Levels of these are high/low/normal in an anorexic patient: 1. FSH 2. LH 3. GH 4. Albumin 5. Cortisol

1. Low 2. Low 3. High 4. Normal 5. High

Nutrition Flashcards by Ben Hicken

When should we further investigate IDA

All post menopausal women and men over 50years

Perform TTG, OGD, colonoscopy

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In pre-menopausal women identified as IDA what test should be performed next

TTG

DO FURTHER IX IF STRONG FH OR SYMPTOMATIC

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Pellagra is a deficiency of what

Niacin (vitamin B3)

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Symptoms of pellagra

4Ds

Dementia
Dermatitis
Diarrhoea
Death

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Pellagra is classically cause by niacin deficiency, by what other mechanisms can we develop pellagra and so which syndrome may the patient have

Reduced TRYPTOPHAN - this is linked to carcinoid syndrome as the precursor tryptophan is used to make serotonin instead of niacin

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What an thiamine (B1) deficiency lead to…

Beri-beri - wet = heart failure, dry = neurological symptoms
Wernickes-korsakoffs

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Vitamin B2 is also known as

Riboflavin

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Deficiency of riboflavin (B2) causes what symptoms?

Dermatitis
Geographic tongue
Stomatitis

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Describe how folic acid becomes biologically active

Folic acid is found in green veg and animal products in the polyglutamate form. It is cleaves to the monoglutamate form in the jejunum where it is absorbed and transformed to form the active tetrahydrofolic acid needed for DNA synthesis

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Causes of folate deficiency

MTX
Trimethoprim
Malabsorption
SIBO
CD
ETOH excess

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First line management in obese patient coming for surgical options

Lifestyle - exercise, diet, behavioural interventions

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If obese patient has failed lifestyle measures for >3 months in weight loss aims, what treatment can be offered next

Orlistat

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How does orlistat work

Lipase inhibitor

Prevents conversion of dietary fat to its absorbable form

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When should anti-obesity surgery be considered

Failure of non-surgical measures - no clinical weight loss over 6/12

BMI>40

BMI >35 and significant comorbidity that would likely benefit from surgery

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Vitamin B6 is also called

Pyridoxine

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Symptoms of pyridoxine (B6) deficiency

Seizures

Peripheral neuritis

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Levels of these are high/low/normal in an anorexic patient:

FSH
LH
GH
Albumin
Cortisol

Low
Low
High
Normal
High

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Describe the mechanism of B12 absorption

B12 liberated from protein binding by acid in stomach

B12 binds to R-factors

In duodenum B12 is release from R-factors by pancreatic protease allowing it to be bound to IF

Then absorbed in TI

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Which drugs can cause low B12

Metformin

Nitrous oxide

PPI

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A patient is defined as malnourished if…

BMI <18.5

Unintentional weight loss >10% in last 3-6/12

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Daily total energy requirement in unwell patient or those at risk of re-feeding are…

25-35kcal/kg/day

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Daily nitrogen requirement in unwell patient or those at risk of re-feeding are…

0.23-0.24g/kg/day

Daily total protein requirement in unwell patient or those at risk of re-feeding are…

0.8-1.5g/kg/day

Daily total water requirement in unwell patient or those at risk of re-feeding are…

30-35ml/kg/day

Describe basic physiology in re-feeding syndrome

When starved intracellular minerals are depleted. When start eating get relative fly Seima with increased insulin which stimulates fat/protein/glycogen synthesis which all requires electrolytes (including PO4)

Gastroparesis happens in what proportion of pt with T1DM

25-55%

Gastroparesis happens in what proportion of pt with T2DM

30%

What is the gold standard test to evaluate gastroparesis?

Gastric scintigraphy Measure residual content at 4 hours. More than 10% left is abnormal

Gold standard test for SIBO

Duodenal aspirate - >10 to the 5

Causes SIBO

Excess bacteria entering small bowel - atrophic gastritis, PPI use, gastro jejunostomy, gastrectomy, enteral fistulae Delayed small bowel clearance - pseudo-obstruction, scleroderma, strictures, autonomic neuropathy Reduced host defences - old age, chronic pancreatitis, immunodeficiency, HIV

What is the risk of malignant change at the anastomoses in patients who have had gastrectomy?

3% over 15 years

What proportion of patients have dumping syndrome after a roux-en-Y gastric bypass?

50-70%

Describe symptoms of early dumping

Ab pain Bloating Diarrhoea Vasomotor symptoms - headache, flushing, fatigue, hypotension

What is early dumping syndrome caused by?

Rapid influx of hyperosmolar contents into the duodenum which causes fluid shifts INTO the lumen and luminal distension

After eating, when do the symptoms of early dumping syndrome occur

30-60minutes after

Cause of late dumping syndrome

Reactive hypoglycaemia, confirm by OGTT after overnight fast

When do symptoms of late dumping syndrome occur after eating?

1-3 hours after eating

Manage to of dumping syndrome

Dietary manipulation - eat small and often, high protein diet, avoid simple sugars, avoid drinking liquid after eating. Lie supine for 30mins after eating helps delay gastric emptying Medical - octreotide

Describe CT findings of autoimmune pancreatitis

Diffuse enlargement of pancreas (sausage shape) with loss of definition of pancreatic cleft. Pancreatic duct abnormality

Blood test to investigate autoimmune pancreatitis

IgG4

Histology finding in autoimmune pancreatitis

Lymphoplasmocytic infiltrate

Treatment of autoimmune pancreatitis

Steroids

In patients with jejunostomy and high aroma output, what measures can be taken to reduce atoms output

1. Reduce intake of oral hypotonic fluid 2. Glucose-saline solution 3. PPI, loperamide, octreotide

Why do patients with jejunostomy get renal stones

Increased oxalate absorption from colon as more oxalate unbound to calcium and more oxalate bound to free fatty acids (do worse if have fat malabsorption)

Signs of a buried bumper

``` Difficult to push PEG difficult to rotate PEG Hard to flush Slowly obstructed Leakage around site ```

Preventing buried number

Ensure 1cm between external fixator and skin | Push in and rotate PEG weekly

Signs of zinc deficiency

Rash (Peri-oral), alopecia, taste impairment An now added to all TPN

Selenium deficiency associated with?

Congestive cardiomyopathy due to myocardial necrosis Hypothyroidism

Alcoholic drinks without gluten

``` Cider All SPIRITS champagne Port Wine ```

Why is glucose-saline solution used in short bowel

Maximises Na absorption via co-transporter. If have too much hypotonic fluid it causes net Na loss into gut and therefore increased water excretion by the short gut

Describe the MUST scoring system

SCORE 0 = BMI >20, weight loss <5% in last 6/12 SCORE 1 = BMI 18.5-20, weight loss 5-10% in last 6/22 Score 2 = BMI <18.5, weight loss >10% in last 6/12 Acutely Ill patients with no suspected nutritional intake in 5/7 = 2 points

Best way to screen for malnutrition in patients with ascites and muscle wasting

Subjective global assessment (SGA)

Signs of zinc deficiency

``` Skin lesions Night blind Confusion HE altered taste Altered wound healing ```