Intestinal Bowel Disease Flashcards by Sydney Perry

What does the term IBD refer to?

Collective term for chronic inflammatory diseases of the intestine
including Crohn’s disease & Ulcerative Colitis

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IBD is Characterized by ___________
Impact of IBD depends on the _______ and ______
Often develops at age _____
Often confused with __________

periods of remissions & exacerbations
site & extent of inflammation
15-30
Irritable Bowel Syndrome (IBS)

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risk factors for IBD

Positive family history
Jewish ancestry
Caucasian
Smoking increases risk for Crohn’s Disease
Antibiotic use

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Possible Dietary Risk Factors for IBD

_________ deficiency
High intake of ________
Low intake of _______________
Increased consumption of _______ and __________

High intake of ______ and low intake of __________
High intake of ______________

Vitamin D
sucrose
fruits & veg, dietary fiber
red meat and alcohol

omega-6 fatty acids
omega-3 fatty acids
ultra-processed food

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What is Crohn’s Disease ?

Chronic inflammation of the mucosa resulting in ulcerations

Inflammation progresses to involve all layers of the intestinal wall

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where does Crohn’s disease usually occur?

small & large intestine but can occur anywhere in the GIT
- Terminal ileum is the most common site

Disease is segmental with spared areas=> “skip lesions”

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Clinical Manifestations of Crohn’s Disease

Abdominal pain
Diarrhea
Anorexia
Weight loss

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Complications of Crohn’s Disease

Strictures=> obstruction
Malabsorption
Abscesses
Perianal disease
Fistulas
Possible short bowel syndrome
Increased risk of intestinal cancer

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What is Ulcerative Colitis (UC) ?
Where?

Chronic inflammatory disease that causes ulceration of the colonic mucosa

Begins in the rectosigmoid area & may extend proximally to affect the entire colon (rectum almost always involved)
- usually only involves the mucosa

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UC contains Deep ulcers that _____

Mucosal inflammation/destruction=> loss of _______ surface area, large volumes of ________, bleeding, cramping pain, and ______(need to empty bowel)

bleed

absorptive
watery diarrhea
tenesmus

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Clinical Manifestations of UC

Crampy abdominal pain
Frequent bloody diarrhea
Dehydration
Anorexia & weight loss
Anemia

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Complications of UC

Severe bleeding
Perirectal abscess
Toxic megacolon
Increased risk for colon cancer

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Malnutrition in IBD is more common with _____

Malnutrition is caused by ______, _______, and _______

decreased nutrient intake
malabsorption
increased enteric losses

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Malnutrition further compromises digestive & absorptive function and may increase permeability of the GIT to potential ________

inflammatory agents

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factors that lead to Decreased nutrient intake leading to malnutrition

Avoidance behavior
Disease-related anorexia
Iatrogenic—restrictive diets

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Malabsorption of macro- & micronutrients due to:

Decreased__________
_________
____________

Secondary ________

functional absorptive surface area
Medications
Bacterial overgrowth

lactose intolerance

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What can cause fat malabsorption in IBD?

Crohn’s disease
- Ileal disease
- Jejunal disease

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explanation of fat malabsorption from ileal disease

decreased bile salt pool due to malabsorption or deconjugation by bacteria

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explanation of fat malabsorption from jejunal disease

decreased absorptive surface area due to inflammation/disease

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During periods of inflammation, there is enteric leakage of:
_____, _____, and _____

Fluid & electrolytes
Blood
Protein (protein-losing enteropathy)

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micronutrient deficiencies are caused by ____, ____, and ____

decreased intake
malabsorption
food-medication interactions

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fat soluble vitamin deficiency can be due to ___________ and also _________

Which vit def is most common ?

ill or jejunal resection or disease
meds - cholestyramine

vit D

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Water-Soluble Vitamin Deficiencies from IBD

Vitamin B12=> malabsorption due to ileal disease

Folate=> decreased intake, sulfasalazine

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Minerals & Trace Element Deficiencies and causes

Zn, K+, Mg, Cu=> diarrhea, steatorrhea

Iron=> GI bleeding

Calcium=> avoidance of dairy, corticosteroids, fat malabsorption

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Additional Nutritional Consequences of IBD

Nutritional anemia Osteoporosis & osteomalacia Growth impairment in children

In general, energy requirements in IBD are similar to those of the healthy population No evidence of ____________ in inactive IBD There may be an ________ in metabolic activity at times of acute severe disease activity; however, the ______ in REE is likely offset by _______ of physical activity Individualized—consider current nutrition status, & disease condition _____ kcal/kg

hypermetabolism increase increase reduction 30-35

FOR IBD _____ kcal/kg ____ g/kg protein for remission ______ g/kg protein for active IBD

30-35 1 1.2-1.5

Factors that increase protein needs for IBD:

Active inflammation Malnutrition Post-operative healing Infection Corticosteroids Enteric losses: blood, protein-losing enteropathy Malabsorption Fistulas

Provide fluid as per age recommendations and additional fluid to replace losses Factors which increase fluid needs:

Enteric losses: diarrhea, high ostomy output, fistulas Fever Sulfasalazine

Dietary Interventions for Complications of IBD restriction of _______ and ______ Low fiber used only for _______ to ______, ___________ If confirmed steatorrhea=> _____________

Lactose and fructose Strictures=> to avoid obstruction s/p intestinal resection 40-gram Low Fat Diet

Supplementation for IBD ? If deficiencies or high risk, additional supplementation ?

MVI w/ minerals Vitamin B12=> 1000 mcg/month IM Calcium (if on corticosteroids or poor intake)=> 1000-1200 g/d Vitamin D: 2000-4000 IU daily for maintenance; 50,000 IU weekly for 12 weeks for treatment of deficiency Folate (if on sulfasalazine) => 1 mg/d If fat malabsorption=> fat-soluble vitamins in water-soluble form Zinc=> 220 mg zinc sulfate 1-2 times/day

For IBD If person has fat malabsorption=> recommend ____________ (e.g., Peptamen with Prebio) More research is needed on use of ___________ (e.g., probiotics, prebiotics, omega-3 fatty acids)

partially-hydrolyzed, peptide-based with MCT oil nutraceutical supplements

Indications if enteral nutrition need

poor appetite malnutrition induction of remission of Crohn’s disease in children & adolescents

EN is preferred over PN due to ______, ______, _______, and _____

lesser complications ability to maintain GIT integrity & function provide trophic nutrients lower cost

Formula Choice for enteral nutrition for IBD ? if fat malabsorption ?

Polymeric formulas use semi-elemental formulas - contain MCT oil and protein is hydrolyzed to peptides

Parenteral Nutrition Indications

complications (SBO, fistulas, SBS) prolonged small bowel ileus after surgical resection

Medications used for IBD

Anti-inflammatory agents corticosteroids immunosuppressive agents anti-TNF medications

Anti-inflammatory agents are _______ examples ?

aminosalicylates sulfasalazine mesalamine

corticosteroids are _________ and ______ drugs

anti-inflammatory immunosuppressive

immunosuppressive agents example?

azathioprine (Imuran)

anti-TNF medications example ?

infliximab (Remicade)

sulfasalazine FDI and interventions

Inhibits folate absorption Can cause anorexia; N/V/D Drink 8-10 glasses of fluid/d to prevent kidney stones

mesalamine FDI

nausea dyspepsia diarrhea anorexia

Corticosteroids FDI

Decrease calcium absorption=> osteoporosis Increase protein catabolism Increase blood glucose levels

azathioprine (Imuran) FDI

anorexia N/V/D steatorrhea esophagitis

infliximab (Remicade) use ? FDI ?

Use=> More severe cases of Crohn’s disease Abdominal pain N/V serious infections

Surgery for IBD involves surgical ____________ and patient may require ____________ or ____________ _________________ is curative for UC

resection of diseased areas ileostomy or colostomy Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis (IPAA)

Post-Operative Diet Therapy Diet progression: ______ diet => advance to _______ MNT for _______ Need to provide diet education

low fiber regular diet ileostomy

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etiology of IBD ? potential factors being explored?

unclear etiology effects on microbiome stress use of antibiotics/NSAIDS use of food additives, emulsifiers, processing

what is the role of diet in the development of IBD?

gut microbiome processed food/food additives inflammatory properties

diet for prevention of IBD

diet rich in fruit and veggies rich in n-3 fatty acids low in n-6 fatty acids breastfeeding for infants

microbiome in the GI tract includes _____, ______, and ______

bacteria viruses fungi

_______ microbiota is potential for involvement in the pathogenesis of IBD

dysbiotic

nutritional interventions that have shown potential anti-inflammatory properties

specific carbohydrate diet mediterranean diet anti-inflammatory diet crohn's disease exclusion diet

medical history to collect

Remission vs. Active disease Crohn’s Disease vs. Ulcerative Colitis Location in GI tract, severity, strictures Surgical history Food-Drug Interactions - Corticosteroids, methotrexate, sulfasalazine

social history assessment involves

Employed/ability to buy food Home/access to kitchen Social/Family support/eating with others Cultural or religious eating preferences

what labs to review ? If increased fluid loss (diarrhea, ostomy output) ______. Other vitamins and minerals to consider:

Vitamin D, B12 CBC, CMP Iron zinc, urine sodium Thiamine, folate, B6, B12, Vitamin C (scurvy) Selenium, magnesium

what to look for in their diet recall

time of meals supplement use

malnutrition risks in IBD include decreased oral intake due to _______. metabolic needs are _____

food fear, intolerances, elimination diets increased

sarcopenia occurs 52% from ________ and 37% from ________. 19% of patients with sarcopenia have a BMI above ______ and 41% have a BMI of ______

Crohn's disease ulcerative colitis 25 normal

two questions to ask for malnutrition screening

how much weight have you lost recently has your eating decreases

identification of food intolerances or restrictions is important. You should include ______, ______, and _______ Also include assessment of ______

time GI symptoms Stress symptoms food fear (AFRID)

Foods and flare ups

foods do not cause flare ups, but symptoms when flare ups are happening

if no stricture or obstructive disease, encourage _______

fiber (may need to adapt texture)

should have ____ calorie and ____ protein with ____ meals, _____ per day

high increases small 4-6

for fiber increase ______ and decrease ______, and make it ______

soluble insoluble soft

ACTIVE IBD ____ g/kg protein if anemia ______

1.2-1.5 IV iron

INACTIVE IBD ______ g/kg protein if anemia _____

1 oral iron

Vitamin D Deficiency: _____ ng/ml Reccommendation ? Vitamin D Insufficiency: between ___ ng/ml. Reccommendation? Maintenance: >____ ng/ml Recommendation? Toxicity occurs with levels of ____ ng/ml or more

<20 50,000 IU Vitamin D2 weekly x 12 weeks recheck levels in 3 months 20-30 4000 IU Vitamin D3 daily recheck levels in 3 months 30 2000-4000 IU D3 daily (depends on weight, race, and pregnancy) 100

_____ levels can be very high when replaced

vitamin B12

VITAMIN B12 Goal: _____ pg/ml

> 400

Vitamin B12 formulas available

Intramuscular/deep subcutaneous injection Oral Sublingual *Oral and Sublingual forms are just as effective as replacement with injection

Oral Replacement: ________ mcg _____ Repeat level in _______ Injection Replacement: ______ mcg/ml ________ Repeat level in ______ Vitamin B12 is water soluble – tolerated at high doses

1000-2000 daily 3 months 1000 weekly x 4 weeks, then monthly 3 months

does probiotic use in IBD help? example

some evidence for moderate UC ineffective in CD VSL#3 (Visbiome)

For eating behaviors make sure patient is ______

chewing thoroughly spacing and sizing meals correctly sitting up straight eating slowly limiting distractions

for introducing new foods ?

smooth increase texture combining textures

therapeutic diets for Crohn's disease?

Mediterranean Diet Specific Carbohydrate Diet (SCD) Anti-Inflammatory Diet for IBD (IBD-AID) Crohn’s Disease Exclusion Diet Exclusive Enteral Nutrition* (pediatrics)

what has larger focus on avoiding red and processed meat

Main idea od Mediterranean diet

↑ whole foods (fruit, veg, beans/legumes), fish, lean protein (chicken/dairy), healthy fats ↓ ultra-processed foods, desserts, and red meats

Specific Carbohydrate Diet (SCD) Low in _______________ Aims for diversity of __________ Risk of insufficient intake: ___________

starchy vegetables, grains, processed/added sugars, lactose, artificial ingredients produce, nuts, animal proteins, yogurt, aged cheeses calcium, vitamin D, vit A, potassium, thiamine, folate, pyridoxine, vitamin E

IBD Anti-Inflammatory Diet (IBD-AID) Modified from _____ More _____ and _____ foods and _____ Low in _______ carbohydrates (refined sugars, grains with ____) Restricts _____, _____, ______, and ______ ____ phases – slow progression of textures, depends on disease status

SCD prebiotic and probiotic omega 3 fats complex gluten emulsifiers, maltodextrins, milk (unless fermented), sweeteners 3

In IBD Anti-Inflammatory Diet (IBD-AID) focuses on Soluble fibers such as ______ can have _____________ for omega 3 fats Probiotic foods such as ______ Prebiotic foods such as _______

ground flax, lentils, or oats Beans, nuts, avocado, fish kefir, miso, yogurt, or sauerkraut leeks or artichokes

Crohn’s Disease Exclusion Diet (CDED) Decrease foods that may harm the _______ or ________ ______ + _______ : ___ phases, slow ________ as they transition through the phases Avoids: ___________ Encourages: ________

microbiome or intestinal barrier PEN + whole food diet 3 decrease of PEN Emulsifiers, coffee, alcohol, canned foods, dairy, soy, gluten, processed foods Fruits & vegetables, Chicken, Fish