Celiac, IBS, IBD, Ostomy Care Flashcards
What are nutrients of concern for malabsorption in Celiac Disease?
Iron
Folate
Calcium
Vitamin D
Fat
Fat soluble vitamins
What are typical and atypical symptoms of celiac?
Typical:
Anorexia
Abdominal pain
Abdominal Distension
Diarrhea
Vomiting
Gas
Weight loss or Failure to thrive in infants
Atypical:
Iron deficiency, headache, tremors, fatigue, constipation
What are the Non-GI manifestations of celiac?
Hepatitis
Arthritis
Epilepsy
Poor bone health
Brain fog
Poor dentition
Can you eat oats on a gluten free diet? What are the recommendations?
Oats can be contaminated with gluten and require a gluten free label to be safe for the patient.
Avinin can still cause an autoimmune response with some people and it is recommended to avoid oats for the first 6 months of a gluten free diet (At this time disease should be considered stable)
Must not exceed 50g to 70g daily for adults and
20g to 25g daily for children
What is a skin condition they may develop in Celiacs?
Dermatitis herpetiformis - terrible itchy skin and pruritis all year round
What are the macronutrient concerns for a gluten free diet?
Products tend to be higher in saturated fats and total sugar while they have a lower fiber content
Why would folate be a concern after a patient adheres to a gluten free diet?
Gluten free products are not required to be enriched like regular flours are.
What are some supplements to consider for celiacs?
Iron should be based on individual cases - will only need it short term because once the gut heals, absorption should return
Calcium and Vitamin D
For adults: 1000mg Ca and 1000IU D
For Children: 500mg calcium and 1000IU Vitamin D
Fiber such as Metamucil
What is irritable bowel disease or syndrome?
A chronic disorder characterized by abdominal pain or discomfort associated with disordered defecation. Symptoms should have developed at least 6 months before the patient appears for formal evaluation
What is the first criteria for IBS Diagnosis?
Abdominal discomfort or pain at least 3 days per month for 3 months and should be associated with 2 or more of the following at least 25% of the time:
Improvement with defecation
Onset associated with change in stool frequency of stool
Onset associated with a change in form (appearance) of stool
What is the second diagnostic criteria for Irritable Bowel Syndrome?
No evidence of inflammatory, anatomic, metabolic or neoplastic process that explains the patient’s symptoms
What lifestyle changes can a patient with Irritable Bowel Syndrome make?
Elimination of identified irritants
Stress management
Small, frequent meals
Relaxed eating environment
FODMAPS diet
Fibre therapy - slowly and gradually increase fibre supplements but this may work for one person and not the other
What are FODMAPs?
Group of short chain CHO that are:
Rapidly absorbed in the SI
Rapidly fermented by colonic bacteria
Increase water delivery into the bowel due to their high osmolarity
What are the two subtypes of Inflammatory Bowel Disease?
Crohn’s Disease and Ulcerative Colitis
What is the pathophysiology for Ulcerative Colitis?
Mucosal Inflammation and Continuous lesions
These occur in the colon and rectum only
What is the pathophysiology for Crohn’s Disease?
Transmural Inflammation and skip lesions at any site of the GI tract (nose and mouth all the way to the anus)
What are the complications associated with Ulcerative Colitis?
Toxic Megacolon - a full blown obstruction and breaking down of the colon which then becomes necrotic
Weight loss
Malnutrition
Colon Cancer
What is the most common first presentation for Crohn’s Disease?
Ileal Crohn’s
What are complications of Crohn’s Disease?
Fistula - an abnormal passageway between two body parts which can result in drainage into other cavities
Obstruction
Stricture - narrowing of colon
Toxic Megacolon
Weight loss
malnutrition
Colon Cancer
What contributes to malnutrition in IBD?
Inadequate Intake - due to anorexia, nausea, vomiting, dietary restriction
Decreased Absorption - due to decreased absorptive capacity, inflammation, resections, strictures, fistulas
Excessive Losses - due to diarrhea, blood, protein losing enteropathy, bile salts
Increased Requirements - due to inflammation, surgery, infection, fever, repletion of stores
What are the drug nutrient effects of malnutrition when treating IBD?
Corticosteroids can increase the requirement for protein, vitamin B6, vitamin D, zinc and can result in poor bone health
Sulfasalazine - an NSAID is a folic acid inhibitor
Cholestyramine - reduces absorption of fat soluble vitamins
What deficiencies can result from a >100cm Ileum resection?
bile salt depletion
severe steatorrhea
fat soluble vitamin deficiency
hypomagnesemia and hypocalcemia
B12 deficiency
fluid and electrolyte imbalance
What deficiencies can result from a problem with the Ileocecal valve?
Bacterial overgrowth leading to diarrhea/steatorrhea
choleretic diarrhea
reduced mucosal contact time
Reflux
What are the typical approaches to for a Crohn’s flare up?
1) Bowel rest - NPO with TPN and treatment with IV meds
In this scenario, TPN is the supportive therapy and IV Meds are the treatment
2) Exclusive Ng tube feeding - typically 4-8 weeks via Ng tubes with clear fluids
**In this scenario, the Tube feed is the treatment as there are no corticosteroids being given*
Introduction of food after 4-8 weeks of EN feeds, slowly taper off EN
THESE APPROACHES ONLY WORK IN SMALL BOWEL CROHNS. WILL NOT WORK FOR COLITIS
What is the Crohn’s Disease exclusive diet?
Excludes dairy, gluten, processed meats, animal fats, canned and packaged foods, coffee, alcohol, emulsifying agents
What are the three methods of treatment of IBD?
- Nutritional Therapy - micronutrient supplementation, fluid intake, electrolyte monitoring
- Drug Therapy - anti-inflammatory drugs (corticosteroids like prednisone) antibiotics, analgesics for both CD and UC
- Surgical Therapy bowel resection with or without ileostomy - common for Ulcerative Colitis. UC - colectomy is curative
Surgery is only used for Crohn’s in extreme cases
Define the following:
Diverticula
Diverticulosis
Diverticulitis
Diverticula: Herniation or outpouching of the colonic mucosa through the colonic muscle wall
Diverticulosis: presence of diverticula
Diverticulitis: diverticula become inflamed, can have impacted feces and inadequate drainage from diverticula
Which populations is Diverticular Disease the most common in?
The elderly
Low fiber diets
What are symptoms of diverticular disease?
Abdominal pain, distension
Fever
Anorexia
Flatulence
Belching
What is the treatment for Diverticular Disease?
Surgery - if there are abscesses, perforations, fistulas or obstructions - may require an ostomy
Diet:
Acute - low fiber
Chronic - gradual progression to high fiber with adequate fluid - soluble fiber is preferred to get things moving
What are Hemorrhoids?
Protrusion of enlarged veins into anal cavity or canal - can be internal or external
What are some causes of hemorrhoids?
Pregnancy
Constipation/Straining
Infiltrating carcinoma
portal hypertension
What are some treatments of hemorrhoids?
Surgery
Similar diet as diverticular disease
What potential triggers can be eliminated and reintroduced to test for tolerance in IBS?
Lactose
Milk Proteins
Wheat and Gluten
Sugar Alcohols
FODMAPS
Fructose
What are general guidelines for postoperative Nutrition (Ostomies)?
Low fiber for the first 6-8 weeks postop - want to limit the risk of obstruction. Better to decrease insoluble fiber
Adequate protein - important for post operative healing. Clients usually have a higher likelihood of poor nutrition status at baseline
Smaller frequent meals - eat every 2-3 hours to manage reduced appetite - this may reduce the gastrocotic reflex
Adequate fluid - 9-12 cups (2.25-3L) daily to make up for reduced absorption
Chew foods thoroughly to reduce the risk of blockage
What is recommended for long term nutrition in ostomies?
After 6-8 weeks, most people can return to normal intake including a regular fiber diet with no restrictions
Encourage food journaling to determine what foods, amounts and preparation methods are triggering
Still important to achieve adequate fluid intake to prevent dehydration
What micronutrient supplementation is appropriate for an Ileostomy?
B12 indicated if >60cm resected
Fat soluble vitamin supplementation indicated if > 100cm resected and steatorrhea occurs
What micronutrient supplementation is appropriate for an colostomy?
No specific recommendations if functioning well
What micronutrient supplementation is appropriate for a high output ostomy?
Electrolyte replacement: Magnesium, Zinc & Selenium due to large losses
What factors impact gas and bloating for someone with an Ostomy?
Eating Quickly
Chewing Gum
Drinking with a straw or from a bottle
Carbonated beverages
How does an Ileostomy and Ascending Colostomy impact output?
Output is more liquid consistency due to reduced water absorption
Requires emptying several times per day
Contains some degree of digestive enzymes that can be irritating to the skin/mucosa
How does a Descending & Sigmoid Colostomy impact output considerations?
Output is more formed
Amount can vary
Output will not contain digestive enzymes
What is the expected output over 24 hours for an Ileostomy? How can you characterize the output?
1200mL (Mature 600-800mL)
Contain significant amounts of sodium and potassium
Increased risk for dehydration
What is the expected output for a colostomy?
200-600mL
What is defined as a high output ostomy?
> 1000-1500ml
What are contributors to loose ostomy outputs?
Spicy foods - least amount of evidence to support this
Caffeine - reduces intestinal transit time and has a diuretic effect
High fat foods - when missing part of the ileum there is an increased risk of steatorrhea
Very high sugar foods - draws water into the bowel
Alcohol - can have a laxative effect and diuretic effect
Sugar Alcohols - draws water into the bowel
What are signs of dehydration in ostomy patients?
Dry mouth
Dry Skin
Headaches
Thirst
Dizziness
Muscle Cramping
Nausea
Low Blood Pressure
Low or dark urine output
What is the course of action when an ostomy has > 2000ml of output daily?
Require hospitalization for IV hydration until output improves or a long term outpatient IV plan
What populations are at risk of high ostomy output?
Extensive surgical resection (<200cm residual bowel)
more proximal location of stoma - higher in the GI tract, such as ileostomy
Intra abdominal sepsis
partial or intermittent bowel obstruction
Recurrent disease in the remaining bowel
sudden discontinuation of medications
use of prokinetic medications that stimulate gut movement
Bacterial overgrowth or enteric pathogens
What are important factors for nutritive care in high output ostomies?
Adequate fluid intake: 9-12 cups daily minimum and choose oral rehydration solutions
Limit sugar - draws water into the bowel and increases risk of dehydration (includes dried fruit)
Increase soluble fibre intake to thicken output and slow transit time
Decrease insoluble fibre intake
Replace electrolytes
What are oral rehydration solutions and what is their purpose?
Isotonic solutions that promote absorption of water by being similar in solute concentration to the bowel. They will have modest amounts of sugar and salts to promote hydration and do not decrease stool volume
What are hypertonic fluids? Give examples
Pull water into the small bowel and increase stool volume
examples include: milk, popsicles, fruit juice, soda, broth, regular Gatorade
What are hypotonic solutions?
Give examples
They pull sodium into the small bowel to increase osmolarity of the fluid thus, increasing stool volume.
examples include: water, tea, coffee, sugar free drinks, G2
What medications can be given for high output ostomys?
Anti-Diarrheal - loperamide, Lomotil, codeine
Fibre supplements (Metamucil) - this is not effective without a colon
Cholestyramine: for bile acid induced high output ostomy following terminal ileum resection
Anti-secretory drugs
What are concerns with EN regarding Ostomy patients?
Osmolarity can be an issue as formulas are often hyperosmolar
Are there dietary restrictions following an ostomy reversal?
No dietary restrictions
Bowel habits will be heavily impacted by the amount and health of bowel added back after the reversal
What is happening with silent or latent Celiac’s Disease?
Silent: no or minimal symptoms, damaged mucosa and positive serology
Latent: no symptoms, normal mucosa, may show positive serology but will develop later mucosal changes and/or symptoms
