Final Flashcards
1
Q
What are the 4 factors malnutrition can be caused by?
A
- Insufficient intake
- Impaired absorption
- Increased nutrient requirements
- Altered nutrient transport and utilization
2
Q
Name indications for nutrition support
A
- Inadequate oral intake for 7-14 days
- Altered GI function
- Impaired nutrient utilization
- Swallowing/chewing difficulties
- PEM
- Increased nutrient needs that cannot be met orally (major infections, burns, trauma)
- Significant involuntary weight loss
3
Q
Name indications for EN
A
Patients with a functional GI tract AND
o Unable to meet their nutritional needs orally (< 50% of needs) for 7-14 days (unsafe, insufficient or impossible)
o Expected not to meet their nutritional needs orally for at least 7- to 14- day period
o Hemodynamically stable
4
Q
Name contraindications for EN
A
- Mechanical GI obstruction (tube cannot enter)
- Intractable N/V (untreatable with medication; common in whole body radiation from bone marrow transplant)
- Short bowel syndrome (malabsorption); < 100-150 cm in the absence of colon and < 50-70 cm in presence of colon
- Paralytic ileus (flexible)
- High-output GIT fistula (> 500 ml/d)
- Severe GI bleeds or malabsorption
- Short supply period (< 5-7 days in malnourished; < 7-9 days in nourished)
- Aggressive intervention not warranted/desired (end of life, palliative care)
5
Q
Name contraindications to PEG
A
Severe ascites, severe gastroparesis, coagulopathy (high risk for placement), gastric varices (upper GI hemorrhage), neoplastic or inflammatory disease of the gastric or abdominal wall
Active head and neck cancer, morbid obesity.
6
Q
What is the only case in which IMFs can be used?
A
Post-op in SICU and TBI
7
Q
What are the nutrient needs for obese critically ill patients?
A
Energy:
PENN state x 0.65-0.7
BMI 30-50: 11-14 kcal/kg ABW
BMI > 50: 22-25 kcal/kg IBW
Protein:
2g/kg ABW/d
8
Q
When should fiber NOT be used?
A
- Possible cases of bowel ischemia
- On vasopressors (levophed, epinephrine, phenylephrine)
- Strictures or acute exacerbations/obstructions of CD
9
Q
How should EN be initiated in stable non-critically ill patients?
A
Stable non-critically ill patients usually tolerate EN initiated at the goal rate (or advance to goal within 24-48 hours)
Standard EN protocols usually indicate to start EN at a rate of 50 mL/hr and advance by 15mL/hr q4h until goal rate
Bolus feedings may be advanced by volumes of 60-120 mLq8-12 hours
10
Q
How should EN be initiated in critically ill patients?
A
Critically ill patients: Start EN at 10-40 mL/hour and advance at the goal rate by 10-20mL/hour q 8-12 hours – But starting too low and slow may result in energy and protein deficits.
11
Q
How should EN be initiated in sepsis?
A
Sepsis: Start EN at 60-70% of goal in first week, then advance to > 80% after first week. –> but ADEQUATE PROTEIN!
12
Q
What is the stress factor for fever?
A
1.2 per 1°C over 37°C
13
Q
In what circumstances do we use Adjusted BW?
A
If close to IBW, use ABW
If underweight, (i.e. < 90% IBW), use ABW and add energy when ready to gain weight (+ 500 kcal/d) or use IBW in equation to accommodate recovery
If overweight (i.e. > 125% IBW), use adjusted BW for fluids. Use ABW with MSJ and Ireton-Jones but adjusted with HB
14
Q
What can increase chances that the tube will clog?
A
High fiber, small diameter tubes, use of silicone tubes, checking of GRVs, and improper medication administration via the tube
15
Q
When do we initiate EN in well-nourished non-critically ill patients?
A
> 7 days for NRS < 3
16
Q
When do we initiate EN in high-risk critically ill patients?
A
24-48h for NRS2002 ≥ 3
NRS ≥ 5: Advance to goal as quickly as tolerated over 24-48h while monitoring for RS – efforts to provide > 80% of estimated or calculated goal energy and protein within 48-72 hours should be made.
17
Q
When should GRVs be checked?
A
GRVs should be checked every 4 hours during the first 48 hours of gastric feeding, after that, every 6-8 hours for patients who are not critically ill. d/c after 24h if no signs of intolerance.
In critically ill: Check q 4h
18
Q
What to do in patients at risk of RS?
A
Initiate E intake at 25-50% of needs in the first 24h Dextrose < 1.5g/kg/d Thiamin 100-300 mg/d IV x 3-7 days MVI x 7 days Folate 1-5 mg/d (watch meds though)
19
Q
What are the risk factors for RS?
A
Patients who have 1 or + of the following:
BMI < 16
Unintentional weight loss > 15% within last 3-6 months
Little or no nutritional intake for more than 10 days
Low levels of K, PO3 or Mg prior to feeding
OR patients who have 2 or + of the following
BMI < 18.5
Unintentional weight loss > 10% within the last 3-6 months
Little or no nutritional intake for more than 5 days
History of alcohol abuse
20
Q
What are questions to ask for the management of diarrhea?
A
- Distended, tympanic, painful abdomen?
- Is medical/surgical history consistent with diarrhea? (E.g. IBD, terminal ileal resection, chemotherapy, short bowel, pancreatic insufficiency…)
- Is there risk of stool impaction? (e.g. chronic constipation, absent BM x 5d, regular narcotic use, limited fluid intake)
- Receiving cathartic agents? (substances that accelerate defecation) (e.g. citromag, docusate, milk of magnesia, cascara, enema, PEG, hypertonic or sorbitol-containing liquid medications, oral electrolyte solutions, lactulose, kayexalate, etc.)
- C. Diff? Ischemia? –> if NO –> EN with fiber or semi-elemental
21
Q
What is the minimum urine output required to remove wastes?
A
30mL/h or 700 mL/d
22
Q
What is the max dextrose concentration for PPN? AA? K? Ca?
A
Dextrose: 150-300 g/d or 5-10% final concentration
AA: 50-100 g/d or 3% final concentration
K: < 40 mEq/L
Ca: < 5 mEq/L
23
Q
At what point do high TG cause pancreatitis?
A
11.30 mmol/L
24
Q
When can IC not be used?
A
Cannot be used in the presence of air leaks, chest tubes, supplemental oxygen, ventilator setting, CRRT, anaesthesia, physical therapy, excessive movement (e.g. seizures)
25
What is the predictive equation for energy in critically ill patients?
25-30 kcal/kg/d
26
What are the protein needs of critically ill obese patients?
2g/kg/d IBW
27
What are the protein needs of critically ill patients?
1.2-2.0 g/kg/d
28
When is PN started in ICU?
Low risk NRS2002 =< 3 or NUTRIC =< 5: withhold exclusive PN for 7 days if volitional intake inadequate and early EN not feasible
High risk NRS2002 >= 5 or severely malnourished and EN not feasible: Initiate exclusive PN as soon as possible
29
How much energy is fed to high risk or severely malnourished patients on their first week in the ICU?
First ICU week: Hypocaloric PN (<20 kcal/kg/d) or 80% EEE) with adequate protein (>= 1.2 g/kg/d) in high risk or severely malnourished patients
Withhold soybean oil lipids during first week. If concerned for EFAD, use 100g/week maximum divided into 2 doses/week
30
When is PN discontinued in ICU?
When EN/PO intake > 60%
31
What are the nutrient needs for ICU patients with pulmonary failure?
Consider E dense EN (fluid restriction is common)
Monitor serum phosphate and replace when needed
Careful not to overfeed
32
What are the nutrient needs for ICU patients with Acute kidney injury (AKI)?
25-30 kcal/kg/d and 1.2-2.0 g/kg/d protein (normal for ARF and AKI)
If receiving HD or CRRT, use 2.0-2.5 g/kg/d and add replavit
33
What are the nutrient needs for ICU patients with chronic renal failure?
On HD: 1.2-1.5 g/kg/d protein
| CRRT:1.5-2.0 g/kg/d protein – up to 2.5 g/kg (especially in obese patients)
34
What are the nutrient needs for ICU patients with hepatic failure?
Avoid protein restrictions, use 1.2-2.0 g/kg/d
| Preferentially use EN in acute and/or chronic liver failure
35
What are the nutrient needs for ICU patients with acute pancreatitis?
Moderate to severe acute pancreatitis: EN: started at trophic rate and advanced to goal within 24-48h
If EN not feasible, may start PN after one week from the onset of pancreatitis
36
What are the nutrient needs for ICU patients with a trauma?
Initiate early EN feeding within 24-48h
High protein polymeric EN may be used; use higher end of 1.2-2.0g/kg/d recommendation for protein
Use 20-35 kcal/kg/d – 20 early in the resuscitative phase and increase with time
37
What are the nutrient needs for ICU patients with TBI?
E: 25 kcal/kg/d
Protein: 1.5-2.5 g/kg/d
TBI patients are difficult to feed gastrically because they often have suppressed vagal nerve activity 2/2 increased intracranial pressure and multiple meds (i.e. sedatives, opioids)
Feed post-pylorically
May use IMF (either arginine-containing or EPA/DHA supplement)
38
What are the nutrient needs for ICU patients with severe sepsis/septic shock?
Trophic feeds for initial phase of sepsis, advance after 24-48h to reach > 80% of target over 1 week
Protein 1.2-2.0 g/kg/d (ASPEN 1.5-2.0; up to 2.5)
CHO: between 50-60% of energy to prevent excess lipogenesis
ILE < 1.0g/kg/d if soybean oil. Can increase if ILE mixture includes more omega 3s, SCFA and MCT
39
What are the nutrient needs for ICU patients with open abdomen?
EN within 24-48hr unless contraindicated
E and prot needs same as other ICU patients, but add protein for exudates
Higher protein needs monitor abdominal drains
15-30g protein/L lost in exudate
40
What rate of propofol infusion is necessary to r/o IVFE?
> 5-10 mL/hr
41
What are the NS needs for ICU patients on postop SICU?
May use IMF
Provide EN within 24h of surgery
Major upper GI surgery (EN not feasible) --> do PN only if the therapy is anticipated to last > 7 days (except if patient is at high nutrition risk)
Clear liquid diet not necessary, pt may advance to solid foods when possible.
42
What are the nutrient needs for ICU patients with burns?
- Protein 1.5-2.0 g/kg/d (20-25% of E); large surface area burns 3-4 g/kg/d
- Very early initiation of EN (4-6 hours)
- Presence of arginine, glutamine and omega 3s in the formulation should be considered
- Burns < 20% TBSA = Daily MV recommended
- Burns > 20% TBSA = daily MV + 20,000 IU Vitamin A, 220 mg Zn, 2x 500 mg Vitamin C
- Supplement Copper, Selenium and Zinc for 30 days after burn injury
43
What are the nutrient needs for chronic critically ill patients?
Aggressive high protein EN therapy + exercise program
44
When do we initiate PN in previously well-nourished critically ill patients?
In previously well-nourished patients, PN should be reserved and initiated only after efforts to provide EN have failed to advance to > 60% of E goals within 7-10 days.
Exceptions to this delay are: Patients who are severely malnourished, those who cannot receive EN, and those who are expected to undergo elective major upper GI surgery. For those, ASPEN recommends 5-7 days of PREOP PN with continued PN POSTOP.
If unable to provide PN preop, delay postop PN by 5-7 days.
45
Name the 4 likely etiologies of crohn's disease
1. Genetic susceptibility (cannot predict for sure but can determine susceptibility)
2. Environmental triggers
3. Immune response (linked with the 2 above)
4. Luminal and microbial antigens and adjuvants
46
When do we initiate PN in previously well-nourished critically ill patients?
In previously well-nourished patients, PN should be reserved and initiated only after efforts to provide EN have failed to advance to > 60% of E goals within 7-10 days.
Exceptions to this delay are: Patients who are severely malnourished, those who cannot receive EN, and those who are expected to undergo elective major upper GI surgery. For those, ASPEN recommends 5-7 days of PREOP PN with continued PN POSTOP.
If unable to provide PN preop, delay post-op PN by 5-7 days.
47
What are the guidelines for endoscopy preparation?
≈ 8h NPO before; depending on just scope or upper GI series
| Also, cannot eat or drink a few (2) hours after d/t risks of aspiration (sedation)
48
What are the guidelines for colonoscopy preparation?
1. Obtain bowel preparation solution at least 2 days before the test
2. Day before test: clear liquids all day. From 6 to 8 PM, drink 2L of any polyethylene glycol (PEG)-based solution
3. Day of test, no solid food. 4h before appointment: drink remaining 2L of the PEG-based solution and finish it 2h before the test.
4. Stop drinking all liquids including water 2h before the test
49
What is the PO nutrition prescription for people with active IBD?
Progress to low-fat, low fiber, high protein, high kcal, small frequent meals with return to normal diet as tolerated
Watch for: iron, Mg, Zn, Ca, VD, B12, Folate
50
What is the PO nutrition prescription for people with active IBD?
Progress to low-fat, low fiber, high protein, high kcal, small frequent meals with return to normal diet as tolerated
Watch for: iron, Mg, Zn, Ca, VD, B12, Folate
```
Fluid 1mL/kcal
Energy: 25-30 kcal/kg
Protein 1.0-1.5 g/kg/d
Iron supplement prn
Ca 1500 mg/d
VD 800-1000 IU/d
Normal fiber
Complex CHO (osmolality)
Fat as tolerated (may need low fat if steatorrhea)
```
51
Which 2 medications cause folate deficiency?
```
o Sulfasalazine (not other aminoacylates) competes with folate in intestinal lumen, causes reduced availability of folate
o Methotrexate is an antagonist to folic acid
```
52
When do we initiate EN in people with SBS? PN?
Start with PN directly
53
What are the pre-op guidelines for standard GI surgery?
* Clear fluids the day prior to surgery (to bring electrolytes and some energy)
* NPO after 24:00 hours
* If using EN already, d/c and NPO after 24:00 hours (midnight) – let time for GI content to clear (easy to clear because probably low-residue product)
* If fed by PN, this may run prior, during and after the surgery. Up to discretion of anaesthetist and team.
54
What are the post-op guidelines for standard GI surgery?
NPO
Clear fluids
Full fluid
Small, frequent meals
*SBS: TPN for few weeks
55
Name 5 factors for favorable outcome after GI resection.
```
< 70-80% resection
Jejunum resected (active transport of nutrients)
Absent concomitant GI disease
> 1 year after onset
Ileocecal valve present
Non-diseased colon present
```
56
What is SBS?
Less than 200 cm of functional small intestine
57
What is needed to wean off PN in..
Jejunoileocolonic anastomosis
Jejunocolonic anastomosis
End jejunostomy
Jejunoileocolonic anastomosis: 30 cm
Jejunocolonic anastomosis: 60 cm
End jejunostomy: 100 cm
o > 70 to 90 cm of SI remaining PLUS intact colon
o > 30 cm PLUS intact colon to wean off PN
58
How much of the terminal ileum is needed to have enough bile salt reabsorption?
< 100 cm resected
59
Explain the post-op period in SBS.
3 phases:
7-10 days: Extensive fluid and electrolyte losses, large volumes of diarrhea, TPN
- Do not use the GI tract in this period (will lose fluid and electrolytes…)
Several months: Try to transition to use of GI. Reduced diarrhea volume, adaptation of remaining bowel, EN, transition to oral diet
- This period could be short for some people, and may never happen for others
- Could be trophic feed added to TPN to start
1-2 years: Continued adaptation of bowel, intestinal tract increases in length, diameter, and villous height. May get off TPN, or not. May also get transplant.
60
How should PO nutrition be in SBS?
* TPN postoperatively
* Oral diets introduced as diarrhea decreases (start EN and oral when no more diarrhea)
* May require combination of TPN and EN
* Sugar-free, isotonic clear liquids introduced first (may have sodium, a bit of carbs)
* Progress slowly to low-residue, low-fat, lactose-free, low-oxalate diet
* Avoid caffeine and alcohol
* Avoid sugar alcohols and insoluble fiber
61
What is nutritionally done in SIBO?
* Diarrhea, steatorrhea, anemia, weight loss
* Diagnosis with H breath test
* Antibiotics
* Fat and lactose eliminated initially
* Identify and treat nutrient of malabsorption
62
Nutritional prescription for SBS?
```
5-6 small meals/d
Normal fiber
Low oxalate if steatorrhea
Energy: 30-40 kcal/kg; may be 40-60 kcal/kg
Protein: 1.5-2.0 g/kg/d
Complex CHO
May use MCT oil prn
```
63
What is post-op nutrition prescription for ileostomy?
```
Clear fluid --> low-soluble fiber diet --> normal diet
Small, frequent meals
Limit fluids with meals
Encourage high sodium intake
Restrict high oxalate foods
ORB
Avoid foods that may cause obstruction
```
64
What is post-op nutrition prescription for ileostomy?
```
Clear fluid --> low-soluble fiber diet --> normal diet
Small, frequent meals
Limit fluids with meals
Encourage high sodium intake
Restrict high oxalate foods
ORB
Avoid foods that may cause obstruction
Fruits after meals
```
65
Name foods that can cause obstruction that need to be restricted in those with colostomy and ileostomy
o Vegetables: Corn, peas, mushrooms, bean sprouts, raw cabbage and carrots
o Fruit: Fruit skins and seeds, dried fruits
o Other: Nuts, popcorn
Fruits after meals
66
Name foods that can cause obstruction that need to be restricted in those with colostomy and ileostomy
o Vegetables: Corn, peas, mushrooms, bean sprouts, raw cabbage and carrots
o Fruit: Fruit skins and seeds, dried fruits
o Other: Nuts, popcorn
67
What is nutrition prescription for people with ileostomy?
```
o Higher fat
o Fat: 50-60% of energy
o CHO: 20-30% of energy
o Protein: 20-30% of energy
o Add salty meals/snacks
o Smaller meals more often
o Fluid between meals
```
68
What is nutrition prescription for people with colostomy?
o Lower fat higher CHO
o CHO: 50-60% energy
o Fat: 20-30% of energy
o Protein: 20-30% of energy
69
Who are candidates for ERAS?
Nutrition risk screening (NRS 2002 score ≥ 5 or PG-SGA ≥ 4)
70
If EN is not feasible and the patient is malnourished, what must be done pre-op based on the ERAS protocol?
Delay surgery and begin PN 5-7 days pre-op
Avoid soy-based lipid emulsions (may confer proinflammatory responses)
If EN not feasible post-op, PN should be continued post-op the day after surgery once adequate resuscitation is complete
71
What is the ERAS protocol with EN?
o Solid meals up to 6h before surgery
o Midnight before surgery: have 800 mL 12.5% CHO beverage
o Morning 2h prior to induction of anesthesia (unless contraindicated): 400 mL 12.5% CHO beverage
o Early provision of EN within 24h of Sx
Use of probiotics should be considered
72
What is the ERAS protocol with PN?
o d/c PN 2-3h before surgery, restart morning after (permissive underfeeding 80% EEE)
o If continue PN, glucose control closely monitored d/t sudden changes in insulin sensitivity
73
In urgent surgeries when EN is not feasible, what should be done?
do not use PN post-op
Delay until 5-7 days
Only initiate PN if > 7 days is anticipated to be needed as poses risk to patient without major benefits
74
Which EN formula should be used pre-op in ERAS?
Major elective surgery – receive immune-modulating formula containing arginine, fish oil, nucleotides and antioxidants 500-1000 mL/d for 5-7 days before scheduled procedure (oral or EN)
75
What are the nutrient needs post-op major GI sx?
1.5g/kg BW (use adjusted weight for obese)
| 25 kcal/kg (permissive underfeeding)
76
Name factors associated with cholesterol stones
* Heredity; Northern Europe, N & S America
* Female sex (probably d/t hormones)
* Drugs (dehydration, changes in CH, changes in bile salts)
* Long-term TPN (cholestasis)
* Diabetes (dehydration, often high cholesterol (metabolic syndrome), obesity)
* Ileal disease
* Obesity (cholesterol synthesis)
* Weight reduction (mobilisation of tissue cholesterol)
* Very high energy diet (linked to high cholesterol as well)
77
Name factors associated with bilirubin pigment stones
* Chronic hemodialysis
* TPN
* Thalassemia (can only manage, not change because hereditary)
* Cirrhosis
* Age
78
What is a cholecystogram?
o Radio-opaque dye given orally, dye excreted by liver into gallbladder, x-ray
o Shows whole biliary tree
o Liver function needs to be normal
79
Explain the post-cholecystectomy diet prescription
- Individual tolerance mediates amount of fat after cholecystectomy, modest protein intake
- Full fluid diet ASAP (clear fluids and milk)
- 1 mL fluid/kcal; adjust for losses by fever and diarrhea
- fat 30% of E, foods with < 3g per serving; small frequent meals
Avoid high fat foods, fried foods, foods with strong odors (nausea) and foods that cause gas (distention; subjective)
Surgery (cholecystectomy) – low fat diet initially, then return to healthy “normal” diet
80
What diet do people with gallstones need?
- Choose lean meat, 1 oz or 25g = 2g fat
- Grain/starches, no fat but some may have 1-5 g if baked product
- Hidden fat in granola, baked products (muffins, croissants)
- Fruits/vegetables, no fat (Limit avocados, olives)
- Milk and milk products, low fat
- No servings of fat added as a rule
- Need to be flexible, i.e. some foods allowed, but limited frequency (e.g. regular cheese on one day, nothing else high in fat that day)
- Low fat diet may be temporary
- Ensure adequate fluid intake
- Moderate alcohol intake
81
Explain the nutritional prescription pre gallbladder surgery
```
Eat and drink normally to midnight
Drink 1 CHO drink in 10 minutes
Apple juice 850 mL
Commercial iced tea 1100 mL
Cranberry cocktail 650 mL
Lemonade no pulp 1000 mL
Orange juice no pulp 1000mL
No pulp --> we do not want fiber residues to be stuck in the GI later.
```
Morning of surgery:
Do not eat any food
Drink 1 CHO drink (10 minutes) as above but ½ the amount 2h before surgery
82
Explain the nutritional prescription post- gallbladder surgery
```
Post-op nutrition (moving to ERAS more and more)
Day 1-3:
- Clear fluids first, sipped
- Full fluids, but avoiding high-fat
- Can use EN products, low in fat
```
Day 3:
- If tolerating fluids, low fat diet
- Small meals depending on tolerance
Nutrition support is reserved for:
- Severe cases such as pancreatitis, sepsis, shock… or
- Extended postoperative period and bowel rest are indicated
83
Name possible causes of acute pancreatitis
Common causes (90%)
o Biliary tract disease/cholelithiasis (more common in women)
o Alcoholism (more common in men)
o Idiopathic
```
Other causes
o Infection, drugs, surgery, cancer
o Obesity, hyperlipidemia
o Hyperparathyroidism, hypercalcemia
o Exposure to toxins
o Trauma
o ERCP (to fix gallbladder = affect something else)
```
84
What is the nutritional management of acute pancreatitis?
NPO vs TPN vs EN depends on severity
• NPO for milder conditions
• NS for more severe; Oral feeds for mild and moderate cases
• Standard nutrition therapy
• Low fat high CHO and protein foods for some, especially biliary issues
• Clear fluids to begin, transition to full fluid diets (consider fat)
• No alcohol
• Frequent small meals
85
What is the nutritional management of chronic pancreatitis?
Replacement enzymes with meals
Antacids (to neutralize stomach acid & activates enzymes in duodenum)
Low fat high protein
CHO depends on islet function
MCT oil and EN if fat malabsorption
No alcohol
Vitamin supplements (fat-soluble vits and B12)
Alcohol, coffee, tea, spices, irritant condiments should be avoided. No smoking.
o Why? Irritants affect transit rate – enzymes already work w/o food there
If EN: Choose elemental or semi-elemental (no enzymes in tube feeds)
86
What is the nutrition prescription for acute pancreatitis with Ranson score < 2 and APACHE II score < 9?
- Focus on symptom management = Prevent N/V, Minimize pain, Reduce steatorrhea
- Maintain or achieve normal nutrition status
- Avoid alcohol
ASPEN: no evidence for low-fat foods in mild states (liberal). Self-selection is suitable in context of standard nutrition therapy.
If oral intake fails, initiate EN after 4 days
87
What is the nutrition prescription for acute pancreatitis with Ranson score > 3 and APACHE II score > 10?
E: 25 kcal/kg/d or MSJ x 1.39
Initiate within 48-72 hours of admission
Continuous infusion over 24h
Initiate feeding 25 mL/hr, advance to reach 25 kcal/kg over 24-48h
EER: 25 kcal/kg/d (or IC)
Protein: 1.5 g/kg/d (2.0 g/kg/d MUHC)
Standard polymeric formulas, mixed protein, fat, CHO
Advance to oral diet when no pain for 24 h (ASPEN). Nelms also suggests when amylase (declines first) and lipase decrease towards normal. Evidence is not strong according to ASPEN.
Start PN if intolerant to EN > 5 d
88
What are the replacement doses for pancreatic enzymes per meal? Per day? Per g fat?
- 500-2500 U lipase/kg/meal
- < 10,000 U lipase/kg/day
- 1000-4000 U lipase/1g dietary fat at meals and snacks
≈ 30,000 units lipase with each meal
89
Name 3 theories for celiac disease triggers.
o Young age of introduction
o Short duration of breastfeeding
o Viral infections in infancy
90
Name atypical symptoms of celiac disease
```
o Bone and joint pain
o Muscle cramping, fatigue
o Peripheral neuropathy, seizures
o Skin rash
o Mouth ulcerations
o Higher risk for lymphoma and osteoporosis
```
91
Name common symptoms of celiac disease
```
o Diarrhea
o Fatigue
o Borborygmus (a rumbling or gurgling noise made by the movement of fluid and gas in the intestines)
o Abdominal pain
o Weight loss
o Abdominal distention
o Flatulence
```
92
Name uncommon symptoms of celiac disease
```
o Osteopenia/osteoporosis
o Abnormal liver function
o Vomiting
o Iron-deficiency anemia
o Neurologic dysfunction
o Constipation (vs. diarrhea + common)
o Nausea
```
93
What is koilonychia and what deficiency is it a sign of?
Spoon-shaped nails (iron, chromium); white cuticles
94
What are the 3 most common symptoms of celiac?
1. Abdominal pain
2. Diarrhea
3. Weight loss
95
What are the nutrients to monitor in GFD?
Iron
Folate
CHO
Fiber
96
What are the mucosal changes seen in the SI biopsy of someone with celiac disease?
* Partial to total villous atrophy
* May be characterized by subtle crypt lengthening
* Increased epithelial lymphocytes
97
Name common deficiencies in celiac
folic acid (= Fatigue, irritability, neuropathy, anemia…), B12, fat-soluble vitamins, and iron
98
Are alcohol and liquors GF?
– All distilled alcohols and liqueurs are gluten free, unless a gluten-containing ingredient has been added after distillation
o Distillation process eliminates all of the wheat
– Wine is gluten free
– Regular beer and gluten-reduced beers made from barley, rye and/or wheat are NOT gluten free
– Gluten-free beer made with gluten-free grains (e.g., amaranth, buckwheat, chestnuts, corn, millet, quinoa, rice and/or sorghum) are allowed
– Hard ciders are gluten free unless they contain barley malt.
– Premixed alcoholic beverages are gluten free unless they contain barley malt or hydrolyzed wheat protein
99
What are the energy and protein requirements post-op N&N cancer?
– Estimated energy requirements: Mifflin St. Jeor x activity factor (1.2 – 1.3) x stress factor (at least 1.3).
– Estimated protein requirements: at least 1.3 g/kg
