GI APM Flashcards
1
Q
What does DIGIN stand for?
A
Digestion/Absorption Intestinal Permeability Gastrointestinal Microflora Inflammation/Immune Regulation Nervous System - Gut Feelings
2
Q
What are the 5 R’s?
A
Remove, replace, reinoculate, repair, re-balance
3
Q
What can you treat Entamoeba Histolytica with?
A
Nitazoxanide 500 mg bid x 10 days, Oregano Oil 200 mg tid x 10 days
4
Q
What GI condition is associated with RLS?
A
SIBO
5
Q
What are some alarming GI symptoms/criteria that might warrant a further specific diagnostic testing first before applying a functional medicine approach?
A
Age over 50 Fever, chills, unintended weight loss Family history of GI malignancy Severe unresponsive diarrhea Severe or unrelenting abdominal pain Lower GI bleeding Nocturnal Symptoms Physical findings - abdominal mass, skin abnormalities, lymphadenopathy, arthritis
6
Q
What digestive enzyme is secreted in saliva and what does it digest?
A
Amylase - starches
7
Q
What digestive enzyme is secreted in stomach and what does it digest?
A
HCL/acid, Pepsin - proteins into polypeptides
8
Q
What digestive enzymes are secreted in small intestine and what does it digest?
A
Pancreatic amylase/lipase - starches, fats
Trypsin and other enzymes - polypeptides into amino acids
Brush border enzymes - starches
9
Q
What digestive enzyme is secreted in large intestine and what does it digest?
A
Bacterial enzymes - fiber
10
Q
What are some impairments in Digestion and Absorption?
A
Mastication so do good mouth exam Hypochlorhydria Pancreatic insufficiency Bile insufficiency Brush Border injury - lacking enzymes or inadequate brush border enyzmes
11
Q
What are some causes of poor digestion?
A
1) Poor dietary habits in regard to food selection, timing, food prep and chewing.
2) Altered bowel transit time
3) Villous Atrophy - decrease brush border enzymes and transporters which affect absorption
4) Dysbiosis - affects brush border enzymes
5) Altered gut/Neuroendocrine signaling
6) Low endogenous levels of stomach acid, pancreatic enzymes, saliva and bile
7) Pharmaceutical agents - acid blocking, laxatives, nutrient inhibition
12
Q
What are consequences of poor digestion?
A
1) Reduced bioavailability of nutrients and bio active ingredients to tissues(GI and systemic symptoms) - potential deficiency related outcome, reduced metabolic efficiency, alterned genomic activation, altered epigenetic signaling
2) Increased availability of undigested and/or un-neutralized food particles(mostly GI symptoms) - Increased allergenicity/immunogenicity, increased inflammatory triggers, increase burden for detoxification, increased fermentation and putrefaction via gut microbiota
13
Q
Define maldigestion.
A
Refers to defective hydrolysis of nutrients.
14
Q
Define malabsorption.
A
Refers to impaired mucosal absorption.
15
Q
What gets digested absorbed in the proximal small intestine(duodenum)?
A
Fat, Sugars, peptides/amino acids,
Iron, Folate, Calcium, Water, Electrolytes
16
Q
What gets digested absorbed in the middle small intestine(jejunum)?
A
Sugars, peptides/amino acids
Calcium, Water, Electrolytes
17
Q
What gets digested absorbed in the distal small intestine(ileum)?
A
Bile Salts, B12, Water, Electrolytes
18
Q
What gets digested absorbed large intestine(colon)?
A
Water, electrolytes, MCT oil, amino acids
19
Q
What are some causes of Conjugated Bile Acid Deficiency?
A
Liver disease, biliary obstruction, SIBO, ileal disease, CCK deficiency
20
Q
What are the malabsorbed substrates in Conjugated Bile Acid Deficiency?
A
Fat, Fat soluble vitamins, calcium, magnesium
21
Q
What are causes of pancreatic insufficiency?
A
Congenital, chronic pancreatitis, pancreatic tumors, hyperacidity(inactivating pancreatic enzymes)
22
Q
What are malabsorbed substrates of pancreatic insufficiency?
A
Fat, protein, CHO, fat soluble vitamins, B12
23
Q
What are the causes of reduced mucosal digestion?
A
Mucosal disease(Crohn’s, Celiac), brush border enzyme deficiency(ex:lactase)
24
Q
What are the malabsorbed substrates in reduced mucosal digestion?
A
CHO, protein
25
What are causes of intraluminal consumption of nutrients?
SIBO, parasitic infection(ex:D. latum)
26
What are the malabsorbed substrates of intraluminal consumption of nutrients?
B12, macronutrients
27
What are some mechanisms of maldigestion?
Conjugated Bile Acid Deficiency, Pancreatic Insufficiency, Reduced Mucosal Digestion and Intraluminal consumption of nutrients.
28
What are some mechanisms of malabsorption?
Reduced Mucosal Absorption, Decreased transport, Decreased Gastric Acid, IF, Rapid Gastric Emptying or Decreased Gastric Mixing.
29
What are causes of Reduced Mucosal Absorption?
Mucosal Disease(Crohn's or Celiac), intestinal surgery, infections, malignancy
30
What are causes of Decreased Transport?
Lymphatic disease, venous stasis(ex. CHF)
31
What are causes of Decreased Gastric Acid, IF?
Atrophic gastritis, pernicious anemia, prior gastric resection
32
What are causes of Rapid Gastric Emptying and Decreased Gastric Mixing?
Gastroparesis, prior surgery, autonomic dysfunction
33
What substrates are malabsorbed in Reduced mucosal absorption?
Fat, CHO, protein, vitamins and minerals
34
What substrates are malabsorbed in Decreased transport?
Fat, protein
35
What substrates are malabsorbed in Decreased gastric acid, IF?
B12
36
What substrates are malabsorbed in Rapid gastric emptying, decreased gastric mixing?
Fat, protein
37
How does prior gastric surgery affect absorption?
Involves the pylorus and/or including vagatomy - accelerates gastric emptying and decreased time for absorption in the small bowel.
38
How does gastroparesis affect absorption?
decreased gastric mixing and impaired protein and fat assimilation.
39
What are some signs of fat malabsorption?
Pale, voluminous, greasy diarrhea
40
What are signs of protein malabsorption?
Edema, muscle atrophy, amenorrhea
41
What are signs of CHO malabsorption?
Abdominal bloating, flatus, diarrhea
42
What are signs of B12 malabsorption?
Macrocytic anemia, SSCD spinal cord
43
What are signs of folate malabsorption?
Macrocytic anemia
44
What are signs of B vitamin malabsorption?
Cheilosis, glossitis, stomatitis, acrodermatitis
45
What are signs of Iron malabsorption?
Microcytic anemia
46
What are signs of Calcium and Vitamin D malabsorption?
Osteomalacia, bone pain, fractures, tetany
47
What are signs of Vitamin A malabsorption?
Follicular hyperkeratosis, night blindness
48
What are signs of Vitamin K malabsorption?
Bleeding diathesis, hematoma
49
What are some signs of pancreatic exocrine insufficiency?
Steatorrhea, diarrhea, gas, bloating, stomach pain, weight loss; compounded conditions that increase fat malabsorption - crohns, SIBO, short bowel syndrome, GB dysfunction
50
What are some diseases associated with Enzyme Insufficiencies?
Chronic pancreatitis, CF, Diabetes esp insulin dependent, celiac, Gi surgery/bypass, gastric ulcers, obstructions of pancreatic duct, Crohns, Autoimmune dz, Zollinger Ellison Syndrome, anemia, bone loss, neurological problems.
51
What contributes to Enzyme Deficiency?
Damaged microvilli, toxicity, stress, nutritional insufficiency, imbalanced pH, inhibitors in food, free radical oxidation, alcohol abuse
52
How does nutritional deficiency worsen enzyme deficiency?
Digestive enzymes not working well leads to nutritional insufficiency which then worsens digestive enzymes effectiveness as need nutrients for them to work well
53
How does damaged microvilli contribute to enzyme deficiency?
Affects disaccharides and decreased digestion of gluten which leads to inflammation; results in deficiency in brush border enyzme which leads to decreased CCK and digestive enzymes.
54
What other common enzyme insufficiencies aside from pancreatic is there?
Lactose intolerance, fructose intolerance and sucrose intolerance.
55
What are some facts about fructose malabsorption?
Hereditary fructose intolerance affects 1 in 20,000-30,000 people; Up to 1/3 of us not tolerant; Americans consumed 38.9 lbs of it in 2017 and 60.2 lbs sucrose.
More common in women
83% of people with fructose malabsorption have IBS dx as it can look like it with constipation, diarrhea, abdominal spasms, nausea and flatulence
56
What are some facts about Pancreatic Elastase?
It evaluates exocrine pancreatic function and reflects overall enzyme production of amylase, lipase and protease.
It is a proteolytic enzyme secreted by human pancreas
Not affected by supplemental enzymes(but check lab)
It is 90-100% sensitive and 93-98% specific
57
What are some basics for supporting enzyme function?
Rest and digest
Mastication
Food choices
Digestive Enzyme Supplementation
58
What are some spices that increase amylase production?
Ginger, curcumin, mint, fennel
59
What are some spices that increase lipase production?
Cucurmin increases it by 80%, mint and fennel
60
What are some spices that increase disaccharidase enzymes(sucrase, lactase, maltase)?
Coriander, onion by >300%; ginger, ajowan, fennel, cumin, asafedita, curcumin, capsacin and piperine increase at least 1 disaccharidase.
61
What increase bile secretion?
Mint and fennel
62
What are some selection criteria for digestive enzyme supplements?
Resistance of the enzyme to the GI tract conditions, mostly pH
Activity of enzyme in digestive tract where its action is expected in order to impart the desired benefits
Turnover rate of the enzyme or its activity
Effectiveness of enzyme on the target substrate
Level of purity and absence of toxic compounds
Good manufacturing practices
63
What is DPP4?
Protease enzyme that helps with gluten and dairy
64
What does alpha galactosidase do?
Digestive enzyme supplement that helps with digestion of beans
65
What does Pancreatic enzyme replacement therapies(PERT) go by in terms of units?
They go by units of lipase but they all have amylase and protease.
66
Which PERT requires acid suppression?
Brand Viokase
67
How are PERTs dosed?
Based on body weight
68
What are PERTS based on ?
Porcine based
69
What is Pancreatin?
It has protease, lipase, amylase supplement. Animal derived. Dose ranges 500-2500 units/kg/meal.
70
What digestive enzyme is non animal based?
Aspergillus Derived Digestive Enzymes.
71
What are some food derived digestive enzymes?
Bromelain(pineapple) 250-500 mg with food and digests protein. Taken between meals, it decreases inflammation
Papain(Papaya) - typically chewable, 100-250 mg
72
What is a normal pancreatic elastase level?
>350 microgram/g
73
What does a level of 200-350 microgram/g pancreatic elastase indicate?
Declining pancreatic function, consider supplementation
74
What does a level of 100-200 microgram/g of pancreatic elastase indicate?
Moderate pancreatic insufficiency.
| Supplement with broad array of pancreatic enzymes
75
What does a level of less than 100 microgram/g of pancreatic elastase indicate?
Severe pancreatic insufficiency
| Supplement with broad array of pancreatic enzymes
76
In which patients would you test pancreatic elastase?
Unexplained diarrhea, weight loss, other signs of malabsorption, abdominal pain
77
What can exocrine pancreatic insufficiency occur secondary to?
Chronic pancreatitis, diabetes, celiac, inflammatory bowel dz, CF, alcohol consumption, gallstone dz
78
Is pancreatic elastase more reliable with formed or unformed stool?
Formed stool. If unformed it is not as reliable and results in low levels.
79
What increases risks for hypochlorhydria?
```
Surgery
AI gastritis
Aging
Stress
Fasting
H PYlori
PPIs, H2 Blockers, Antacid abuse
Severe iron deficiency
Viral or bacterial infection
Debilitating chronic condition(takes 600-800 cls per day to concentrate H+ ions)
```
80
What are consequences of hypochlorhydria?
```
SIBO
Parasite
H Pylori
Chronic candida
Iron deficiency
Other mineral deficiency(Ca, Mg, Zn, Fe, Cr, Mo, Mn, Cu) - osteroporosis or anemia
B12 deficiency(indirectly)
```
81
What can you take to support gastric acidity?
```
Best to take with protein containing meal:
Betaine
Bitters
Vinegars
Umeboshi plums
Digestive enzymes with acid PH range
Stress mgmt
Accupuncture
```
82
What are some signs of Bile Acid Insufficiency?
```
Incomplete digestion/absorption of fats
Steatorrhea
Diarrhea
Bitter taste in mouth after meals
N/V
Queasy after fatty meal
Constant feeling of fullness
Deferred pain to head, abdomen, under shoulder blades, etc
```
83
What supports fat digestion and absorption?
Lipase containing digestive enzymes
Bile salts
Cholagogues/Choleretics
84
What can maintain motility?
```
F/V, ancient grains, beans, seeds, water
Probiotic foods, fermented foods
Psyllium, pectin
Flax, flaxseed oil
Cod liver oil
Natural colonic laxatives
Addressing root causes
```
85
What are some natural colonic laxatives?
Aloe vera, senna, buckthorn, rhubarb. (Don't use anthraquinones longterm as they are stimulant laxatives. )
86
What are non pharmacologic prokinetics?
```
Iberogast
Ginger root
Tryptophan
Mag citrate, dietary magnesium
Ascorbic acid, sodium ascorbate
Vitamin D
Swedish bitters
D limonene
Triphala
Chinese herbs
Accupuncture/pressure
Deep breathing, stress reduction
Exercise
```
87
What do you want to remove as part of the 5R?
Foods that pt are sensitive, intolerant or allergic to
Pathogenic microflora(bacteria, fungi, parasite)
Environmental stressors such as pollutants
Stress
88
What do you want to replace as part of the 5R?
Factors that are inadequate or lacking
89
What do you want to reinoculate as part of the 5R?
Desirable gut microflora(pre/pro/synbiotics) to obtain a more desirable balance to the intestinal milieu
90
What do you want to repair as part of the 5R?
Providing nutritional support for healing and regeneration of the gut mucosa
91
What do you want to rebalance as part of the 5R?
Providing support for restorative processes in patient's life
92
What are some clinical approaches to "remove"?
Oligoantigenic elimination diet
Botanical antimicrobrials or bacteriostatic/cidal phytonutrients
Antibiotics/Antifungals
93
What are some clinical approaches to "replace"?
```
Digestive factors
HCL
Pancreatic Enzymes
Bile salts
Fiber to support transit and general GI fxn
```
94
What are some clinical approaches to "reinoculate"?
Probiotics
Prebiotics
Synbiotics
95
What are some clinical approaches to "repair"?
Nutrients for GI repair and healing
Mucosal lining support
Mucosal secretion protectants
Support for GALT fxn
Antioxidants known to function in GI(ex catechins)
Nutritional and phytonutritional antiinflammatories(cucurmin, EPA, DHA)
96
What are some clinical approaches to "rebalance"?
```
Scheduling and relaxation
Mindful eating and better choices
HRV, biofeedback
Yoga, meditation, prayer, breathing and other centering practices
Psychotherapy
```
97
What should you hold if have yeast in GI tract?
Prebiotics as can act as fertilizers for eat; Probiotics are okay.
98
What are some nutrients important for GI repair?
Glutamine, arginine, vitamin A, D, C, B5, E, zinc and carotenoids
99
What helps mucosal lining support?
Phosphytidylcholine
100
What are mucosal secretion protectants?
PC, plantain, polysaccharides
101
What supports GALT fxn?
Lactoferrin, lactoperoxidase, whey, Immunoglobulins
102
What are some triggers and mediators to cause gut dysregulation?
Diminished HCL, Bile acids, gastric/pancreatic/brush border enzymes
CCK hypersensitivity
Food allergies/intolerances/sensitivities
Psych/emot stress
Travel
Hypoxia(ischemia, low O2 sat)
103
What is the autoimmune triad?
Genetic predisoposition, trigger, leaky gut
104
What are different types of Elimination Diets?
Comprehensive
6 food elimination(SFED) wheat, eggs, dairy, legumes/peanuts, soy, seafood/fish
4 food elimination - wheat, eggs, dairy, legumes/peanuts
Simplified(caveman) - eating lamb, rice, pear, sweet potato
Single food group elimination
Sugar
FODMAP
PALEO
105
What botanicals tx yeast?
```
Oregano
Thyme
Garlic
Goldenseal
In general use in combination
```
106
What are botanical tx for parasites?
```
Oregano
Thyme
Goldenseal
Artemis
Tx 4-6 weeks
```
107
What increases sIgA?
Presence of harmful antigens - bacteria, parasites, fungi, viruses, abnl cell Ag, allergenic proteins
108
What decreases sIgA?
Mental/physical stress, inadequate nutrition
109
What increases Calprotectin and Lactoferrin?
```
IBD
Postinfectious IBS
Cancer GI tract
GI infections
Nsaid enteropathy
Food allergy
Chronic pancreatitis
```
110
What is better at predicting relapse in IBD, calprotectin or lactoferrin?
Both are similiar in prediction of relapse(better in UC then CD); similiar at distinguishing IBD from IBS; both sensitive
111
What conditions is Pancreatic elastase commonly decreased in?
Autism
Osteoporosis
Mood d/o
Diabetes
112
What are the 3 putrefactive SCFA?
Valerate, isovalerate, isobutyrate(products of anaerobic fermentation of proteins)
113
What are good SCFA?
Butyrate, acetate and proprionate(fermentation of fibers)
114
What conditions cause putrefactive SCFA?
Hypochlorhydria, PPI
Low protein digesting enzymes by pancreas
Poor abs of protein d/t inflammation of gut lining
Dysbiosis:SIBO
115
What does level <50 calprotectin mean?
No chance of IBD
116
What does level of 50-120 calprotectin mean?
Some GI inflammation, IBD, inefction, polyps, neoplasia, nsaids
117
What does level of >120 and >200 calprotectin mean?
Significant inflammation - needs referral
| Active disease, relapse imminent in treated patients
118
What does the relationship look like for calprotectin and lactoferrin in response to inflammation?
Calprotectin - linear
| Lactoferrin - hockey stick
119
What is Eosinophil Protein X tell you?
Feces test to evaluate disease activity and predicting relapse in IBD, but not as good as fecal calprotectin in predicting treatment outcome.
120
Which test is better for diagnosing Celiac?
IgG DGP(better than IgA DGP) - has better sensitivity and specificity
121
Positive Anti-tTg IgA, normal total IgA means?
presume celiac
122
Negative anti tTg IgA, low total IgA, negative anti dgp IgA, positive anti tTG IgG, positive anti dGP IgG?
Celiac with IgA deficiency
123
Positive anti dGP IgA and +/- anti dGP IgG with other negative ab?
Possible celiac disease(seen in under 3)
