Midterm II Details Flashcards
1
Q
% of GI resected without major impacts on nutrient absorption?
A
Up to 40-50%
2
Q
Jejunoileocolonic anastomosis bowel length to avoid TPN?
A
30 cm
3
Q
Jejunocolonic anastamosis bowel length to avoid TPN?
A
60 cm
4
Q
End jejunostomy bowel length to avoid TPN?
A
130-150 cm required if no colon is intact
5
Q
SBS is defined when
A
<200 cm of bowel length
6
Q
Generally, if colon is intact how much small bowel do we require to avoid PN?
A
70-90 cm
7
Q
Duodenum nutrients (TIC/PC)
A
Thiamine, Iron, Calcium, Protein, Carbs
8
Q
Jejunum/Proximal Ileum nutrients (FF/AW/CZPM)
A
Fat, Folate, ADEK, Water soluble vitamins,Copper, Zinc, PO4, Magnesium
9
Q
Terminal ileum nutrients (BB)
A
- Bile acids
- B12
10
Q
Ileum resections requiring B12 injection?
A
When >50 cm is removed
Recall the ileum absorbs B12
11
Q
SBS General Nutrition implications when unstable
A
- TPN post-op with sugar-free, isotonic ORS, electroylyte supplement. Consider EN supplement as we want to stimulate the GI tract, but realistically will not be able to reach all needs on EN (Acute Phase)
- Progress very gradually (years to oral), often require EN supplement for life, or Cyclic EN w/ ADEK, MCT and B12 if required.
- Oral diet should be low residue, low fat, lactose free and low oxalate (if colon).
- AVOID GI STIMULANTS (coffee, tea, spicy foods) and ALCOHOL (toxicity which counteracts bowel adaptation) and SIMMPE CHOs (diarrhea, dehydration)
12
Q
Ileum resections resulting in Bile Acid malabasoprtion?
A
> 100 cm of ileum is removed
13
Q
Chronic, stable management of SBS?
A
- Ensure colon is tolerating fluids (issues if >5L of fluids, or FFA and BAs are preventing water reabsorption)
- Normal macro distribution
- SMFQM
- Normal fibre
- Lactose as per patient
- Oxalate as per fat malabsorption and presence of colon
14
Q
Discuss how steatorrhea is a circular problem
A
In fat malabsorption, there is often also malabsorption of BA downstream. To avoid irritating colon (watery diarrhea), we will use BAS to decrease BA and the subsequent irritation. However, this depletes the liver BA pool, and if any of these BA were useful in the upstream fat malabsorption, the BAS have improved the water diarrhea, but may exacerbate the fat malabsorption.
15
Q
General ileostomy nutritional post-op recommendations?
A
- CF diet with decreased soluble fibre, then SMFQM with low fiber, but progression is slower compared to colostomy due to less favourable ostomy
- Address fluid/electrolyte concerns, obstructions and weight management
- LIMIT fluids if high-output
- Encourage HIGHER sodium intake to promote water absorption (recall that the colon is gone and cannot do the work anymore)
16
Q
General colostomy nutritional post-op recommendations
A
- Similar to ileostomy, but tend to progress quicker to oral diet as presence of colon
- Must individualize based on fluid tolerance an absorption capacity
- MAIN issue are fluid losses
- Avoid odour causing, gas causing or diarrheal foods
- Obstructions are less common
17
Q
Two MAIN nutritional issues in ostomies?
A
Diarrhea and Obstruction
18
Q
Chronic management, stable recommendations for ostomies?
A
• Take small bites, chew well
• Regular eating frequency, small frequent meals
• Avoid spicy or fried food, high in sugar
• Thicken stools: Banana, rice, applesauce, toast, pasta
• Odours: onions, eggs, fish, cabbage, broccoli
–> Decrease: yoghurt, parsley, buttermilk
• Avoid gas-producing food
• Avoid swallowing air
• Drink plenty of fluids
19
Q
Recommendations to avoid diarrhea?
A
- Increase fluids between meals
- Salty fluids
- Fruits after meals
- Thicken stools w/ soluble fibre sources; apple juice, sauce, bananas, pasta, toast, oats
- Avoid spicy foods, prunes, coffee etc.
20
Q
Recommendations to avoid obstruction?
A
- Avoid fibrous foods, and chew well/blend
- Avoid corn, peas, mushrooms, bean sprouts, raw cabbage, fruit skins, nuts, popcorns
21
Q
Which ostomy would benefit the MOST from a higher fat, lower CHO/normal protein diet with increased salty foods and fluids and Vitamin K supplements?
A
SBS w/ jejunostomy/ileostomy
22
Q
Which ostomy would benefit the MOST from higher CHO, lower/normal fat/protein?
A
SBS w/ colonostomy
- -> We want to avoid the fat malabsorption, and we are more likely to absorb the fluids downstream, therefore saltier foods/fluids not always #1
- -> Note that higher CHOs does not meal simple CHO, continue to avoid to avoid diarrhea
23
Q
UC and Colonic Crohns have similar presentations, which 5 signs are usually present in CC over UC? (HPPPD)
A
- Hematochezia
- Pain prior to defecation
- Perianal skin tags
- Perianal fistulas
- Deep anal fissures
24
Q
CDAI for mild, moderate and severe? (crohns)
A
Mild = 15-220
Moderate = 220-240
Severe = >450
Controlled with corticosteroids is NOT considered in remission
Decreases of 70 points is a positive prognostic factor
25
Mild Mod CDAI? (POT/3A/10%)
- Painful mass
- Obstruction
- Toxicity/Fever
- Abdo tenderness
- Ambulatory
- Able to tolerate PO intake w/o dehydration
- 10% WL
26
Mod/Severes CDAI? (INV/SS)
Failure to respond to mild/mod Tx plus:
- Intermittent nausea and vomiting
- Significant weight loss
- Significant anemia
27
Severe/Fulminants CDAI? (A-REC)
Persisting symptoms in spite of Steroid Rx and
- Abscess
- Rebound tenderness
- Evidence of intestinal obstruction
- Cachexia
28
Severe criteria for scoring UC? (Truelove and Witts)
- >5 BMS
- Large amounts hematochezia
- Temp >/= 37.5
- Pulse >/= 90
- ESR >/= 30 mm/hr
- HmG = 100 mmol/L
29
Indices of malabsorption in IBD?
- Low xylose in urine
- >6 g of fat in feces
- Presence of H2/methane in breath for lactose
- Low excretion of radioactive B12 in urine (normal =8%, deficient = 3%)
30
Low-oxalate diet recommendations?
- 3-4 L water, low fat (could also be alternative)
- Avoid Vit C supplements
- Probiotics
- One 125 ml serving/day of high oxalate foods
- No more than 4-5 servings of veg, and no more than >3 servings of grains
- -> Test and see if working: If LOW oxalate in urine, less is being absorbed into the bloodstream and therefore our diet is working
31
IBD in remission guidelines?
- Maximize E/P intake
- Avoid high oxalate foods
- Pro/Prebiotics
- Increase antioxidants
- Increase fibres (SCFAs will promote water and H2O reabsorption, act as fuel source, and decrease pro-inflammatory cytokine release, regulate gut motility and healing)
- Consider Omega-3/glutamine supplement
32
When is fibre OK?
- In the non-exacerbated IBD patient, which includes patients with disease controlled on corticosteroids
- EN with fibre is OK in the SBS patient in chronic, non-exacerbated management
- Soluble fibre is OK s/p colectomy or ileostomy if there is persistant diarrhea
* *Bottom line is that when there is no exacerbation, fibre is OK, and normal progression for GI surgeries is CF-->FF--> Low fibre/low fat residue diet, then normal diets (with fibre) as tolerated (usually in about 3 days)***
33
ERAS and patient NRS 2002 <3, plan?
- No special nutrition support
- Meals 6 hr b/f surgery
- 800 ml 12.5% CHO drink at midnight, and 400 ml of same solutions 2 hrs before
34
ERAS and patient NRS 2002 3-4, plan?
- Do not delay Sx
- Provide EN pre-op, consider ONS
- Follow standard ERAS plan with CHO loading
- D/c feeds at 6 hrs b/f Sx
- Post-op; consider oral or EN on POD1
- If EN/oral contraindicated s/p Sx, delay PN 5-7 days if we think it may resolve
35
ERAS and patient NRS 2002 >/5 OR 3-4 but EN contraindicated, plan?
- Delay Sx 5-7 days
- Administer PPN with SMOFlipid
- d/c PPN 2-3 hrs prior to Sx, if continued during Sx caution with blood glucose stress response
- Restart feeds POD1 at 80% permissive underfeeding
36
Total GIT length?
400 cm
37
Duodenum length?
25-30 cm
38
Jejunum length?
160-200 cm
39
Ileum length?
170-215 cm
40
Alk phos?
- Non-specific
- Elevated in hepatic disease, fatty liver or chronic obstruction of biliary ducts
- Elevated in glucocorticoid/methotrexate chronic exposure
41
LDH?
- Non-specific
- Found in cardiac muscle, liver, RBC and kidney
- Differentials mononucleosis from hepatitis
42
What are the 5 causes of jaundice?
- Liver damage
- Hypoalbuminemia
- Excess hemolysis
- Blockage of biliary ducts
- Newborn
43
What does ascites lead to? (Complication of portalHTN due to cirrhosis)
- Hepatorenal syndrome
| - Spont. bacterial peritonitis
44
SulfasalAZINE (Aminosalicylate) nutritional impact?
-Competes with intestinal folate absorption
45
Methotrexate nutritional impact?
- Antagonist to folic acid, folate deficiency
| - Excessive exposure can also cause heptoxicity
46
What does hepatorenal syndrome cause in terms of lab values?
Dilutional hyponatremia
47
Nutritional intervention ascites
-Sodium (<2.5 g/day) and fluid restriction as per MD orfer
48
Nutritional intervention in HE?
- High protein of 1.2-1.5g/kg/day
| - West Haven Score of 5 may suggest NS
49
Most common causes of chronic hepatitis
- Hep C (From body fluids, unclean medical supplies)
- Alcohol, which is associated with malnutrition
- Obesity, insulin resistance and subsequent NAFLD
50
Nutritional intervention hepatitis?
- 30-35 kcal/kg/day
- 1.0-2.0 g/kg/day
- Anorexia, weight-loss,NV and nutritional deficiencies common
51
Nutritional intervention NAFLD?
- Healthy lifestyle intervention, weight-loss, abstinence from alcohol
- 800 IU of Vit E in non-diabetic patients, pro and pre-biotics
52
Nutritional intervention in alcoholic liver disease?
- Metabolism increases, anorexia, dysgeusia
- 5 mg folate, 50-200 mg thiamine, selenium, magnesium and zinc
- Virtually ALL patients with ALD will have malnutrition (prioritize alcohol intake over food)
- Mitigate risk of RF, attenuate malnutrition
53
Furosemide diuretic nutritional implication?
- Incr, K,Mg, Ca in diet (Losing)
- Avoid grapefruit
- K+ losing diuretic
54
Spironolactone diuretic nutritional implication?
- Caution with K+ retention
- Avoid salt substitutes, potassium phosphate, potassium chloride additives
- K+ sparing diuretic
55
Cirrhosis nutritional intervention?
- 30-40 kcal/kg
- Obese 25 kcal/kg of IBW
- Cirrhosis can simulate the starvation state, hypermetabolism but we also want to be cautious to not overfeed (consider fat and CHO clearance)
- Vitamin D supplementation, potentially Vitamin A if chronic
56
Cirrhosis protein for non-malnourished, compensated cirrhosis?
1.2 g/kg/day
57
Cirrhosis protein for malnourished and/or sarcopenic cirrhotic patients?
1.5 g/kg/day
58
Cirrhosis protein for obese patient?
2.0-2.5 g/kg/day
59
Nutritional intervention in pancreatitis?
- 25 kcal/kg/day, use IBW if overweight as we want to avoid overfeeding
- MFSJ or HB x 1.39
- 1.5-2.0 g/kg/day
- 1 g/kg/day as hyperTG is common in pancreatitis
- 3-5 mg/kg/min as hyperBG is common in pancreatitis
- Avoid/eliminate alcohol
- -> Recall that despite being hypermetabolic, we will also want to reduce risk of overfeeding
- -> If we have steatorrhea or diarrhea, consider switching to an SE/E formula as digestive enzyme secretion is often impaired
- There is malabsorption, steatorrhea, hypermetabolism, anorexia and weight loss, often LOTS of pain after eating due to blockages/inflammation in the acinar cells
- If there in a CONRAINDICATION to EN (such as common NV), this is usually TPN, use clinical judgement with provided algorithm
60
Discuss the relationship between pancreatitis and alcohol
- Chronic alcohol abuse can cause an acute episode of pancreatitis, which can eventually develop into chronic pancreatitis
- Chronic pancreatitis can be exacerbated by alcohol intake, chronic pancreatitis signifies pancreatitis insufficiency
- -> Alcohol will damage the acinar cells, and secretin will induct spasms which will encourage protein deposition in the cells, and ultimately decrease function/blockage
61
Patient has an APACHE of <9, Ransons of <2, no SIRS and CT scan shows no necrosis of the pancreas. Nutritional intervention? (Acute Pancreatitis)
- Mild/Moderate
- Oral feeds with low fat, higher CHO, high protein
- No alcohol
- SMFQM
- If s/p surgery, start with CF--> FF
- -> If oral feeds not tolerated for >4 days, try EN
- -> 80% will progress to EN feeds within 1 week
62
Patient has an APACHE of >10, Ransons >3, presence of SIRS at CT scan shows necrosis of the pancreas. Nutritional Intervention? (Acute pancreatitis)
- Initiate EN with NG tube feeds in ICU
- Polymeric OK with pancreatic enzymes, but if steatorrhea use SE/E formula with MCT
- If NG not tolerated, switch to NJ (Below LT will allow for pancreatic rest)
- If EN not tolerated >5 days, PN
- ->0% will progress to oral feeds within a week
63
Nutritional intervention of Chronic Pancreatitis? What is important to consider?
- Enzymes, antacids and B12
- High pro, moderate CHO, lower fat if not tolerance
- MCT, but avoid longterm
- No alcohol
- miscible ADEK supplementation
- --> Many patients with chronic pancreatitis will have acute episodes, and will be managed like an acute episode
- -> Antacids will facilitate fat absorption (activation of bile acids) and digestions (activation of pancreatic enzyme supplementation) when at pH 5
64
Lipase requirements per:
- Meal?
- Day?
- g of dietary fat/day?
- 500-2500 u/kg/MEAL
- <10,000 u/kg/DAY
- 1000-4000 u/1g DIETARY FAT/day
65
Causes of gallstones?
- Too much absorption of water from bile
- Too much absorption of bile acid from bile
- Too much cholesterol from bile
- Inflammation of the epithelium, and decreased absorption
66
Nutritional related symptoms of biliary obstruction?
- Dark coloured urine
- Clay coloured stool
- Marked disturbance in digestion/absorption of lipids
- Severe URQ pain
67
faster ECR indicates?
More inflammation
| -Often used as a test in acute cholethiasis
68
3 scenarios where low fat nutrition prescription is warranted?
- Fat malabsorption and maldigestion
- Cholecystitis
- Pancreatitis
- -> Note that low fat is actually 20-30%, and not really low fat, more normal. Key is that we don't want high fat
- -> Low fat diet does NOT need to be adhered to for life, just until problem is solved
69
Guidelines for low fat diet for cholecystitis or pancreatitis?
- 20% E, chose foods with <3g/serving
- Avoid high fat, fried foods
- Limit dairy products
- Trim fats
- SMFQM
70
Post-op nutrition s/p 3 days cholecystectomy?
- CF first, sipped
- Then Full fluids, but avoid high-fat
- Can use EN products, but low fat
- SMQM
- -> NS only reserved for severe pancreatitis or when bowel rest is indicated
71
SIBO Nutritional implications?
- often experience, early satiety, N/V
- Intestinal bacteria will deconjugate bile acid, impair micelle formation, degrade brush-border enzymes and compete w/ host for available nutrients
- Overgrowth may impair B12 absorption
72
IBD energy
25-30 kcal/kg/day
73
IBD proteins
1.0-1.5 g/kg/day
74
Micronutrients in IBD?
- Consider etiology of disease
- Ca, Vit D, Iron, B12, ADEK and Folate most common
- Iron deficiency most common in UC
75
SBS Energy?
35-45 kcal/kg/day, some may need up to 60 kcal/kg/day
76
SBS Protein?
1.5-2.0 g/kg/day
77
SBS fluid recommendations?
- Fluid losses are common
- Try hypoosomotic/isotonic ORS, or with salty foods/fluids
- Delay fluids, avoid simple sugars, drink between meals
78
SBS CHOS?
- Avoid simple sugars
- Fibre OK and normal if non-exacerbated state
- Higher CHO if colon continuity (Avoid fat malabsorption)
- Do not limit lactose if no intolerance
- Choose complex CHOs
79
SBS Micronutrients?
- Vit B12 if >50 cm ileum is resected
- Zinc and selenium if excessive in stool losses
- Ca and Vit D, especially if on corticosteroids, or Ca to prevent kidney stones
- Mg, K, Ca, B12, PO4
80
What is bound by FFA doing malabsorption?
- Will bind calcium and magnesium
| - Hypocalcemia, hypomagnesmia
81
When should ORS be used?
-When SBS with no colon
-Ileostomies
Will promote fluid reabsorption though maintaining a strict ratio of sodium and glucose to promote water-reabsorption through SGLT1
82
Common vitamin/minerals imbalances s/p GI Sx?
- Microcytic anemia
| - Metabolic bone disease
83
Common issues s/p GI Sx?
-Early satiety, decreased appetite, N/V and distention
84
When is EN contraindicate? (MISS-A-SHIP)
- Mechanical obstruction
- Intractable N/V
- Severe GI bleed
- SBS
- Aggressive care not warranted
- Short-supply period
- High output fistula
- Inability to acces GI Tract (Paralytic Ileus, Mesenteric Ischemia)
- -> Pancolitis, Exacerbated IBD which is unresponsive to meds
85
RF syndrome criteria 1?
1 of:
- BMI<16
- Unintentional weight loss >15% 3-6 mo
- Low/poor intake >10 days
- Low K+, Po4- and Mg2+
86
RF syndrome criteria 2?
2 of:
- BMI <18.5
- Unintentional weight loss >10% in 3-6 months
- Poor or no intake >5 days
- EtOH abuse
87
Beneprotein administration?
1 BP with 60-120 ml H20 and flush with 30-60 ml H20
88
GENERAL administration rate for EN?
50 ml/hour advancing at 15ml/hr q4h until goal is met, meet needs within 24-48 hours
89
Risk of RF considerations for EN and PN?
<25% of E on day 1 (in PN, must make new prescription), with <100-200 g dextrose. Electrolyte supplements
90
RF rate?
EN: Initiate EN at 10-15 ml/hr and increase q12 hr over 4-7 days to reach target
PN: Start with 25% of E or 15 kcal/kg, and keep this rate for 1 day. Increase accordingly per day to meet needs within 2-4 days.
91
CHO clearance?
3-5 mg/kg/day
92
General PN administration?
Administer at 50% of needs on day 1, and <200 g of dextrose, meet needs within 48 hours
93
Fat clearance?
0. 11 g/kg/hr or 2.5 g/kg/day
| 1. 0 g/kg/day if DL or CI
94
CI in ICU EN administation rate?
10-40 ml/hr advancing to qual rate by 10-20 ml/hr q8-12 hrs to meet goal rate in 24-48 hours, reach >80% of E and Pro needs within 48-72 hours to reach clinical benefit
95
CI Obese BMI 30-50 and BMI >50 energy?
- 11-14 kg/kcal ABW
| - 22-25 kcal/kg IBW
96
CI Obese BMI 30-40 and BMI >40 protein?
- 2.0 g/kg/day IBW or Adj. BW
| - 2.5 g/kg/day IBW or Adj. BW
97
If intolerance is observed with feeds in pancreatitis, how should we feed?
Below LOT
| Semi-elemental/elemental formula
98
E3 UC?
- Ulcerative Proctitis
| - Inflammation is distal to the rectosigmoid junction
99
E2 UC?
- Left sided or Distal UC
| - Inflammation of the colorectum distal to the splenic flexture
100
E1 UC?
- Extensive of Pancolitis
| - Inflammation of entire colon proximal to splenic flexture
