Intestinal Bowel Disease Flashcards
What does the term IBD refer to?
Collective term for chronic inflammatory diseases of the intestine
including Crohn’s disease & Ulcerative Colitis
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)
risk factors for IBD
Positive family history
Jewish ancestry
Caucasian
Smoking increases risk for Crohn’s Disease
Antibiotic use
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
What is Crohn’s Disease ?
Chronic inflammation of the mucosa resulting in ulcerations
Inflammation progresses to involve all layers of the intestinal wall
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”
Clinical Manifestations of Crohn’s Disease
Abdominal pain
Diarrhea
Anorexia
Weight loss
Complications of Crohn’s Disease
Strictures=> obstruction
Malabsorption
Abscesses
Perianal disease
Fistulas
Possible short bowel syndrome
Increased risk of intestinal cancer
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
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
Clinical Manifestations of UC
Crampy abdominal pain
Frequent bloody diarrhea
Dehydration
Anorexia & weight loss
Anemia
Complications of UC
Severe bleeding
Perirectal abscess
Toxic megacolon
Increased risk for colon cancer
Malnutrition in IBD is more common with _____
Malnutrition is caused by ______, _______, and _______
CD
decreased nutrient intake
malabsorption
increased enteric losses
Malnutrition further compromises digestive & absorptive function and may increase permeability of the GIT to potential ________
inflammatory agents
factors that lead to Decreased nutrient intake leading to malnutrition
Avoidance behavior
Disease-related anorexia
Iatrogenic—restrictive diets
Malabsorption of macro- & micronutrients due to:
Decreased__________
_________
____________
Secondary ________
functional absorptive surface area
Medications
Bacterial overgrowth
lactose intolerance
What can cause fat malabsorption in IBD?
Crohn’s disease
- Ileal disease
- Jejunal disease
explanation of fat malabsorption from ileal disease
decreased bile salt pool due to malabsorption or deconjugation by bacteria
explanation of fat malabsorption from jejunal disease
decreased absorptive surface area due to inflammation/disease
During periods of inflammation, there is enteric leakage of:
_____, _____, and _____
Fluid & electrolytes
Blood
Protein (protein-losing enteropathy)
micronutrient deficiencies are caused by ____, ____, and ____
decreased intake
malabsorption
food-medication interactions
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
Water-Soluble Vitamin Deficiencies from IBD
Vitamin B12=> malabsorption due to ileal disease
Folate=> decreased intake, sulfasalazine
Minerals & Trace Element Deficiencies and causes
Zn, K+, Mg, Cu=> diarrhea, steatorrhea
Iron=> GI bleeding
Calcium=> avoidance of dairy, corticosteroids, fat malabsorption
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
This is the start of the guest speaker notes
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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
UC
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
