nutrition 101: when, what, how to feed a case-based approach to gastroenterology kimberly carter,...
TRANSCRIPT
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Nutrition 101: When, What, How to Feed
A Case-based Approach to Gastroenterology
Kimberly Carter, MS, PA-CDivision of Gastroenterology
University of [email protected]
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Nutrition: Why should we care….
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Nutrition is an essential component of healthcare and is apart of most of what we do as GI specialists.
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Objective• Discuss the impact of gastrointestinal
disease on nutrition status.• Outline key elements of a nutrition
assessment.• Appraise various nutrition therapies as it
pertains to dietary modifications and nutrition requirements.
• Discuss the appropriateness of nutrition support.
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Nutritional Therapy
Nutrition Support
Nutritional Status
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Nutrition in GI Disease: Nutritional Status
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Nutritional Assessment• Food and Nutrition related history• Medical, Surgical, and Social history• Anthropometric measurements• Nutrition focused physical exam findings• Biochemical data
Bueche J, Charney P, Pavlinac J, et al. Nutrition Care Process and Model Part I: The 2008 Update. Journal of the American Dietetic Association. 2008;108(7)1113-1117.
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Food and Nutrition Related History• Dietary intake: 24 hour recall• Use of dietary supplements• Eating difficulties : poor dentition, taste
disturbances, dysphagia• Gastrointestinal complaints: Nausea,
vomiting, abdominal pain, diarrhea, constipation
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Medical History• Critical illness or chronic disease• Pancreatic insufficiency• IBD• Celiac disease
Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.
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Surgical History• Major abdominal surgery, trauma• Previous GI surgery• Fistula, ostomy, mesenteric ischemia, short
bowel syndrome
Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.
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Social History• Living environment• Caregiver• Functional status• Alcohol or substance abuse• Mental health
Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.
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Anthropometric Measurements• Height• Weight• Usual Body Weight (UBW)• Weight loss• 10 lbs. weight loss over 6 months is noteworthy• >10% of UBW
• BMI• <18.5 underweight
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Nutrition focused PE findings• Loss of muscle mass and subcutaneous fat• Edema and ascites • Hair, skin, nails, perioral exam
Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5): S29-S33.
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Physical SignsSigns Deficiencies
Alopecia Protein energy malnutrition
Brittle Hair Biotin
Follicular keratosis Vitamin A
Ecchymosis Vitamin C or K
Seborrheic dermatitis Vitamin B2, Niacin, Vitamin B6
Spoon-shaped nails Iron
Cheilosis Vitamin B2, Vitamin B6
Bleeding gums Vitamin C
Glossitis Niacin, Folate, Vit B12, Vit B2, Vit B6
Magenta Tongue Vitamin B2
Loss of DTRs Vitamins B1 and B12
Phillips, SM. Jensen, C. Micronutrient deficiencies associated with malnutrition in children. In: UpToDate, Motil, KJ (Ed), UpToDate, Waltham, MA. (Accessed on April 30, 2014).
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Poor nutrient intake and excessive losses may contribute to malnutrition.
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Case Study # 1 • 76-year-old male with lung cancer is referred by his
oncologist for anorexia and weight loss in setting of dysphagia and odynophagia. Endorses 30 lbs weight loss over the past 3 months.
• Medications: Megace• Medical/Surgical history: HTN• Family history: unremarkable• Social History: Lives alone and able to perform ADL. Active
community member. Strong family support. Fixed income.• ROS: fatigue, taste disturbances and weakness
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Case Study # 1• Physical Exam: • Afebrile, 61 inches, 104 lbs. BMI 20• Cachectic man with temporal, chest and deltoid wasting• Edentulous• Otherwise normal exam
• Data:• PET/CT suggestive of extrinsic compression on the
distal esophagus• EGD with evidence of esophagitis• Serology: Albumin 2.3, Prealbumin 15.6
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Assessment: Is this patient malnourished?
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Nutrition in GI Disease:Nutrition Support
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Nutrition Intervention• Oral nutrition supplements• Enteral Nutrition• Parenteral Nutrition
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Nutrition Support
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Enteral Nutrition Support• Functioning GI tract• Short vs. Long Term• NG/NJ vs. PEG/PEJ• Gastric: Bolus feedings• Jejunal: Continuous feedings• Disease Specific Formulas
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Parenteral Nutrition Support• Non-functioning GI tract• Central or PICC• EN vs. PN (Complications)
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Nutrition Support• Multi-disciplinary team• Refeeding Syndrome
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Case Study # 2• 50-year-old male with ulcerative colitis and
mesenteric ischemia s/p total abdominal colectomy with end ileostomy and small bowel resection on chronic TPN referred for nutrition evaluation.
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Prognosis of Short Gut Syndrome (SGS)• Presence of residual underlying disease• Length of remaining small intestine• Presence or absence of colon in continuity
O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10
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Clinical Consequences SGSTable 1.
Jejunal resection of 50-60% is usually well tolerated. Greater than 30% ileal resection is poorly tolerated. Severe malabsorption occurs with residual small bowel < 60 cm.Deficiencies include fluid and electrolytes (mild to moderate cases)/plus nutrient absorption (severe cases). Severe fluid and electrolyte loss is associated with end jejunostomy.Magnesium, calcium, and zinc deficiencies are common.
O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10
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Bowel Adaptation SGS• Gastric hypersecretion• Increased pancreaticobiliary secretions• Mucosal hyperplasia• Increased mucosal blood flow• Improved segmental absorption
O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10
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Short Gut Syndrome Medical Nutrition Therapy (MNT)
Table 2. General Management Strategies for SBSFluids
Avoid drinking water without foodSpread fluid intake throughout the daySip liquidsRestrict hypotonic fluidsDrink oral rehydration solution containing salt and carbohydrates
DietEat small, frequent meals balanced in nutrient contentAdd salt to the diet (only for patient with colon in continuity)Increase quantity of food intakeFollow a high complex-carbohydrate diet (patients with a colon)Avoid osmotically active sweeteners, which might cause diarrhea
O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10
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Short Gut Syndrome MNT• Hypomotility agents• Rotating antibiotics• Enzyme replacement
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Short Gut Syndrome
Site Nutrient (s) absorbedStomach Cu, IDuodenum Fe, Zn, Cu, Se, Vit D,
E, K, B1, B2, B3, folate, Ca
Jejunum Zn, Se, Fe, Ca, Cr, Mn, Vit A, D, E, K, B1, B2, B3, B5, B6, folate, Vit C
Ileum Vit C, D, K, B-12, folate
Shortgutsupport.com
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Nutrition in GI Disease:Nutritional Therapy
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Case Study # 3• 29-year-old female with history of RYGB
referred for evaluation of iron deficiency anemia in the absence of overt GI blood loss.
• Celiac and H Pylori serology negative• Endoscopic evaluation unremarkable • Micronutrient deficiencies: Calcium, Zinc,
Vitamin D, B12
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Nutrition and RYGB Malabsorption• Many patients stop supplements after
bariatric surgery• Look for other micronutrient deficiencies• Often subtle deficiencies are asymptomatic
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Nutrition and Malabsorption• Hypoalbuminemia• Steatorrhea• Fe deficiency anemia• B 12 deficiency• Thiamine deficiency
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Nutritional Therapy• 60-120 grams of protein daily• Long-term vitamin/mineral supplementation• Periodic clinical and biochemical monitoring
Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-4843.
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Biochemical Monitoring• 6, 12, 18, 24 months then annually• Fe, B12, Folate, Calcium, Vitamin D, Albumin,
pre-albumin
• Optional• Vitamin A, Zinc, B1
Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95 (11):4823-4843.
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Dietary modifications • Consume small frequent meals• Avoid ingestion of liquids within 30 min of
solid food• Avoid simple sugars• Increase intake of fiber and complex
carbohydrates• Increase protein intakeHeber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-4843.
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Case Study # 4• 26-year-old male with ileocolonic Crohn’s
disease presents with fatigue, low energy and weight loss.
• Iron, B 12 and Vitamin D deficiency
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Nutrition and IBD• Nutrient deficiencies • Hypoalbuminemia • Fe • B12 • Vitamin D• Folic acid• Calcium• Magnesium
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Nutritional Therapy• Vitamin/Mineral Repletion• Elimination Diet• Lactose Free• Low Residue• Probiotic
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Case Study # 5• 23-year-old female with history of Type I
DM presents with bloating, flatulence, and diarrhea in the setting of anemia
• Positive celiac serology with duodenal biopsy c/w villous atrophy
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Nutrition and Celiac Disease• Micronutrient deficiencies• Pancreatic insufficiency
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Gluten-free diet• Eliminates wheat, rye, and barley• Rice, corn, millet, potato, buckwheat, and
soybeans are safe• Common gluten free foods• fresh fish, meats, milk, cheese, fruits, vegetables
• Gluten-free substitutes are often expensive and may be difficult to access
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Management of Celiac Disease
C Consultation with a skilled dietitianE Education about the disease
L Lifelong adherence to a gluten-free diet
I Identification and treatment of nutritional deficiencies
A Access to an advocacy group
C Continuous long-term follow-up by a multidisciplinary team
Milito T, Muri M, Oakes J, et al. Celiac disease: Early diagnosis leads to the best possible outcome. Journal of the American Academy of Physician Assistants. 2012;25(11):43-47.
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Nutrition in GI Disease:Nutritional Therapy
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Nutrition and IBS• Multifactorial: visceral hypersensitivity, gut
flora, diet
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Nutritional Therapy• Lactose Free diet• Probiotics• Fiber Supplements (Psyllium)• FODMAP Diet
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FODMAP • Fermentable OligoDiMonosaccharides and
Polyols• Poor absorption• Osmotic effect• Bacterial fermentation
Simren M. Diet as a Therapy for irritable bowel syndrome: progress at last. Gastroenterology. 2014;146(1):10-12.
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Absorption of FODMAPs• Presence or absence of enzymes• Small intestinal transit time• Dose of carbohydrate• Presence of underlying mucosal
disease• Food Composition
Simren M. Diet as a Therapy for irritable bowel syndrome: progress at last. Gastroenterology. 2014;146(1):10-12.
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FODMAP Diet
Fedewa A, Rao S. Dietary Fructose Intolerance, Fructan Intolerance and FODMAPS. Current Gastroenterology Reports. 2014;16(1):370.
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FODMAP Approach
Barrett, J. Extending our knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms. Nutrition in Clinical Practice. 2013;28(3):300-306
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FODMAP Approach• Provides therapeutic strategy to manage
symptoms.• Use of dietitian is paramount.• Address long-term efficacy and safety of
dietary intervention.
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Nutrition and GERD• Chronic acid exposure• Reflux triggering foods• Spicy• Acidic• Citrus• Fried/Fatty • Caffeine, coffee, cola• Spearmint/Peppermint• Chocolate• Alcohol
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Nutritional Therapy• Dietary/Behavioral Modifications• Avoidance of reflux triggering foods• Small frequent meals throughout the day• Avoid tobacco use• Avoid tightly fitting clothing• Raise head of bed 6-9 inches• Stay upright 2-3 hours after meals• H2 blockers/PPIs
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Nutrition and Gastroparesis• Hypomotility disorder• Etiology: Idiopathic, post-viral, diabetic
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Nutritional Therapy• Dietary/Behavioral Modifications• Several small frequent meals• Avoid high fat and fiber foods• Chew food slowly/thoroughly• Sit upright• Active• Digestive Enzymes/Probiotics
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Nutrition and Eosinophilic Esophagitis• Chronic allergic disease• Elimination diet
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Nutritional Therapy• Six-Food-Elimination Diet• Milk• Eggs• Nuts• Wheat• Fish/Shellfish• Soy
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Therapeutic Approach• Treat underlying etiology• Diet• Vitamin/Mineral supplementation• Nutrition support• Pharmacotherapy
• If underlying etiology is irreversible-target symptoms• Anti-diarrheal• PERT
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In Summary• Recognize nutrition is apart of most of what
we do as GI specialists• Understand the impact of GI disease on
nutritional status • Utilize a nutrition assessment to dictate
intervention• Consult with a dietitian• Work with multi-disciplinary team