INTRODUCTION	Section 2 of 10
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Background: Lactose intolerance is a common disorder and is due to the inability to digest lactose into its constituents, glucose and galactose, secondary to low levels of lactase enzyme in the brush border of the duodenum. Lactase deficiency is the most common form of disaccharidase deficiency. Enzyme levels are highest shortly after birth and decline with aging, despite a continued intake of lactose. Within the animal world, nonhuman mammals usually lose the ability to digest lactose as they reach adulthood. Some populations of the human species, including those of Asian, South American, and African descent, have a propensity for developing lactase deficiency. By contrast, races descended from northern Europe or from the northwestern Indian subcontinent are likely to retain the ability to absorb lactose into adulthood.

Symptoms of lactose intolerance include loose stools, abdominal bloating and pain, flatulence, nausea, and borborygmi. A diagnosis or even the suggestion of lactose intolerance leads many people to avoid milk and/or consume specially prepared food with digestive aids, adding to health care costs.

Pathophysiology: Lactose, a disaccharide, is present in milk and processed foods. Dietary lactose must be hydrolyzed to a monosaccharide in order to be absorbed by the small intestinal mucosa. A deficiency of intestinal lactase prevents hydrolysis of ingested lactose. The osmotic load of the unabsorbed lactose causes secretion of fluid and electrolytes until osmotic equilibrium is reached. Dilation of the intestine caused by the osmosis induces an acceleration of small intestinal transit, which increases the degree of maldigestion. Within the large intestine, free lactose is fermented by colonic bacteria to yield short-chain fatty acids and hydrogen gas. The combined increase in fecal water, intestinal transit, and generated hydrogen gas accounts for the wide range of gastrointestinal symptoms.

Frequency:

• In the US: The prevalence of primary lactose intolerance varies according to race. As many as 25% of the white population (prevalence in those from southern European roots) is estimated to have lactose intolerance, while among black, Native American, and Asian American populations, prevalence is estimated at 75-90%.

• Internationally: Of the world's population, 75% is estimated to be lactose-deficient. Lactose intolerance is very common among Asian, South American, and African persons.

Mortality/Morbidity:

• Lactose intolerance is not lethal.

• Morbidity is low from lactose intolerance.

• Osteopenia can be a complication of this disorder.

Race:

• Persons of all races are affected, with higher prevalence among Asian, African, and South American persons.

Sex:

• Males and females are equally affected. However, 44% of women who are lactose intolerant regain the ability to digest lactose during pregnancy. This is probably due to slow intestinal transit and bacterial adaptation during pregnancy.

Age:

• Among adults, the age of presentation is 20-40 years.

	CLINICAL	Section 3 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

History:

• History findings may include abdominal fullness/bloating, nausea, abdominal pain, diarrhea, and flatulence.

• The symptoms of irritable bowel syndrome (IBS) resemble those of lactose intolerance and can easily be confused. Some patients with IBS can also have lactose intolerance. Restriction of milk products in these patients may relieve the symptoms of IBS.

Physical:

• Physical examination findings very often are normal.

• Borborygmi may be present.

Causes:

• Congenital lactose intolerance is inherited as an autosomal recessive trait and is very rare.

• Primary lactose intolerance is due to low levels of lactase, which develop after childhood.

• Secondary, or acquired, lactase deficiency may develop in a person with a healthy small intestine during episodes of acute illness. This occurs because of mucosal damage or from medications. Some causes of secondary lactase deficiency are as follows:

• Acute gastroenteritis

• Giardiasis

• Ascariasis

• Crohn disease

• Celiac sprue

• Tropical sprue

• Radiation enteritis

• Diabetic gastropathy

• Carcinoid syndrome

• Whipple syndrome

• HIV enteropathy

• Kwashiorkor

• Chemotherapy

• Gastrinoma