Wann KT,Matthews SB, Lactose causes heart arrhythmia in the water flea Daphnia pulex. Comparative biochemistry and physiology. Part B, Biochemistry     [PubMed]
Suarez FL,Savaiano DA,Levitt MD, A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance. The New England journal of medicine. 1995 Jul 6     [PubMed]
Bayless TM,Brown E,Paige DM, Lactase Non-persistence and Lactose Intolerance. Current gastroenterology reports. 2017 May     [PubMed]
Goh LH,Mohd Said R,Goh KL, Lactase deficiency and lactose intolerance in a multiracial Asian population in Malaysia. JGH open : an open access journal of gastroenterology and hepatology. 2018 Dec;     [PubMed]

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