GI & Hepatology: Malnutrition

Question 1

What is the Malnutrition Universal Score Tool and how is this calculated?

Answer 1

MUST = 5-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan

• Step 1 = work out BMI
• Step 2 = unplanned weight loss
• Step 3 = acutely ill, no nutritional intake
• Step 4 = overall risk of malnutrition - 0 = low risk, 1 = medium, >2 = high

Question 2

What are the possible causes of malnutrition in a 35-year-old man?

Answer 2

Liver disease - alcohol abuse

Eating disorder

Depression

Homelessness

Question 3

How is malnutrition best managed?

Answer 3

Slow refeeding 10kcal/kg/day

Increasing to meet full needs by 4-7days

Restore circulatory vol

Question 4

What is refeeding syndrome? What factors predispose someone to refeeding syndrome + how can it be prevented?

Answer 4

RS = caused by rapid refeeding after a period of under-nutrition, characterised by severe hypophosphatemia/hypomagnesemia/hypokalaemia, electrolyte shifts and has metabolic and clinical complications

Predisposed = BMI under 16, malnourished, anorexia nervosa, chronic alcoholism

Prevention = electrolyte infusions, slower refeeding regimen

Treatment = 10kcal/kg/day, increasing to meet full needs by 4-7days, restore circulatory vol, replace K, Mg, phosphate

Question 5

How can pts be fed?

Answer 5

Oral nutrition support – for example, fortified food, additional snacks and/or sip feeds

Enteral tube feeding – the delivery of a nutritionally complete feed directly into the gut via a tube

• NG
• NJT
• PEG

Parenteral nutrition – the delivery of nutrition intravenously

• TPN
• PPN

Question 6

What are a pts nutritional requirements?

Answer 6

Depends on = age, sex, physical activity, current weight, BMI, current body composition, medical health

25–35 kcal/kg/day total energy (including that derived from protein 0.8–1.5 g protein (0.13–0.24 g nitrogen)/kg/day

Adequate electrolytes, minerals, micronutrients (allowing for any pre-existing deficits, excessive losses or increased demands) and fibre if appropriate

Question 7

When is enteral tube feeding given?

Answer 7

Malnourished

Risk of malnourishment

Gastrophoresis, stomach surgery

Question 8

What is important when using an NG tube?

Answer 8

Need to check positioning

• Aspirate PH <5.5 = gastric PH <6-8 = small bowel
• CXR = looking for it to pass through the corina

Question 9

When is gastrostomy used and what are the types?

Answer 9

Long term >8 weeks

PEG = percutaneous endoscopic gastrostomy

RIG = radiologically inserted gastrostomy

SE - infection

Question 10

What is parenteral feeding and when is it used?

Answer 10

IV feeding

Indication = unsafe oral, non-functional, inaccessible or perforated (leaking) gastrointestinal tract

Step-wise program - build up to requirement, step down to oral

Total Parenteral Nutrition (TPN) = central, lasts 10 days

Peripheral Parenteral Nutrition (PPN) = peripheral

Question 11

Outline the features of coeliac disease

Answer 11

Gluten exposure = auto-Abs, SI inflam, malabsorption, anaemia

S+S = asymptomatic, loose stools, bloating, wind, abdo cramps, weight loss, dermatitis herpetiformis

Ix =

• tissue transglutaminase (tTG) raised (not diagnostic in adults)
• OGD with duodenal biopsies - villous atrophy + intraep lymphocytes (diagnostic)

Mx = dietitian, lifelong gluten free diet - barley, rye, oats, wheat

Complications

• SI lymphoma
• SI cancer
• osteoporosis
• neurological - gluten ataxia, neuropathy

Question 12

What diet should patients with IBS be put on?

Answer 12

FODMAP

Elimination of FODMAP foods (carbs) for 8 weeks