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)
describe benefits of EN
- Primary nutrition therapy mucosal healing rates high
- Fell et al, (2000) found 79% paediatric patients with intestinal CD treated with polymeric EN in clinical remission had macroscopic and histological healing of ileum and colon
- Actively reduces intestinal inflammation (Yakamoto et al 2013)
- Promotes normalisation mucosal cytokine profile
- Changes biodiversity of microflora possibly related to low residue or prebiotic effects of polymeric feeds
- Effects not seen in patients treated with steroids (Forbes et al, 2011)
- EN treatment maintains nitrogen balance and reduces risk of osteoporosis compared with steroid treatment (Dear et al, 2001)
During remission, how does diet vary between non-stricturing and stricturing IBD?
Non stricturing Crohn’s & UC
Healthy balanced diet
Stricturing Crohn’s
Low Fibre, balanced diet
Meat and fish - Avoid gristle and fat, tough skin, small edible bones, e.g,. sardines
Fruit and veg - Avoid fibrous or stringy fruit and vegetables e.g., stalks, celery, coconut, orange pith, stringy beans
Cereals and grains - Avoid wholegrain and wholewheat productse.g., granary bread, popcorn, seeded bread
Nuts and seeds -Avoid all seeds and nuts unless smooth nut butter
Milk and milk products - Avoid yoghurts containing nuts or seeds otherwise include milk/yoghurt and cheese
What are the causes of high output stomas? How does one reduce output?
Illness
Antibiotics/medication
Stress
Too much fluid/fibre
HYDRATION:
Restrict oral hypo and hypertonic fluids
Oral glucose-saline solution
Anti-motility drugs (decrease water and sodium loss)
Anti-secretory drugs (reduce gastric acid secretion to help reduce stomal output)
IV saline (+/- mg sulphate)
May require IV fluids
St. Mark’s / Dioralyte rehydration solution
DIET: Add salt to food Eat salty foods Chew well Leave 30mins – 1 hour between eating and drinking. High fibre foods may need to be avoided
What can cause loose stomas? What foods can relieve issues with stomas?
Alcohol, dried fruit, fried foods, caffeinated drinks, spicy foods, pickles
Thicken output:
Banana, boiled rice, dry toast, marshmallows, smooth peanut butter, yoghurts
Alleviate constipation:
Fresh fruit and vegetables, adequate fluid intake
Increase bulk:
Brown rice, dried fruit, nuts and seeds, sweet corn, wholemeal bread and pasta
Stoma blockage:
Chew food well, beans, pulses, lentils celery, fruit and vegetable skins,
Cause wind and gas:
Carbonated drinks, alcohol (lager/beer), beans and pulses, brocolli, cabbage, cauliflower, mushrooms, onions, garlic
Cause odour:
Asparagus, brussel sprouts, cabbage, eggs, fish, garlic, onion
Alleviate odour:
Orange juice, parsley, tomato juice, yoghurt
Affect colour:
Beetroot, liquorice, iron tablets
What issues arise from having SBS?
<100cm short bowel dehydration malabsorption diarrhoea - malabsorbed bile salts cause this b12 deficiency increased fat loss increased carb and protein loss Flatulence Malabsorbed vits and trace minerals eg zinc
Name the site of absorption of carbs, vits and minerals
Duodenum Iron Calcium Vitamin A & D Some Carb
Jejenum Vitamin B & C Fatty Acids Some carbohydrate Some protein
Ileum
Bile salts
Vitamin B12
Colon
Water
Sodium
What is coeliac disease?
Coeliac disease is an inflammatory AI condition of the small intestinal mucosa that is induced by the ingestion of gluten and which improves clinically and histologically when gluten is excluded from the diet.
Signs and symptoms of coeliac disease include…?
Diarrhoea Abdominal pain Bloating Nausea & vomiting Lethargy Low mood Poor appetite Anaemia
Often asymptomatic
Exacerbated by consuming gluten foods
Indistinguishable from irritable bowel syndrome
How is coeliac dx diagnosed?
Blood test for endomysial antibodies (EMA) and tissue transglutaminase antibodies (TGA).
Endoscopy with duodenal biopsy taken to confirm diagnosis.
What does a gluten free diet NOT entail?
Wheat Barley Rye Wheat starch Wheat flour Wheat rusk Wheat bran Barley malt Barley flour Oat bran Rye flour
What other conditions are those with coeliac’s at higher risk of developing?
Dermatitis Herpetiformis skin condition skin presentation of coeliac disease gluten-freediet but many patients will also need treatment with medication Dapsone
AutoimmuneConditions
increased risk of developingdiabetesandthyroid disease
Lactose Intolerance
Secondary Lactose intolerance caused by the gut damage
Temporary problem
What can non-compliance to a gluten free diet/unidagnosed Coeliac’s result in?
Osteoporosis
Chronic malabsorption of calcium.
Cancer – lymphoma
Once a patient has followed the gluten-free diet for three to five years risk reduced
Depression
Low mood, fatigue
Continued GI symptoms
Diarrhoea, abdominal pain, wind, bloating, nausea, constipation
Micronutrient deficiencies
iron, B12, folate
Anaemia
Infertility& negative outcomes include:
Undiagnosed coeliac disease
Reduced birth weight
Increased risk of preterm birth
Higher caesarean section rates.
The risks are reduced following diagnosis and adherence to the gluten-free diet.
What should be focused on wrt the care of those with refractory coeliac’s?
Refractory Coeliac Disease:
Persistent malabsorptive symptoms & villous atrophy on strict gluten-free diet, with negative serology for anti-tTG or EMA.
Focus on : correction of nutritional status strict gluten-free diet immunosuppression via steroids monitoring for early detection of lymphoma
What is IBS? Name some causal factors.
Common ‘functional’ disorder of the gut. No definitive dx, h/w recurrent abdo PAIN for 3 days per month for 6 months, associated w/ 2 or more of:
- improvement w/ defecation
- Onset associated with frequency of stool
- Onset associated with change in appearance of stool
Factors: Visceral Hypersensitivity Altered brain-gut interaction Altered Motility Infections Environment Genes Childhood Abuse Disordered Sleep Stress Dysfunctional Coping Psychiatric disorders
Name signs & symptoms of IBS
• Abdominal pain which may ease after opening
bowels
• Diarrhoea and/or constipation
• Bloating and wind (flatulence and burping)
• Passing mucus
• Incomplete evacuation
• Urgency to open bowels
What do NICE recommend as tx for those with IBS?
Education
Reassurance
Dietitian supervised diet, strict 6-8 week exclusion. Healthy eating Low fibre/high fibre Probiotics FODMAPs
Medication
Antispasmodics
Antidiarrhoeals/laxatives
Psychological treatment
Counselling
CBT
What’s FODMAP?
Fermentable Oligosaccharides - fructans and GOS Disaccharides - lactose Monosaccharides - fructose And Polyols (sugar alcohols)
Fructans (sugar fructose) i.e. Wheat, rye, onion, garlic
GOS (sugar galactose) i.e. Pulses, legumes
Lactose (double unit sugar) i.e. Dairy products
Fructose (single unit sugar) i.e. Some fruits
Polyols (sugar acohols) i.e. Some sweeteners
