GI 3 Flashcards
Common prebiotics
Oligofructose Inulin Galacto-oligosaccharides Lactulose Breast milk oligosaccharides
recommendations for high output ostomy
High Output: more than 1 litre (4 cups) per day
Add 1-2 extra litres (4-8 cups) of fluid each day. Good choices are: water, milk or milk alternatives, diluted 100% fruit juices, herbal or weak tea
Add 5 mL (1 tsp) of salt throughout the day. You can do this by sprinkling salt on your food and choosing saltier items such as canned soups or crackers.
Include potassium rich foods such as bananas, diluted orange juice, potatoes, tomato juice, milk and milk alternatives.
Do not restrict your fluids to control a high ostomy output. This could lead to dehydration or worsen existing dehydration.S
peak to your doctor or dietitian if you continue to have a high stool output. They may recommend an oral rehydration drink or have other dietary suggestions
what does gut microbiota play a role in?
• energy balance
• resistance to pathogen colonization
• maturation of intestinal and immune
systems
What can gut microbiota be altered by?
- medications
- physiological and psychological stress
- diet
- exercise
prebiotic vs probiotic
Probiotic- bacteria
• Living strains of bacteria that add to
the population of good bacteria in your digestive system when administered in adequate amounts.
Prebiotic- fiber
• Fibres that feed the good bacteria.
This stimulates growth among the preexisting good bacteria
benefit and mechanism of prebiotics
prebiotics get fermented by bacteria to SFA that serve as fuel for the gut and can help maintain the tight junctions this can help down-regulate the inflammation process
impact of gut microbial dysbiosis
gut microbial dysbiosis occurs when harmful bacteria dominates over beneficial bacteria
results in
- increased gut permebaility
- endotoxemia; septicemia
- diarrhea, IBS, IBD, diabetes, obesity, liver disease, CVD
is yoghurt a prebiotic?
no
Types of bleeding in stool
- Frank blood: bright red and on the surface of stool - represents anus or rectum bleeding; blood coming from anus or rectum e.g. in haemorrhoids
- Occult: detected by testing and results from bleeding in lower GI
- Melena: dark stool and results from upper GI bleeding
NELMS definition of diarrhea
increase in frequency of bowel movements and/or increase in water content of stools
• Affects consistency or volume
• >200 g/day adults, >20 g/kg
for children
Acute vs chronic diarrhea
Acute:
- <2 weeks
- increase in frequency of bowel movements and/or increase in water content of stools
Chronic:
- > 4 weeks
- no pain
- loose or watery stools
- loose stools occur 25% of the time
- criteria fulfilled for the last 3 months, with symptoms onset at least 6mo prior to diagnosis
- patients meeting the criteria for IBS should be excluded
osmotic vs secretory diarrhea
Osmotic
- increased water efflux due to an increase in osmolality
- Increased osmolality in intense, body responds by pulling water into lumen
- Caused by: maldigestion (e.g., lactose), excessive sorbitol (e.g., sugar free candies) or fructose (e.g., ++juice), laxative use
- Resolves when NPO/ eliminate offending food
Secretory- underlying disease causes excess secretions (not hyperosmolarity)
• Does not resolve when NPO
• Bacterial, protozoa, viruses
• Traveler’s diarrhea
• Medications
• Antibiotic-related
- Increase GI motility or alter flora of colon E.g., Clostridium difficile (C.diff) major cause of antibiotic-related diarrhea
• Symptom of a GI disease: Crohn’s, UC, celiac, tumor
• AIDS enteropathy, thyroid dysfunction
Concerns with diarrhea
Concerns: dehydration, electrolyte imbalance, acid-base imbalance, malabsorption, malnutrition, weight loss
Jim notices that he gets diarrhea every time he drinks milk. What type of diarrhea is this?
A. Osmotic B. Secretory
A
Diarrhea- Medical Diagnosis components
- Diagnose underlying etiology
- Recurrence of episodes related to time of day and food intake E.g.,lactose intolerance
- Rule out inflammatory process: IBD, Celiac • Stool cultures – parasites, WBCs
- Procedures such as endoscopy
Diarrhea- Treatment goals
Restore fluid, electrolyte, and acid-base balance; decrease GI motility; thicken consistency of stool; repopulate GI with normal flora; introduce foods that do not aggravate symptoms
Diarrhea treatment components
• Treat underlying disease
• Antibiotics if infectious
• Restore fluid, electrolyte, acid-
base balance; IV therapy, rehydration solutions
• Medications to treat symptoms (e.g., Imodium)- slows down transit time
• Suggest prevention strategies E.g., hygiene education, clean water, wash fruit and veg
which acid-base disturbance is associated with diarrhea?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Metabolic acidosis
d. Metabolic acidosis
someone with diarrhea might become acidotic as they are loosing bicarb-> acidosis
Diarrhea- Nutrition diagnosis
E.g.,“inadequate fluid/ energy intake” or “altered GI function”
Diarrhea- nutrition intervention
• NPO or clear liquids (e.g., juice) – OLD recommendation juice usually makes diarrhea worse (sugar is hyperosmolar)
• Oral rehydration solutions should be taken instead, if patient can take PO e.g.Pedialyte, Rehydrlyte, Gastrolyteetc.
• Decrease motility: limit/avoid simple CHO, sugar alcohols, caffeine, alcohol
• Avoid gas-producing foods (e.g., cruciferous veg, legumes)
• Encourage low-residue foods
-> no bulk and easily digested
• BRAT (banana, rice applesauce, toast) can be used for short period-> source of soluble fiber (helps with viscosity), usually well tolerated
• Use of soluble fibre
• Pectin, banana flakes, applesauce, rice
• Pro and prebiotics – know what to look for! One size does not fit all.
Components of low residue diet
Low residue diet = minimize foods that contribute bulk to stool • Low insoluble fibre • Moderate fat - Diary - Meats - Limit fats to 8 tsp/d
low residue diet reccs
Milk and Milk products: recommended and not recommended
notes
recommended: Buttermilk, Skim milk, Soy milk, Low-fat and aged cheese
not recommended: Whole milk, cream, yogurt with berries + dried fruits +nuts
notes: If lactose intolerant, try lactose free products
proteins in low residue diet
recommended:
not recommended:
notes:
recommended: Tender, well cooked meat, pork, poultry, fish, eggs or soy without added fats
not recommended: Fried, salami, bologna, sausage, bacon, hot dogs, fatty meats
grain in low residue diet
recommended:
not recommended:
notes:
recommended: White breads, pasta, cream of wheat, rice, cereals made with refined flour (e.g., puffed rice)
not recommended: Whole wheat or whole grain, brown or wild rice, barely, oats, popcorn, breads made with nuts/seed
notes: <2g fibre/serving
fruit/veg in low residue diet
recommended:
not recommended:
notes:
recommended: Ripe banana, canned unsweetened fruit, cooked veg
not recommended: Fruit juice with pulp, dried fruits, raw veg, broccoli, corn
notes: Remove skins, seeds
Diet • BRK: All bran with whole milk • Fruit salad • Coffee • LUNCH: Baked potato with 2 tbsp margarine • Cucumber and tomato salad • Baked chicken in mushroom soup • Yogurt with nuts and seeds • DINNER: Fried salmon • Barley risotto • Juice with pulp
Write a Low Residue/Diarrhea Diet
refined cereal (e.g., puffed rice) + skim milk or plant-based
banana and canned fruit salad
no coffee
potato w/o margarine
starch veggies are good like carrots, potato w/o skin
low fat chicken w/o soup
remove skins from cuc and tomato or replace with non-gas producing veggies
low- fat yoghurt or plant-based; no nut and seeds or smooth pb
steamed or baked low-fat fish or salmon
white rice risotto
no juice
what should u check for when it comes to probiotics?
- genus, species, strain
- # of viable cells of each probiotic strain
- Shelf-life
- Dosage required for effect
Antibiotic-Associated Diarrhea and probiotics
probiotics are effective in prevention of antibiotic-associated diarrhea
Yogurt with Lactobacillus casei DN114, L. bulgaricus, and Streptococcus thermophilus ≥ 1010 CFU daily
Lactobacillus acidophilus CL1285 and L. casei (Bio-K+ CL1285) ≥ 1010 CFU daily
Your patient has been having diarrhea. To assess food causes, you ask about intake of
a. Diabetic candies
b. Alcohol
c. Lactose
d. Caffeine
e. All of the above
e. All of the above
ROME criteria for constipation
Must have ≥2 of the following:
1. For ≥3 months prior with symptom onset ≥6 months ago
• Straining For >1/4 (25%) of defecations
• Lumpy or hard stools (1 of 2 on the Bristol Stool
Scale) for >1/4 (25%) of defecation
• Sensation of incomplete evacuation for >1/4 (25%) of defecations
• Manual maneuvers to facilitate defecation (E.g.
digital evacuation, pelvic floor support) for>1/4 (25%) of defecations
• < 3 spontaneous bowel movements per week
2. Loose stools rarely present without use of laxatives
3. Does NOT meet Rome IV Criteria for IBS
Diarrhea can be a side effect of which meds?
- Opioids
- Antidepressants
- Diuretics
- Antihistamines
What are the characteristics of idiopathic constipation?
Slowed colonic transit time
What is secondary constipation?
• Obstruction such as a tumor or
adhesions
• Other medical conditions e.g., Multiple Sclerosis, Parkinson’s, Thyroid
how is constipation medically diagnosed?
- Rome Consensus III Criteria
- Complete medical hx, meds & physical
- Colonoscopy
Treatment of constipation
• Treat underlying etiology
• Bowel retraining
- E.g., Make time in the morning and go when have to go!
• Enemas, laxatives
• Bulking agent (psyllium), stool softeners (mineral oil)
Nutrition assessment in patients with constipation
- Fluid and beverage intake
- Dietary fiber intake
- Eating enough?
- Beliefs, attitudes, stress, daily schedule
- Medications; e.g., opioids
- Misuse of meds; esp. laxatives
- Supplements; e.g., calcium and iron
Constipation: nutrition diagnosis
E.g., “inadequate fibre intake” “inadequate fluid intake” “altered GI function” “not ready for diet/lifestyle change”
Daily fibre needs for a man are
A. 25 B. 38 C. 18 D. 100
B 38
25 for a woman
Nutrition therapy in constipation
Nutrition Therapy for Constipation - Nutrition Interventions:
• Increase whole grains, bran, fruits (skins), vegetables, legumes
• Fiber 25-38 grams/day
-> Slowly add 1-2 new high fibre foods each day
• Bulking agents such as psyllium
• Fluid – at least 2.2-3000 mL/day
• Pro and prebiotics:
-> Fructooliogosaccharides (FOS) and fructans: Naturally occurring in wheat-containing grain products such as
bread, pastas, cereal
Other non-medical nutrition therapy approaches for diarrhea
- Hot liquids like herbal teas
- Coffee (caffeine increases gastric motility) • Exercise
- Natural laxatives like prunes or prune juice
- Reduce stress and anxiety
- Routine
IBS: nelms vs ROME
Nelms - abdominal pain related to defecation that occurs in association with altered bowel habits at least 1 day per week over a period of 3 months
ROME:
• For ≥3 months prior with symptom onset ≥6 months ago
• Must have ≥2 of the following:
• Associated with recurrent abdominal pain ≥1 day/wk in the last 3 months (on average)
-> Defecation either increasing or improving pain
-> Associated with a change in stool frequency
-> Associated with a change in stool form
(appearance)
what are the 4 subtypes of IBS?
4 subtypes: IBS-D (diarrhea), IBS-C (constipation), IBS-M (mixed-type), IBS-U (unclassified)
What are the characteristics of IBS subtypes
- Patients with IBS-C have >25% of their bowel movements associated with BSFS 1 or 2.
- IBS-D have >25% of their bowel movements associated with BSFS 6 or 7.
- Those with the mixed subtype of alternating constipation and diarrhea (IBS-M) have >25% of their bowel movements associated with BSFS 1 or 2 and >25% of their bowel movements associated with BSFS 6 or 7.
what are the causes of IBS?
-no one single cause; many theories
• Historically Functional disorder / Now considered a gut-brain interaction disorder
IBS – Medical Treatment
• Guided by symptoms
• IBS-D = antidiarrheal agents (e.g., Loperamide)
• Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) E.g.,amitriptyline (Elavil)
• IBS-C = Bulking agents (e.g., psyllium), osmotic laxatives (e.g., milk of magnesia), stool softeners (e.g., RestoraLAX)
- Psyllium has been tested and found to be effective for IBS-C
• Behavioral therapies (e.g., relaxation)
IBS nutrition assessment
- Do you avoid any foods?
- Assess for deficiencies – might avoid whole food groups • Evaluate malnutrition risk, weight loss
- Food triggers?
- Stress/behavioural triggers?
- What is meal environment like?
- Meds, supplements, alternative tx?
- Allergies and intolerances – have you been tested?
- Assessment related to diarrhea or constipation – describe stool pattern
- Gas production – swallowing air, eating a lot of gas-producing foods?
- Gastrointestinal Symptom Rating Scale (GSRS) - use for monitoring as well.
IBS – Nutrition therapy
Diagnosis
• E.g., “disordered eating pattern” “poor nutrition quality of life” “undesirable food choices”
IBS – Nutrition therapy
Intervention
IBS = abdominal pain, alterations in bowel habits, gas, flatulence, reflux. Your goal is to reduce these sx!
• Guided by symptoms
• Elimination diet
• Try a food diary/mood/activities journal
• Ensure nutritional adequacy if remove foods long-term
• Normalize GI motility (e.g., psyllium if IBS-C) and normalize dietary patterns • Adequate fluid (esp. if increase psyllium)
• Encourage to reduce stress, anxiety (may need to seek help)
• Avoid swallowing air
- No straws, avoid sucking on candy, chew slowly, don’t talk while eating.
IBS and probiotics
“The literature suggests that certain probiotics may alleviate symptoms and improve the quality of life in patients with functional abdominal pain “
- Bifidobacterium bifidum
- Bifidobacterium infantis 1 × 109 CFU, once daily 108 CFU, once daily
IBS nutrition therapy
• May restrict FODMAPs (elimination diet)
• –Fermentable, oligosaccharides, disaccharides, monosaccharaides and polyols (FODMAP)
– Not well digested and contribute to fermentation, which cause gas and bloating.
IBS FODMAP Fermentable What is it? WHy might it be problematic? Example foods
What: Process through which gut bacteria ferments undigested carbs to produce gas
Why: usually good, but in IBS its painful
IBS FODMAP Oligosaccharides What is it? WHy might it be problematic? Example foods
What: Fructans & galacto‐oligosaccharide (GOS)
Why: No human enzyme capable of breaking down fructans and GOS. Highly fermentable.
Example: Wheat, rye, onions, garlic, legumes
IBS FODMAP Disaccharides What is it? WHy might it be problematic? Example foods
What: Lactose
Why: Lactase activity can be reduced in certain ethnicities, with age, and during periods of intestinal inflammation
IBS FODMAP Monosaccharides What is it? WHy might it be problematic? Example foods
What: fructose
Why: High osmotic effect and ability to draw water into the bowel lumen
Examples: Honey, apples, pears, high fructose corn syrup
IBS FODMAP Polyols What is it? WHy might it be problematic? Example foods
What: Sorbitol & Mannitol
Why: Elicit an osmotic effect and ability to draw water into the bowel lumen.
Examples: Apples, pears, stone fruit, cauliflower, mushrooms, sugar- free gum (artificial sweeteners)
FODMAP step 1
Step 1: LOW FODMAP
Swap high FODMAP foods in diet for similar low FODMAP alternatives to reduce IBS symptoms.
After following Step 1 for 2-6 weeks and symptoms are under control, ready for Step 2: Reintroduction
FODMAP step 2
RE-INTRODUCITON
• When symptoms are stable,
reintroduce each FODMAP back into diet, one-by-one, to identify which FODMAPs are tolerated and which trigger symptoms.
• They maintain a low FODMAP diet during this step.
• Some symptoms may return but need to remember that some gas and bloating are normal.
• Patients reintroduce 1 FODMAP group at a time, 1 food source from this group at a time, and start with only a small quantity.
• E.g., Lactose group – Milk
• They increase their serving size of this food over 3 days.
• A full serving is consumed on day 3
• If they experience symptoms, STOP. • Wait 1 day (or until symptoms improve) and then try a new food.
• Patient cannot eat any of the foods they tolerated during step 2 until step 3!
Reintroduce so diet is only as strict as it needs to be to control symptoms! This step can take 8-12 weeks.
FODMAP step 3
• Step 3: FODMAP PERSONALIZATION
• Patient should know which
FODMAPs they tolerate and which they are more sensitive to.
• Find a balance between reintroducing better tolerated FODMAP rich foods while avoiding those not tolerated well.
• They can eat these foods freely, but they might find that they can’t eat FODMAP foods as often or in the same quantities as they used to.
• They should attempt the foods that were not tolerated in a few months.
