Malnutrition and malabsorption

Question 1

What is the definition of malnutrition?

Answer 1

A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form (body shape, size and composition), function and clinical outcome

Question 2

What disease states can lead to malnutrition?

Answer 2

Decreased intake
Impaired digestion and/or absorption
Increased nutritional requirements
Increased nutrient losses

Question 3

How common is malnutrition in hospitals?

Answer 3

30-40% of admissions identified as malnourished

Question 4

What are some of the psychosocial causes of malnutrition?

Answer 4

Lack of access to food
Self-neglect
Lack of assistance
Loneliness
Lack of kitchen/cooking facilities
Deprivation

Question 5

What are some of the adverse effects of malnutrition?

Answer 5

Water and electrolyte disturbances
Impaired wound healing
Impaired immune responses
Impaired thermoregulation
Menstrual abnormalities
Reduced muscle strength and fatigue
Pressure sores

Question 6

What does MUST stand for?

Answer 6

Malnutrition Universal Screening Tool

Question 7

Which patients require nutritional support?

Answer 7

BMI 10% within the last 3–6 months
BMI 5% within the last 3–6 months
Have eaten or are likely to eat little or nothing for more than 5 days or longer
Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism

Question 8

Which patients are oral supplements indicated for?

Answer 8

Disease related malnutrition
Intractable malabsorption
Per-operative preparation of malnourished patients
Dysphagia
Proven IBD
Post total gastrectomy
Bowel fistulae

Question 9

Which patients do oral nutritional supplements benefit in particular?

Answer 9

Acutely ill elderly patients

Question 10

In which patients is enteral tube feeding indicated?

Answer 10

Unconscious patients
Neuromuscular swallowing disorder
Upper GI obstruction
GI dysfunction
Increased nutritional requirements

Question 11

In which patients is enteral tube feeding contraindicated?

Answer 11

Lower gastrointestinal obstruction
Prolonged intestinal ileus
Severe diarrhoea or vomiting
High enterocutaneous fistula
Intestinal ischaemia

Question 12

What are some of the disadvantages of parenteral nutrition?

Answer 12

Expensive
Complications are life-threatening
Needs specialist skills
Not physiological
Psycho-social disturbance

Question 13

In which patients is parenteral nutrition indicated?

Answer 13

Inadequate or unsafe oral and/or enteral nutritional intake or a non-functional, inaccessible or perforated (leaking) gastrointestinal tract:
IBD with severe malabsorption
Radiation enteritis
Short bowel syndrome
Motility disorders

Question 14

What four things should be taken into consideration when prescribing alternative feeding?

Answer 14

Energy, protein, fluid, electrolyte, mineral, micronutrient and fibre needs
Activity levels and the underlying condition
GI tolerance, potential metabolic instability and risk of refeeding syndrome
Likely duration of nutrition support

Question 15

What is refeeding syndrome?

Answer 15

Potentially fatal shifts in fluids and electrolytes and disturbances in organ function and metabolic regulation that may result from rapid initiation of re-feeding after a period of under nutrition

Question 16

What are the metabolic features of re-feeding syndrome?

Answer 16

Hypokalaemia
Hypophosphataemia
Hypomagnesaemia
Altered glucose metabolism
Fluid overload

Question 17

What are some of the physiological features of re-feeding syndrome?

Answer 17

Arrhythmias
Altered level of consciousness
Seizure
Respiratory failure
Cardiovascular collapse
Death

Question 18

Which patients are at moderate risk of re-feeding syndrome?

Answer 18

Those who have had no nutrition for five days or more

Question 19

Which patients are at high risk of re-feeding syndrome?

Answer 19

Patients with BMI 15% of body mass

Little or no nutritional intake for >10 days

Question 20

Which patients are at extremely high risk of re-feeding syndrome?

Answer 20

BMI 15 days

Question 21

Which electrolytes must be monitored when introducing nutrition to a patient at high risk of re-feeding syndrome?

Answer 21

PO4, Mg2+, K+ and Ca2+

Question 22

What biochemical markers can be measured to estimate malnutrition?

Answer 22

Albumin
Transferrin
Pre-albumin
Retinol binding protein

Question 23

How is MUST carried out?

Answer 23

BMI:
>20 = Score 0
18.5 -20.0 = Score 1
10% = Score 2
Add a score of 2 if there has been or is likely to be no nutritional intake for > 5 days

Question 24

What are the MUST score parameters?

Answer 24

0 = Low risk - normal care
1 = Moderate risk - re-screen
2+ = High risk - nutritional support

Question 25

What are some of the complications of enteral feeding?

Answer 25

Malposition
Blockage
Diarrhoea
Aspiration
Metabolic disturbance

Question 26

What is intestinal failure?

Answer 26

Gut is no longer able to supply the hydration and nutritional needs of the body

Question 27

What are some of the causes of chronic intestinal failure?

Answer 27

Short gut syndrome 
Severe Crohn’s disease
Neoplasia
Vascular
Mechanical
Radiation enteritis
Dysmotility

Question 28

What length is the small bowel when “short bowel syndrome” is diagnosed?

Answer 28

<200cm

Question 29

At what length of small bowel in “short bowel syndrome” is parenteral nutrition required?

Answer 29

<50cm

Question 30

What are some of the causes of malabsorption?

Answer 30

Coeliac Disease
Crohn’s Disease
Post Infectious
Biliary Obstruction
Cirrhosis
Pancreatic Cancer
Parasites
Bacterial Overgrowth
Drugs
Short Bowel (inc. resections)