Psychological Aspects of GI Disease

Question 1

Vomiting and Weight loss suggest what type of GI disease?

Answer 1

Weight loss suggests a structural disease rather than functional

Question 2

What should you focus on when you are struggling to find a structural problem?

Answer 2

Taking a careful history to establish any functional issues

Question 3

Does abdominal pain signify a serious underlying problem?

Answer 3

Not on its own.
Pain should be taken into context.
If you treat the pain does that solve most of the issue for the patient?

Question 4

What do we mean by organic disease and how does it present?

Answer 4

More structural diseases. Something develops.
More likely to come about in older patients.

i.e. functional problems come up early. As you get older more likely to be organic

Question 5

What are the metabolic causes of anorexia, nausea or vomiting?

Answer 5

Diabetic ketoacidosis
Renal tubular acidosis
Hypercalcaemia (breast or prostate cancer metastases in bone)
Adenocortical insufficiency
Other rare causes of acidosis or alkalosis
Porphyia (failure to breakdown haemoglobin

Question 6

How do you arrive at suspecting a functional disease?

Answer 6

You exclude structural disease

Question 7

Why is timeframe important when deciding if problem is structural or functional?

Answer 7

Functional problems usually start in teens and have “gone on for years”

Structural problems are more recent. Change in what is normal

Question 8

Why do you need to establish when vomiting has occurred?

Answer 8

Obstructed pyloris = vomiting 2-4 hours after eating

Vomiting as soon as food swallowed suggests more functional

Question 9

Why is drug history important in nausea and vomiting?

Answer 9

Many drugs can cause vomiting:

• Opiates
• Digoxin

Question 10

list some appropriate investigations for vomiting and weight loss

Answer 10

FBC
Biochemical profile (blood glucose)
Pregnancy test (bloating)
Urinalysis/culture
-H. Pylori
-Anti TTG
Erect CXR
Abdominal film (AXR)
Ultrasound scan

Question 11

What MUST you assess in someone presenting with weight loss

Answer 11

Nutritional risk

BMI
Weight loss
Have they eaten anything in the last 5 days?

Question 12

What simple measures can you take with someone coming into hospital with nausea and vomiting?

Answer 12

IV Fluids
Pabrinex: standard multivitamin IV preparation (Contains Thiamine)
Dietetic review in morning
? NG Tube etc?

Question 13

What should you be careful with when feeding someone in hospital?

Answer 13

Refeeding syndrome

Monitor K+, PO4^2-, Ca2+, Mg2+

Question 14

What state does your body develop during starvation?

Answer 14

Glycogen has been all used up and there is barely any insulin being secreted.
Fat and protein all being burned and so reduced intracellular phosphate.
Atrophy of gut and heart muscles.
ATP at absolute minimum

Body basically goes through a controlled series of shutdowns

Question 15

What is refeeding syndrome?

Answer 15

Basically an electrolyte disturbance.

• Food eaten (carbs the worst)
• Huge spike in insulin
• This drives electrolytes esp potassium into cells
• This all restarts the cells suddenly and lots of nutrients pulled inside to power processes
• No reserve in the blood so all the nutrients required to power heart are gone

Must refeed SLOWLY

Question 16

What occurs when you refeed too quickly with carbohydrates?

Answer 16

Rapid rise in insulin
Rapid generation of ATP
Phosphate moves into cells
Hypophosphataemia rapidly develops

Question 17

What are the consequences of refeeding syndrome?

Answer 17

Rhabdomyolsis 
Respiratory failure
Cardiac failure
Leucocyte dysfunction
Hypotension
Arrhythmias
Seizures
Coma
Sudden

Question 18

What is Rhabdomyolsis?

Answer 18

Breakdown of muscles produces nephrotoxic substances such as myoglobin which can lead to renal failure

Question 19

What single criteria would identify someone in risk of a refeeding problem?

Answer 19

BMI less than 16kg/m2

Unintentional weight loss greater than 15% within last 3-6 months

Little or no nutritional intake for more than 10 days

Low levels of potassium, phosphate or magnesium prior to feeding

Question 20

What criteria (if two are met) would identify someone at risk of refeeding syndrome?

Answer 20

BMI less than 18.5 kg/m2

Unintentional weight loss greater than 10% within the last 3-6 months

Little or no nutritional intake for more than 5 days

A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

Question 21

How do you build someone back up while avoiding refeeding syndrome?

Answer 21

START SLOW

• Correct fluid depletion (cautiosly)
• Thiamine at least 30 mins before feeding starts
• Feed at 5-10kcal/kg over 24 hours
• Gradual increase to requirement over 1 week

REPLACE

• Phosphate (IV)
• K

Question 22

What are some of the conditions that produce disordered eating?

Answer 22

Crohn’s
Coeliac disease
Missing false teeth

There are lots

Question 23

How are functional disorders described to patients?

Answer 23

“Software Faults”

Question 24

What is a more common treatment for IBS nowadays compared with antispasmotics?

Answer 24

Antispasmotics don’t work that well. IBS not spasms
Hypersensitive bowel
IBS sufferers can feel a much smaller distention of their bowel compared to others.

Dampen this response with low doses of antidepressants (e.g. amitriptyline)

Question 25

What are some of the behaviours seen in eating disorders?

Answer 25

Self-starvation, self-induced vomiting, compulsive activity and exercise, use of laxatives, diet pills, herbal medicines and deliberate exposure to the cold are some of the behaviours seen in the pursuit of thinness.

Question 26

What are the criteria for anorexia nervosa?

Answer 26

• Refusal to maintain body weight at or above a minimally normal weight for age and height
• Intense fear of gaining weight or becoming fat even though underweight
• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight
• Loss of menstral cycles
• Often obsession with exercise

Question 27

What are the criteria for bulimia nervosa?

Answer 27

• Recurrent episodes of binge-eating, (e.g eating a massive amount of food in a short period of time)
• A sense of lack of control during the episode
• Recurrent inappropriate compensatory behaviour (vomiting, laxatives, diuretics)