Malnutrition

Question 1

Questions to ask in malnutrition

Answer 1

Patients at risk are underweight malabsorption syndrome, critically ill, prolonged hospital stay, chronic disease with high catabolic state, poor intake with dysphagia, neuromuscular disease, dementia, depression, visually impaired, pregnancy, lactation and growth, alcohol, food intolerances, social isolation and poor mobility.

Question 2

Initial assessment:

Answer 2

Physical, weight change ( loss of >10% in 6 months) BMI and skin fold thickness.
Assess food intake via food diary/chart
Measurement of nutritional marker: Albumin, cholesterol
Screen for malnutrition: iron, B vitamins, folate, Zn, Mg, fat soluble vitamin ADEK, calcium and iodine.
Screen for possible cause: Pancreatic insufficiency ( fecal elastase, fecal calproptectin), p- ANCA ( specific to UC)

Question 3

Management of malnutrition:

Answer 3

Estimate energy and protein requirement
Assess need for nutritional supplement
Decide on route: oral, NGT, PEG or total parenteral nutrition
institute a plan

Question 4

Nutritional requirement

Answer 4

Fluid
Energy- glucose
Protein and amino acids
Fat
Carbohydrate
Mineral and vitamins

Question 5

Monitor the patient:
Assess for complications:

Answer 5

Clinical: strength, fluid balance, vital signs ( POTS), weight and dietary equipment. ( TPN, catheter site- infection, level)
LAb testing: UEC, cal, Mg, Phosphate, pH, LFT- albumin, lipid profile, Hb, WCC, micronutrients

Complications:
realted to lines, NGT, PEG and location/placement
Metabolic, hyper and hypoglycaemia, electrolytes and renal function
Aspiration and diarhoea

Question 6

Malabsorption syndrome

Answer 6

Aetiology:
Bowel surgery- bariartric surgery ( roux-en Y surgery, partial gastrectomy), ileal resection (e.g Crohn’s)
Previous liver and pancreatic disease, diabetes ( type 1)
Autoimmune disease ( pernicious anaemia, Coeliac disease, IBD)
ETOH
Trial of gluten diet
Neomycin, cholestyramine
Social: chronic disease, distressing symptoms- diarrhoea, complaince- insight, depression and prognosis

Question 7

Management of underlying disease and replacement of essential nutrient with the assistance of dietitian and addressing any relevant psychosocial issue.

Answer 7

Address Coeliac disease
Pancreatic enzyme deficiency
Bile salt deficiency
Mucosal defects- bariatric surgery, colorectal surgery, ileal surgery, IBD ( Crohn’s and UC)

Question 8

Coeliac disease

Answer 8

Diagnosis is aid by
1. Evidence of malabsorption
2. Abnormal jejunal biopsy with villous atrophy
3. Improvement on gluten free diet
4. Relapse with gluten

Question 9

Complication of Coeliac disease

Answer 9

T -cell lymphoma
Ulceration of small bowel
Carcinoma of GI tract

Question 10

Investigation of Coeliac disease

Answer 10

tTg ( anti-tissue transgutaminase antibody), total Ig A
Intestinal biopsy: villous atrophy
BMD- to dx Osteopenia and osteoporosis

Question 11

Treatment of Coeliac disease

Answer 11

Gluten free diet ( wheat, barley) Oats is controversial
Consider rebiopsy in 3 months to confirm healing
Pneumococcal vaccine ( hyposplenism)
Treat osteoporosis

Question 12

Pancreatic enzyme deficiency: Chronic pancreatitis, Cystic fibrosis

Answer 12

Treat:
Reverse causes
Pancreatic enzyme replacement-Creon
Medium chain triglyceride ( for steatorrhoea)

Question 13

Bile salt deficiency:
Extrahepatic billiary obstruction,
chronic liver disease,
Bacterial overgrowth,
Terminal ileal disease ( Crohn’s/resection)

Answer 13

Treatment:
Reverse causes
Antibiotics for bacterial overgrowth
Cholestyramine
Medium chain triglycerides
Fat soluble vitmain supplements

Question 14

Mucosal defects:
Coeliac disease
Tropical sprue
Lymphoma
Whipples
Small bowel resection
Hypogammaglobulinaemia
HIV( Kaposi’s sarcoma/idiopathic)
Amyloidosis

Answer 14

Treatment:
Reverse causes
GLuten free diet for Coeliac
Antibiotics
Fat soluble vitamins