GI Flashcards
Define UC and CD
UC: Diffuse mucosal inflammation limited to the colon
CD: Patchy transmural inflammation affecting any part of the GIT
Both may present with bloody diarrhoea, abdo pain, frequent bowel movements, weight loss and fatigue.
What are the methods used to restore nutrition in IBD ps?
UC: minimise exacerbation of diarrhoea
CD: Liquid diet, low fibre/low residue, food reintro, prebiotics/probiotics, (possibly)
What are the complications of malnutrition in IBD ps?
B12 deficiency
Bile acid malabsorption
Primary sclerosing cholangitis or malignancy – Anti-TNF
Osteoporosis and osteomalacia
Anaemia
Mood disorders in IBD
Surgical – Entercutaneous Fistula, strictures, abscesses, fissures, Short Bowel
How is IBD treated?
Aminosalicylates - 5-ASA Corticosteroids Thiopurines Methotrexate with steroids Calcineurin inhibitors Anti-TNF therapies
What is the liquid diet and what are its indications?
Using nutritionally complete liquid feeds.
If other medical therapies are contraindicated
Adjunctive treatment with corticosteroids & other treatments
Nutrition support
Food reintroduction diets - when are they used?
Nutritional supplementation after exclusive liquid diet
Identify “trigger/problem” foods
LOFFLEX diet (LOw Fibre, Fat Limited, Exclusion diet) before slowly Helps maintain remission of Crohn’s disease
Slow ‘re-introduction phase
‘high risk foods’ one by one ‘safe diet’
High relapse rates
Service cost implications as requires intensive dietary supervision
Jones et al 1985, Woolner et al. 1998
What is the evidence for low fat diets?
High LCT – long chain triglycerides - in enteral nutrition associated with reduced efficacy
Meta-analysis (Middleton et al 1995)
Diet intended to increase remission rate should be low fat
Other small studies found low fat diets and high MCT superior to high fat diets in induction and maintenance remission
Evidence for low fibre diets?
Reducing fibre often recommended as reduces stool weight and slows rate of intestinal transit
Fibre more likely to cause obstruction in stricturing disease
Generally suggested to build up fibre gradually after period on oral or tube feeding
Why are pro/prebiotics used?
Probiotic – live beneficial bacteria
VSL#3 : Treatment and prevention of pouchitis
Some evidence for remission of U.C.
Lack of evidence for Crohn’s treatment/remission
Prebiotics - provide a food source for beneficial bacteria in the gut to encourage them to breed.
May cause: abdominal pain abdominal bloating diarrhoea Flatulence
Why do ps with IBD suffer from malnutrition?
Inadequate intake due to:
Anorexia - CD (Common ileal or stricturing disease)
–>Pain
–>Food aversions
Nausea
Vomiting
Diarrhoea
Starvation for investigations – NBM
Malabsorption – Micro & Macronutrients CD and w/ mucus in UC
Blood loss
Dyspepsia - UC Upper GI disease, drug side effects (e.g., 5 ASA’s, metronidazole, corticosteroids
Increased requirements due to catabolic state:
increased metabolic rate
increased energy expenditure
stress response (Pro-inflammatory cytokines, surgery, pyrexia and infection) - common in CD, severe UC.
increased protein (or nitrogen) turnover
What’s suggested in those with diarrhoea?
Fluid
10 cups per day
Nutritious drinks
Replace salt
Soluble Fibre Jelly like fibre Helps the stool absorb water Softens stool May help improve diarrhoea Helps gut absorb more water from the stool
What should be avoided in those with diarrhoea?
Gas-producing foods High fibre or wholegrain cereals Alcohol can worsen dehydration Caffeine Personal triggers
What nutrient deficiencies may IBD ps suffer from?
Calcium - Use of corticosteriods, malnutrition and malabsorption, inflammation, poor dietary intake. CD.
Vitamin D - Increased requirements with steroid use, malabsorption.
Other fat soluble vitamins
(Zinc - Increased intestinal losses or high output fistulae)
Iron - Inflammation, Blood loss, anaemia of chronic disease, low dietary intake due to food aversions/intolerances
Vitamin B12 (after ileal resection especially) - CD.
Folate. - Blood loss, long term use sulphasalazine/methotrexate, poor dietary intake, mucosal inflammation
Serum vitamin B12 - Terminal Ileal resection or disease, poor dietary intake, mucosal inflammation. CD.
How does nutritional support vary during remission and active dx?
During active disease:
Patient is in a catabolic state.
Aim to maintain current nutritional state.
Prevent further deterioration
During remission:
Aim is to maintain/improve nutritional state.
Healthy BMI.
When should EN vs PN be used?
Enteral tube feeds:
to top up oral
Post surgery
If liquid diet can’t be tolerated orally.
Parenteral nutrition: Post surgery ileus Bowel obstruction Enterocutaneous fistula High output fistula (> 500ml/24h) Anastomotic breakdown after GI surgery Short Bowel Syndrome (<100cm viable bowel)
