Urgent considerations
See Differentials for more details
Hypocalcemia
Malabsorption may cause vitamin D deficiency, which in turn leads to hypocalcemia. When the serum total calcium concentration falls below 7.5 mg/dL (1.9 mmol/L), patients can develop tetany, paresthesias, seizures, and cardiac arrhythmias.[27] These patients require urgent correction with intravenous calcium. Calcium gluconate is preferred over calcium chloride because it causes less tissue necrosis if extravasation occurs. The first 100-200 mg of elemental calcium should be given over 10 to 20 minutes.[27] Faster administration may result in cardiac dysfunction, even arrest. This should be followed by a slow calcium infusion. Calcium infusion should be continued until the patient is receiving effective doses of oral calcium and vitamin D.
Hypokalemia
Prolonged diarrhea may cause intestinal loss of potassium. When the plasma concentration falls below 3.0 mEq/L, patients may experience muscle weakness, muscle cramps, and cardiac arrhythmias. Potassium replacement is required urgently in patients with severe hypokalemia (serum potassium <2.5 mEq/L) or in patients who are symptomatic.[28] Additional caution is required when replacing potassium in patients with a concurrent disorder or therapy (such as during diuretic therapy for heart failure, or insulin therapy for diabetic ketoacidosis [DKA] or hyperosmolar hyperglycemic state [HHS]).
Potassium repletion is most easily done orally, even in people with severe hypokalemia. Patients unable to tolerate oral intake and those with DTK or HHS will require intravenous potassium replacement. Serum potassium concentration is monitored frequently during repletion, to avoid hyperkalemia. Careful monitoring of the physiologic effects of severe hypokalemia (ECG abnormalities with continuous cardiac monitoring, muscle weakness, or paralysis) is also essential. Concurrent magnesium deficiency should also be corrected, to increase potassium absorption and reduce further losses.[29]
Coagulopathy
Steatorrhea may rarely lead to deficiency in vitamin K, which is required for normal clotting function. A baseline prothrombin level should be checked in patients with steatorrhea to evaluate for this. If there is evidence of significant bleeding, intravenous vitamin K should be administered. Oral vitamin K can be used in patients with minor bleeding.
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