Nutrition Flashcards
When should we further investigate IDA
All post menopausal women and men over 50years
Perform TTG, OGD, colonoscopy
In pre-menopausal women identified as IDA what test should be performed next
TTG
DO FURTHER IX IF STRONG FH OR SYMPTOMATIC
Pellagra is a deficiency of what
Niacin (vitamin B3)
Symptoms of pellagra
4Ds
Dementia
Dermatitis
Diarrhoea
Death
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
What an thiamine (B1) deficiency lead to…
- Beri-beri - wet = heart failure, dry = neurological symptoms
- Wernickes-korsakoffs
Vitamin B2 is also known as
Riboflavin
Deficiency of riboflavin (B2) causes what symptoms?
Dermatitis
Geographic tongue
Stomatitis
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
Causes of folate deficiency
MTX Trimethoprim Malabsorption SIBO CD ETOH excess
First line management in obese patient coming for surgical options
Lifestyle - exercise, diet, behavioural interventions
If obese patient has failed lifestyle measures for >3 months in weight loss aims, what treatment can be offered next
Orlistat
How does orlistat work
Lipase inhibitor
Prevents conversion of dietary fat to its absorbable form
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
Vitamin B6 is also called
Pyridoxine
Symptoms of pyridoxine (B6) deficiency
Seizures
Peripheral neuritis
Levels of these are high/low/normal in an anorexic patient:
- FSH
- LH
- GH
- Albumin
- Cortisol
- Low
- Low
- High
- Normal
- High
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
Which drugs can cause low B12
Metformin
Nitrous oxide
PPI
A patient is defined as malnourished if…
- BMI <18.5
Unintentional weight loss >10% in last 3-6/12
Daily total energy requirement in unwell patient or those at risk of re-feeding are…
25-35kcal/kg/day
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
- Reduce intake of oral hypotonic fluid
- Glucose-saline solution
- 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
