Gastro Flashcards
Irritable Bowel Syndrome (IBS)
Definition: Chronic condition with recurrent abdominal pain and bowel habit changes.
Prevalence: Affects ~30% of Australians.
Symptoms & Triggers: Abdominal pain, bloating, constipation/diarrhea; triggered by stress, food intolerances, certain medications.
Management: Low FODMAP diet (75% effective), high-fiber foods, reduced gas-producing foods, gut-directed hypnotherapy.
FODMAPs
Definition: Poorly absorbed short-chain carbs causing gas and bloating.
Types:
Oligosaccharides: Fructans (wheat, garlic), GOS (legumes).
Disaccharides: Lactose (dairy).
Monosaccharides: XS fructose (fruit, honey).
Polyols: Sugar alcohols (sorbitol, mannitol).
Diet Phases:
Elimination: Avoid high FODMAPs (2-6 weeks).
Reintroduction: Gradually reintroduce foods (6-8 weeks).
Maintenance: Sustainable, less restrictive diet.
Diverticular Disease
Diverticulosis: Formation of pouches in the colon, typically asymptomatic.
Diverticulitis: Inflamed or infected pouches, causing severe pain, fever, nausea, and bowel habit changes.
Treatment:
Diverticulosis: High-fiber diet, fluid intake, probiotics.
Diverticulitis: Low-residue diet during flares; severe cases require antibiotics or surgery.
Constipation
Definition: Infrequent passage of stools with straining or discomfort.
Types:
Primary: Functional (normal or slow transit, pelvic floor dysfunction).
Secondary: Due to medical conditions, medications, or structural issues.
Prevalence: Up to 24%; 80% in elderly.
Dietary Goals: 25-30g fiber/day, adequate hydration, physical activity.
First-Line IBS Dietary Advice
Include: High-fiber foods (whole grains, legumes, fruits, vegetables).
Avoid/Limit: Gas-producing foods (onion, cabbage), lactose, alcohol, artificial sweeteners.
Key Foods to Avoid: Garlic, onion, apples, mushrooms, bread, chickpeas (high FODMAP).
Fibre Overview
Types:
Soluble: Found in oats, beans, and fruit; lowers cholesterol, stabilizes blood sugar.
Insoluble: Found in whole grains, fruit skins, vegetables; promotes regularity.
Resistant Starch: Found in cooled rice, underripe bananas; feeds healthy gut bacteria.
Daily Targets: 25g for women, 30g for men.
Toileting Habits for Constipation
Optimal Timing: After waking or meals when the bowel is most active.
Posture: Knees above hips, feet flat.
Avoid Distractions: Reading or phone use during toileting.
Treatment Options for Constipation
Mild Cases: High-fiber diet, fluid intake, physical activity, trial probiotics.
Severe Cases: Use of fiber supplements, laxatives (bulking agents, stool softeners, stimulants).
Advanced: Colonic transit study, pelvic floor therapy, or medical intervention.
High-Fiber Food Examples
Grains: Wholemeal pasta (7.9g/cup), rolled oats (4.5g/½ cup).
Vegetables: Carrot (6.9g), broccoli (3.8g).
Fruits: Dried apricots (2.5g), apple (2.2g).
Legumes: Kidney beans (6.5g/100g).
Nuts: Almonds (3g/30g).
Diverticulosis Recommendations
Dietary Goals: Gradual fiber increase (25-30g/day) and hydration (35-45 ml/kg/day).
Other Tips: Avoid alcohol/caffeine; don’t restrict nuts/seeds unnecessarily.
Probiotics: Optional, avoid during acute diverticulitis.
Definition of IBD
Chronic inflammatory condition including Crohn’s Disease (CD) and Ulcerative Colitis (UC).
IBD Nutritional Requirements
Energy Needs: Generally 30-35 kcal/kg/day; may increase during active disease due to inflammation.
Protein Needs: Increased during active disease (1.2-1.5 g/kg/day); similar to general population during remission (~1 g/kg/day).
Micronutrient Monitoring: Annual assessment for deficiencies, focusing on iron, vitamin D, zinc, selenium, and vitamin B12.
Nutritional Strategies for Active IBD
Exclusive Enteral Nutrition (EEN): First-line treatment for inducing remission in pediatric CD; alternative for adults with mild to moderate CD who cannot tolerate drugs.
Crohn’s Disease Exclusion Diet (CDED): Effective in combination with partial enteral nutrition, especially in pediatric patients.
Diet Texture: Modified or liquid diets for patients with strictures or intestinal obstruction.
Supplementation: Address deficiencies of calcium, vitamin D, and iron based on active disease and treatment plans.
IBD Micronutrient Management
Iron: Oral iron is preferred in mild anemia and inactive disease. Intravenous iron recommended for severe anemia or active inflammation.
Vitamin D & Calcium: Supplement in corticosteroid use or suspected deficiencies to prevent osteoporosis.
B12 & Folate: Essential after ileocecal resection or methotrexate/sulfasalazine treatment.
Fat-Soluble Vitamins (A, D, E, K): Supplement in cases of fat malabsorption or prolonged disease activity.
IBD Dietary Patterns & Prevention
Dietary Risk Factors: Ultra-processed foods and emulsifiers may increase IBD risk; fiber and omega-3 intake offer protection.
Breastfeeding: Reduces risk of developing IBD.
Dietary Goals: Healthy, balanced diet focusing on fruits, vegetables, whole grains, and lean proteins during remission.
EN & PN in IBD
EN as Supportive Therapy: Used when oral feeding is insufficient; standard polymeric diets are preferred.
PN Indications: Severe malabsorption, short bowel syndrome, or gastrointestinal obstruction.
Administration: Nasogastric or nasoenteric routes preferred; pump feeding is optimal for jejunal feeding.
IBD Post Surgical Nutrition
Assessment: Evaluate nutritional status before and after surgery.
Nutritional Support: Oral nutrition with supplements preferred post-surgery; PN if oral or EN is not feasible.
Micronutrient Focus: Maintain adequate levels of iron, B12, calcium, and vitamins D, A, E, and K.
IBD Management During Remission
Dietary Advice: Maintain a healthy diet and avoid known food triggers.
Nutritional Supplements: Use oral supplements or EN if malnutrition persists.
Lifestyle Considerations: Encourage regular meal patterns and physical activity to maintain nutritional health.
Osteoporosis risk in IBD
Common in IBD; ensure regular DEXA scans and supplement with calcium and vitamin D.
Dehydration Management in IBD
Critical in patients with high-output stomas or severe diarrhea; consider tailored oral rehydration solutions.
IBD General Overview
IBD Types: Crohn’s Disease (CD) and Ulcerative Colitis (UC).
Disease Characteristics:
CD: Inflammation from mouth to anus; affects all bowel layers.
UC: Limited to the mucosal lining of the colon and rectum.
Symptoms: Abdominal pain, diarrhea, malabsorption, weight loss, fatigue, and nutrient deficiencies.
IBD Nutritional Status Considerations
Risk of malnutrition, growth retardation (children), and osteoporosis (prolonged steroid use).
Micronutrient deficiencies: iron, B12, vitamin C, vitamin D, calcium, fat-soluble vitamins, zinc.
IBD Dietary Modification Considerations
CD: Low-fat, low-fiber diets during active disease (LOFLEX protocol).
UC: Avoid specific food triggers; balanced diet.
Dietary management in active IBD
General Guidelines:
High-protein (1.2–1.5 g/kg/day).
Energy needs: 30–35 kcal/kg/day.
Elemental Diet: Pre-digested nutrients, suitable for severe disease but may exacerbate diarrhea due to high osmolarity.
Polymeric Diet: Standard feeds with intact nutrients; fiber contraindicated during active flares.
Exclusive Enteral Nutrition (EEN):
First-line therapy in pediatric CD.
Partial EN with tailored diets for adults with UC or CD.
Nutritional Management During IBD Exacerbations
Goals: Minimise nutrient losses, manage symptoms, and maintain intake.
Interventions:
Oral nutritional supplements (ONS).
Enteral Nutrition (EN) if oral intake is insufficient.
Parenteral Nutrition (PN) for severe malabsorption or bowel dysfunction.
Modified Fiber Diet: Low fiber, low lactose, adequate fluids during diarrhea.
Nutritional Strategies During IBD Remission
Goals: Maintain nutritional status and prevent relapse.
Diet Recommendations:
Healthy, varied diet: focus on fruits, vegetables, whole grains, and lean proteins.
Modified high-energy, high-protein diet if indicated.
Micronutrient monitoring: vitamin D, calcium, iron, zinc.
Exclusive EN: Alternative to steroids in maintaining remission, especially in pediatric CD.
Surgery and Post-Surgical Nutrition in IBD
Surgical Options:
- UC: Total colectomy can be curative.
- CD: Surgery to manage symptoms; not curative.
Nutritional Impact: Ileostomy/colostomy increases fluid loss and reduces absorption.
Dietary Adjustments:
- Avoid high-fibre, odorous foods; manage flatulence and stool frequency.
- Balanced diet and supplementation to maintain nutrition.
IBD Micronutrient Management
Iron & B12: Address anemia and deficiencies due to malabsorption or ileal damage.
Vitamin D & Calcium: Prevent osteoporosis, especially during steroid use.
Fat-Soluble Vitamins (ADEK): Supplement in cases of fat malabsorption.
Zinc & Folate: Supplement to support immune function and repair.
MNT for Paediatric IBD
Focus on Growth: Early intervention with EN to support growth and nutritional status.
CDED (Crohn’s Disease Exclusion Diet):
- Combined with partial EN for achieving remission.
- Gradual reintroduction of foods to identify triggers.
LOWFLEX protocol
Low fat, fibre limited exclusive diet
Initial low-fat (50g/day), low-fiber (10g/day) diet for 2–4 weeks.
Gradual reintroduction of foods to identify triggers.
IBD Nutritional Management in Special Situations
Acute Phase: Modified fibre, low lactose, vitamin and mineral supplements, PN if needed.
Long-Term: General healthy eating guidelines, individualized to maintain remission.
Additional IBD considerations
Hydration: Adequate fluids for patients with diarrhea or stomas.
Fat Malabsorption: Assess and treat as needed.
Prolonged Steroid Use: Manage associated risks like osteoporosis and micronutrient depletion.
Steroid Use in IBD
Purpose: Steroids (e.g., prednisone, budesonide) manage acute IBD flare-ups by reducing inflammation.
Common Side Effects: Arise with high doses or prolonged use.
Short-term side effects of steroids
Increased Appetite & Weight Gain: Fat deposition in the face, neck, and abdomen.
Mood Swings: Anxiety, irritability, or mood disorders.
Insomnia: Difficulty falling or staying asleep.
Increased Blood Sugar: Higher risk in pre-diabetic or diabetic individuals.
Fluid Retention & Swelling: Sodium and water retention causing swelling in extremities and face.
Long-term side effects of steroids
Osteoporosis: Weakening of bones; higher fracture risk.
Cataracts: Vision problems from prolonged use.
Skin Changes: Fragile, thin skin prone to bruising.
Muscle Weakness: Reduced muscle mass and strength.
Suppressed Immunity: Increased infection risk.
Growth Retardation (Children): Potential impact on growth and development.
Adrenal Gland Suppression: Reduced cortisol production, leading to insufficiency when steroids are tapered off.
Steroid impact on nutrient malabsorption
Calcium: Reduced absorption and increased excretion → osteoporosis risk.
Potassium: Increased urinary loss → hypokalemia.
Sodium: Retention → high blood pressure, electrolyte imbalances.
Protein: Increased breakdown → muscle wasting.
Vitamin C: Reduced absorption → decreased antioxidant levels.
Vitamin D: Impaired metabolism → reduced calcium utilization and bone health.
Steroid Use Management Strategies in IBD
Lowest Effective Dose: Use steroids at the minimum effective dose and duration.
Nutritional Support:
- Supplement calcium, vitamin D, and potassium as needed.
- Include high-protein foods to offset muscle breakdown.
- Monitor nutrient levels (e.g., vitamin C, protein, and electrolytes).
Alternative Therapies: Consider non-steroidal medications to reduce reliance on steroids.
Definition of eosinophilic oesophagitis
Allergic condition causing inflammation in the esophagus, leading to impaired contraction.
Prevalence of eosinophilic oesophagitis
More common in men than women.
Dietary management of eosinophilic oesophagitis
6-food elimination diet: Avoid animal milk, wheat, egg, soy, nuts, fish, and shellfish.
2-food elimination diet: Focus on eliminating milk and wheat first.
GORD definition
Reflux occurring more than twice a week due to an incompetent esophageal sphincter.
Medical management of GORD
Antacids: Gaviscon.
Prokinetics: Promote stomach emptying.
PPIs: Omeprazole (take 30-60 minutes before meals).
H-2 Receptor Blockers: Reduce acid production.
Some medications can worsen symptoms.
Surgical management of GORD
Laparoscopic Nissen Fundoplication
MNT of GORD
Aim for BMI ≤ 25; a BMI reduction of 3.5 can reduce symptoms by 40%.
Avoid alcohol, caffeine, fatty foods, acidic/creamy/fizzy foods, and peppermint tea.
Sit upright after meals; avoid drinking with meals.
Stop gum chewing.
Complications associated with GORD
Barrett’s esophagus, dysphagia, ulceration, odynophagia, otitis media, chest pain.
Causes of GORD
Overweight, age, genetics, pregnancy, trauma, hiatus hernia.
Overview of absorption in the GI tracts (stomach -> lower GI)
Stomach: Intrinsic factor binds to B12; pancreatic enzymes released.
Small Intestine:
Jejunum: Absorbs CHO, protein, water-soluble vitamins.
Ileum: Primary site for bile salt and B12 absorption.
Lower GI Tract: Absorbs water, vitamin K, Na, K, and SCFA.
Normal stoma outputs (ileostomy & colostomy)
Normal output: 600–1000 ml/day, toothpaste consistency.
Colostomy:
Normal output: 300–400 ml/day, semi-solid stool.
Definition & causes of high output stomas
Defined as 1500–2000 ml/day.
Causes: Inflammation, infection, SIBO, obstruction, bile salt malabsorption, medications.
High stoma output management
ORS (Oral Rehydration Solution) with high salt diet.
Starch CHO to thicken output.
Low fiber intake.
Oral rehydration solution recipe
St Mark’s solution:
3.5 g salt.
2.5 g sodium bicarbonate.
20 g glucose.
1L water or 2 sachets of Dioralyte.
What is the definition of short bowel syndrome?
A disorder causing malabsorption, diarrhea, steatorrhea, fluid/electrolyte disturbances, and malnutrition due to inadequate functional bowel.
What length of bowel is considered high risk for short bowel syndrome?
<200cm of bowel
What is the most common cause of short bowel syndrome?
Crohn’s disease
What is the normal Na+ concentration in the bowel?
~90–120 mmol
What should the sodium concentration in oral rehydration solutions (ORS) for short bowel syndrome be?
90–120 mmol, with CHO concentration ~60 mmol.
What type of enteral feeds are recommended for short bowel syndrome?
Isotonic feeds with an osmolarity of 300–500 osm/kg.
Why should elemental feeds be avoided in short bowel syndrome?
They are hypertonic and can exacerbate symptoms.
When is parenteral nutrition (PN) not required in short bowel syndrome?
If the ileum is intact and large portions of the jejunum remain functional.
What is the minimum bowel length needed to avoid PN in patients without a colon?
At least 100 cm of bowel.
Which medication is used to decrease stomach acid in short bowel syndrome?
Proton pump inhibitors (PPIs), such as omeprazole.
Which medication can be used as an antimotility agent in short bowel syndrome?
Codeine phosphate.
What supplements are necessary in short bowel syndrome due to malabsorption in the ileum?
Vitamin B12 and bile salts.
What is the gold standard diagnostic test for coeliac disease?
Small bowel biopsy
How is lactose intolerance diagnosed?
Hydrogen breath test
How is IBS diagnosed?
Based on symptom criteria and excluding other conditions
What diagnostic tools are used for ulcerative colitis?
Blood tests, endoscopy, stool tests, scans, colonoscopy
What tests are used to diagnose Crohn’s disease?
Faecal calprotectin, MRI, CT scan
How is diverticular disease diagnosed?
Colonoscopy, CT, X-ray, barium enema
Which tests are used to diagnose GORD?
Endoscopy, 24hr pH monitoring, oesophageal manometry
What are the diagnostic tests for peptic ulcer disease?
Endoscopy & H. Pylori testing (breath or stool)
How can faecal calprotectin be used in differentiating between IBS & IBD?
Detects inflammation = present in IBD, not IBS
What are other inflammatory markers used in GI diagnostics?
Erythrocyte sedimentation rate (ESR) & CRP
