practitioner highlight nutrition in action new to pen diner update … · 2017-01-12 · nutrition...
TRANSCRIPT
DAA GASTRO IG
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Hot Off The Press
Nutrition in Action
Practitioner Highlight
New to PEN
Diner Update
Medical Update
Nutrition in Action - Answers
NEWSLETTERMay 2016 I Issue 04
WELCOME TO THE DAA GASTRO IG NEWSLETTER
DAA GASTRO IG NEWSLETTER ISSUE 04
Welcome to our fourth edition. I hope you
enjoyed the third edition in February. Once the
new DAA wesite is up and running there will be
access to each edition online. I have decided to
include the case study answers in each edition,
just in a different section.I would love to hear
any feedback from you about the content or
layout or any suggestions about what else you
might want to see in the newsletter.
This edition has been the result of the
volunteering efforts of six fantastic APD’s who
have come together to share this vision. They
are Lauren Reece, Felicity Ritorni, Lina Briek,
Shamley Chand, Trang Soriano and Hannah
Ryrie.
My role is overseer and editor. My background
is acute care clinical dietetics specialising in
gastrointestinal surgery. Regardless of my frame
of reference, I intend to do my upmost at
providing something of benefit to all the different
settings and applications of nutrition members of
the Gastro IG belong to.
Enjoy!
Ruth Vo
Gastro IG Convenor
Editor
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HOT OFF THE PRESSBY FEL IC I TY R ITORN I AND HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 04
We’ve searched through the academic databases to
provide a list of recent and relevant literature in nutrition
related gastroenterology topics.
Nutritional Therapy in adult hospitalised patient:
McClave S, DiBaise J, Mullin G, Martindale R. American
College of Gastroenterology (ACG) Clinical Guideline:
Nutrition Therapy in the Adult Hospitalized Patient.
American Journal of Gastroenterology 2016, 111 (3):
31534
Pancreatic neuroendocrine tumours:
Viúdez A, De JesusAcosta A, Carvalho F, Vera R, Martín
Algarra S, Ramírez N. Pancreatic neuroendocrine tumors:
Challenges in an underestimated disease. Critical Reviews
in Oncology/hematology 2016, 101: 193206
Chronic liver failureValerio C, Theocharidou E, Davenport, Agarwal B. Human
albumin solution for patients with cirrhosis and acute on
chronic liver failure: Beyond simple volume expansion.
World Journal of Hepatology 2016 March 8, 8 (7): 34554
Total Parenteral Nutrition Beath S, Kelly D. Total Parenteral NutritionInduced
Cholestasis: Prevention and Management. [Review]
Clinics in Liver Disease. 20(1):15976, 2016 Feb.
Nguyen D, Parekh N, Bechtold ML, Jamal MM. National
Trends and InHospital Outcomes of Adult Patients with
inflammatory bowel disease receiving parenteral
nutritional support . Jpen: Journal of Parenteral & Enteral
Nutrition. 40(3):4126, 2016 Mar.
Acute Diarrhoea
Riddle M, DuPont H, Connor B. American College of
Gastroenterology (ACG) Clinical Guideline: Diagnosis,
Treatment, and Prevention of Acute Diarrheal Infections in
Adults. American Journal of Gastroenterology 2016 April
12; doi:10.1038/ajg.2016.126.
Microbiota and IBD
Chu H, Khosravi A, Kusumawardhani I P, Kwon AHK,
Vasconcelos AC, Cunha LD, Mayer AE, Shen Y, Wu WL,
Kambal A, Targan SR, Xavier RJ, Ernst PB, Green DR,
McGovern DPB, Virgin HW, Mazmanian SK.
Genemicrobiota interactions contribute to the
pathogenesis of inflammatory bowel disease. Science.
2016 May 05; DOI: 10.1126/science.aad9948
Cleynen I, Boucher G, Jostins L, Schumm P, Zeissig S,
Ahmad T et al. Inherited determinants of crohn's disease
and ulcerative colitis phenotypes: A genetic association
study. The Lancet, 387(10014), 156167. 2016 January
09. Doi: http://dx.doi.org/10.1016/S01406736(15)004651
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Guo Y, Qi Y, Yang X, Zhao L, Wen S, Liu Y, and Tang L.
Association between polycystic ovary syndrome and gut
microbiota. PLoS One, 11(4). 2016 April. Doi:
http://dx.doi.org/10.1371/journal.pone.0153196
HOT OFF THE PRESSBY FEL IC I TY R ITORN I AND HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 04
Microbiota and peptic ulcer disease
Ford AC, Gurusamy KS, Delaney B, Forman D, Moayyedi
P. Eradication therapy for peptic ulcer disease in
Helicobacter pyloripositive people. Cochrane Database of
Systematic Reviews 2016, Issue 4. Art. No.: CD003840.
DOI:10.1002/14651858.CD003840.pub5.
Genetic testing in Gastroenterology
Goodman RP and Chung DC. Clinical genetic testing in
gastroenterology. Clinical and Translational
Gastroenterology, 7, 7. 2016 April. Doi:http://dx.doi.org
/10.1038/ctg.2016.23
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Atay O. Neonatology and gastrointestinal issues.
International Journal of Child Health and Human
Development, 9(1), 121130. 2016. Retrieved from
http://search.proquest.com/docview
/1781595214?accountid=34512
Paediatrics
Preece K, Blincoe A, Grangaard E, Ostring G, Purvis D,
Sinclair J et al. Paediatric nonIgE mediated food allergy:
Guide for practitioners.The New Zealand Medical Journal
(Online), 129(1430), 7888,6. 2016 February 16. Retrieved
from http://search.proquest.com/docview
/1771408123?accountid=34512
Pancreas
Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich
JO, Nathens A, et al. Clinical practice guideline:
Management of acute pancreatitis. Canadian Journal of
Surgery,59(2), 128140. 2016 April. Doi:http://dx.doi.org
/10.1503/cjs.015015
Smith RC, Smith SF, Wilson J, Pearce C, Wray N, Vo R, et
al. Summary and recommendations from the australasian
guidelines for the management of pancreatic exocrine
insufficiency. Pancreatology, 16(2), 164180. 2016.
Doi:http://dx.doi.org/10.1016/j.pan.2015.12.006
Diabetes and gallbladder disease
Aune D, and Vatten LJ. Diabetes mellitus and the risk
of gallbladder disease: A systematic review and
metaanalysis of prospective studies. Journal of
Diabetes and its Complications, 30(2), 368373. 2016.
doi:http://dx.doi.org/10.1016/j.jdiacomp.2015.11.012
Halmos EP, Christophersen CT, Bird AR, Shepherd
SJ, Muir JG, and Gibson PR. Consistent prebiotic
effect on gut microbiota with altered FODMAP intake
in patients with crohn's disease: A randomised,
controlled crossover trial of welldefined diets. Clinical
and Translational Gastroenterology, 7, 10. 2016.
Doi:http://dx.doi.org/10.1038/ctg.2016.22
Probiotics and prebiotics
Reid G. Probiotics: Definition, scope and mechanisms
of action. Best Practice & Research, 30(1), 1725.
2016. doi:http://dx.doi.org/10.1016/j.bpg.2015.12.001
Fatty Liver disease
Rahimlou M, Yari Z, Hekmatdoost A, Alavian SM, and
Keshavarz SA. Ginger supplementation in
nonalcoholic fatty liver disease: A randomized,
doubleblind, placebocontrolled pilot study. Hepatitis
Monthly, 16(1), 15. 2016. Doi:http://dx.doi.org
/10.5812/hepatmon.3489
Papamiltiadous ES, Roberts SK, Nicoll AJ, Ryan MC,
Itsiopoulos C, Salim A, and Tierney AC. A randomised
controlled trial of a mediterranean dietary intervention
for adults with non alcoholic fatty liver disease
(MEDINA): Study protocol. BMC Gastroenterology,
16. 2016. Retrieved from http://search.proquest.com
/docview/1773790976?accountid=34512
Haque TR, and Barritt AS. Intestinal microbiota in liver
disease. Best Practice & Research, 30(1), 133142.
2016. Doi:http://dx.doi.org/10.1016/j.bpg.2016.02.004
HOT OFF THE PRESSBY FEL IC I TY R ITORN I AND HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 04
Nutrition support in chyle leaks
Sriram K, Meguid RA, and Meguid MM. Nutritional support
in adults with chyle leaks. Nutrition, 32(2), 281286. 2016.
Doi:http://dx.doi.org/10.1016/j.nut.2015.08.002
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Eosinophilic Esophagitis
Singla MB, and Moawad FJ. An overview of the diagnosis
and management of eosinophilic esophagitis. Clinical and
Translational Gastroenterology, 7, 8. 2016. Doi:
http://dx.doi.org/10.1038/ctg.2016.4
Pilot study: smart phone apps for IBS tracking
Zia J, Schroeder J, Munson S, Fogarty J, Nguyen L,
Barney P, et al. Feasibility and usability pilot study of a
novel irritable bowel syndrome food and gastrointestinal
symptom journal smartphone app. Clinical and
Translational Gastroenterology, 7, 9. 2016.
Doi:http://dx.doi.org/10.1038/ctg.2016.9
NUTRITION IN ACTION CASE STUDY 3: COMMUNITY SETTING
BY L INA BR IEK
Case Study – Mr. APP (A Pancreatic Problem)
By Lina Breik
Mr. APP is a 54yearold male admitted to the gastroenterology ward with pancreatitis on the background of alcohol abuse.
His wife died not too long ago from cancer and since, he has spiraled downwards losing his job, increasing his
dependence on alcohol, consuming high fat junk food (if anything), and losing of his 9% body weight in 3 weeks.
Mr. APP is quite distressed on admission and you have been asked to assess his nutritional status. Mr. APP is fatigued,
nauseated and in severe pain when you go to assess him.
Q1. What energy and protein requirements would you be aiming to reach during his hospital stay?
Q2. What macronutrient(s) would you be taking into account when selecting an appropriate oral nutrition
supplement?
By day 3 when you go to review Mr. APP’s progress, the doctors had upgraded him to a free fluid diet.
Q3. List 4 clinical/biochemical signs of resolving pancreatitis?
On day 4, during handover meeting, you hear Mr. APP had a rough night. He vomited 500mls of bile and his abdomen has
become severely distended. He is now nil by mouth (NBM) with a nasogastric tube (NGT) insitu on free drainage.
Q4. What could potentially be causing this vomiting and abdominal distension?
You return to review Mr. APP on day 6. He is still NBM, with a mild reduction in NGT output from 2L on day 4, 1.2L on day
5 and 500mls by 1500 when you review him on day 6. The doctors have documented no improvement in abdominal
distension, ongoing nausea, NGT to remain on free drainage and to continue NBM.
Q5. Would you recommend parenteral nutrition? Please explain your reasoning as to why or why not.
DAA GASTRO IG NEWSLETTER ISSUE 04
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PRACTITIONER HIGHLIGHTBY TRANG SOR IANO
DAA GASTRO IG NEWSLETTER ISSUE 04
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Could you please give me a background of your clinical experience and where you currentlywork?
I graduated with a Bachelor of Nutrition and Dietetics from Monash University in 2008, but chose to add
on an honours research year, knowing I would possibly like to complete a PhD later in my career. I was
lucky enough to secure a new graduate position at Monash Medical Centre which gave me a fantastic
and varied clinical knowledge base. When this position ended I used the opportunity to do some
overseas travel, and on returning home in 2011, I started at The Royal Melbourne Hospital where I have
worked ever since, moving from a rotational position gaining experience in many different caseloads,
and eventually specialising in Gastroenterology and Intensive Care.
What does your role entail? Could you describe your average day at work?
I am lucky enough to have a diverse clinical role at RMH, working with both in and outpatients with
Gastroenterological conditions, as well as in the Intensive Care Unit. I typically start my day by attending
the ICU ward round where I would advise on the nutritional management of critically ill patients including
optimal feeding routes and composition of formulae. I then head to the wards and see a range of
patients under the care of the gastroenterology unit including those with IBD, liver disease, intestinal
failure, and those requiring enteral and parenteral nutrition. Once a week I run an outpatient
Gastroenterology Nutrition Clinic where I follow up recently discharged inpatients, or see patients with
newly diagnosed coeliac disease, functional GI disorders, and the 30or so home enteral nutrition (HEN)
patients I look after. Of course thrown in there are department meetings with the Dietetic team,
multidisciplinary meetings with medical and allied health staff, work on quality improvement projects, and
daytoday operational tasks.
What are the main gastroclinical patient group/s you see?
On the wards, the most common patient groups I see would be inflammatory bowel disease, chronic
liver disease, acute pancreatitis, and intestinal failure/short gut. Working with one of the leading
Australian Gastroenterologists in motility disorders, particularly Gastroparesis, the RMH tends to be a
referral hub for these patients and this makes up a large part of my outpatient and HEN caseload.
SEN IOR CL IN IC IAN : JESS ICA PETERS ,GASTROENTEROLOGY AND INTENS IVE CARE
PRACTITIONER HIGHLIGHT - CONT...BY TRANG SOR IANO
DAA GASTRO IG NEWSLETTER ISSUE 04
SEN IOR CL IN IC IAN : JESS ICA PETERS ,GASTROENTEROLOGY AND INTENS IVE CARE
How do you keep current on the changing science of nutrition?
To keep uptodate with the latest literature I subscribe to email alerts from the key journals in Clinical Dietetics
and Gastroenterology, attend weekly Professional Development meetings both with the Gastro unit and the
Dietetics department, and keep an eye on the DAA interest group emails. I usually try to attend one local or
international conference each year, and last year was fortunate enough to attend the combined World
Gastroenterology Organisation (WGO)/AuSPEN conference in Brisbane, enabling me to learn about exciting
new research, and complete 2 ESPEN lifelong learning courses which I would highly recommend.
What’s the best thing you like about your job?
The thing I like most about my job is that every day is different. I enjoy trying to wrap my head around a complex
clinical case, and the fact that I can still learn something new on most days. One of the most rewarding moments
for me is seeing patients who have been in hospital for months, have had multiple surgeries or setbacks, finally
transition from PN or EN to oral diet and reach the point where they are well enough to get home and back to
work or to the things they love doing.
What are some gastro related challenges you find about your job?I find functional gastroenterology one of themost challenging areas, but also one of the most fascinating. There is often such an interplay of psychological
factors and dietary factors, and it can be very difficult to separate these out, and to help the patient to
understand the influence that their state of mind can have on their symptoms.
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NEW TO PENBY TRANG SOR IANO
Position Paper: Introduction of Gluten into Infant's Diet
Gluten Introduction and the Risk of Coeliac Disease. A Position Paper by the European Society for
Pediatric Gastroenterology, Hepatology & Nutrition (ESPGHAN) and described in a Newswise
post. Bottom line: there is no evidence that timing of gluten introduction affects celiac disease risk.
The guidelines will be reviewed and incorporated into PEN as appropriate.
Posted: 20160119
DINER UPDATE BY LAUREN REECE
DAA GASTRO IG NEWSLETTER ISSUE 04
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Keeping Up to DateThis edition includes the regular update of recently added resources to DINER, however also includes
some other free resources available to assist with self education and keeping up to date.
If you are currently using freely available apps/ resources/ podcasts/ websites to keep up to date and you
think others may also benefit, please get in touch to have it included in the newsletter
DINER Webinars
2016 Nutrition Trends and Highlights by Sarah Hyland, Brooke Longfield and Alison BaldwinAn overview of the 2016 nutrition trends and highlights from a consumer insight, media and food industry
perspective.
Downloadable from DINER
How to facilitate a cooking class Charlotte Miller, APD and Chef: Reviewed March 2016)The presentation covers: Logistics of running a class group size, location, cost, equipment Personal requirements insurance, food handling, food safety
Popular meals and request
Tips for success
$38 through www.educationinnutrition.com.au
Inflammatory Bowel Disease by DR Guru Iyngkaran, PHD, Gastroenterologist (Reviewed February2016)The presentation covers: Pathophysiology of Crohn’s disease and ulcerative colitis Diagnosis and management
Complications Dietary considerations$38 through www.educationinnutrition.com.au
Iron and Zinc by Associate Professor Lynn Riddell, Registered Nutritionist (Reviewed February2016)The presentation covers:
Metabolism and functions of iron and zinc
Deficiency of iron and zinc
Food sources and current intakes
$38 through www.educationinnutrition.com.au
DINER UPDATE - CONT...BY LAUREN REECE
DAA GASTRO IG NEWSLETTER ISSUE 04
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Science into Literacy Symposium 2016, Meat and Live Stock Australia
A collection of presentations including
Associate Professor Felice Jacka ‘If improve my diet, will my mental health improve?’
Dr Jane Muir ‘How much of which dietary fibres is required to achieve optimal gut health?’
Dr Lisa Houghton ‘Complementary feeding practices in Indonesian infants: Opportunities for optimizing
nutrition’
Prof Carpk Nowson ‘Guidelines for active ageing’
Anna Rangan ‘Portion Size: What are Australians eating? An analysis from the Australian health Survey
20112012’
Prof Manny Noakes ‘Diet quality, quantity and GHG emissions: is there a link?’
Downloadable for free from DINER
DINER Websites and Resources
Telehealth /Technology based Clinical Consultations by DAA
Outlines the considerations that are needed when providing consultations over the phone or internet.
Downloadable for free from DINER
Antiinflammatory Eating: Recipes from you Dietitian’s Kitchen by Chloe McLeod, Monica Kubizniak,
Kate Bennet, BJC Health
The first ecook book to be released by BJC Health for people with inflammatory conditions such as arthritis,
autoimmune conditions, obesity, CVD, diabetes or people wanting to improve their health and prevent lifestyle
conditions. Includes 50+ recipes with modifications for low FODMAP diets.
$9.99 Available from http://shop.bjchealth.com.au
Australasian Society of Clinical Immunology and Allergy (ASCIA)
Food Allergy eTraining for Dietitians
This course focuses primarily on IgE mediated food allergy and provides information on how to manage
patients including patient education. The course includes a module on conditions associated with food allergy
such as FPIES and EoE.
Allergy Clinical Update for Dietitians
This document complements the ASCIA Food Allergy etraining. The document provides an evidenced based,
quick reference guide to assist Dietitians in the management of patients with IgE and nonIgE mediated food
allergy.
Infant Feeding Advice and ASCIA Guidelines for Allergy Prevention in Children
Infant feeding for prevention of allergy; when to introduce complementary foods; introducing allergenic foods;
general infant feeding information; other allergy prevention recommendations.
All ASCIA resources available for free at http://www.allergy.org.au/
DINER UPDATE - CONT...BY LAUREN REECE
DAA GASTRO IG NEWSLETTER ISSUE 04
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Other Useful Resources
QxMD A smart phone app is a single platform to keep up to date with the latest scientific andmedical research, topic reviews and allows you to search Pub Med. Using the App you can get full
text PDFs through the app or your institution subscription, follow key words, collections or journals,
share articles with colleagues and organise your personal library.
Downloadable from Smart phone App Stores or www.qxmd.com
Research Gate A networking website for scientists and researchers around the world. Thewebsite allows you to access and discuss publications, share work at any stage of the research
cycle, ask and/or answer questions, get stats on your research and citations and connect with
colleagues.
www.researchgate.net
MEDICAL UPDATEBY LAUREN REECE & FEL IC I TY R ITORN I
DAA GASTRO IG NEWSLETTER ISSUE 04
MEDICATIONS
Chronic Hepatitis C (HBV)
Asunaprevir
Asunaprevir is an antivital drug used in chronichepatitis C compensated liver disease,including cirrhosis It is used in combination withother antivirals such daclatasvir or withdaclatasvir, peginterferon alfa and ribavirin. Itworks by inhibiting the viral nonstructural 3/4Aserine protease required for viral replication.Use is contraindicated in moderate or severehepatic impairment (ChildPugh class B or C)and in those with decompensated cirrhosis as itmay cause hepatotoxicity.http://www.australianprescriber.com/
Gastric cancer
Ramucirumab
Ramucirumab is a monoclonal antibody used
in patients with advanced or metastatic
gastric or gastrooesophageal junction
adenocarcinoma. It works by binding to
vascular endothelial growth factor receptors,
which is important in the progression of
gastric cancer. It is most often used in
combination with paclitaxel or as
monotherapy if paclitaxel cannot be given
when the disease has progressed after
cytotoxic chemotherapy.
http://www.australianprescriber.com/
Ibavyr (ribavirin)
Ribavirin is a nucleoside analogue used in
treatment of chronic hepatitis C with other
agents such as peginterferon alfa, daclatasvir or
sofosbuvir. It works by interfering with RNA and
DNA synthesis, thereby inhibiting protein
synthesis and viral replication. the different
treatment combinations used with ribavirin
depend on the viral genotype, the patients
cirrhotic status and whether thet have previously
received treatment for HCV infection
https://amhonline.amh.net.au.acs.hcn.com.au/
Nausea and vomiting
Akynzeo
Akynzeo is a fixed combination of Netupitant
and Palonosetron used for the prevention of
acute and delayed nausea and vomiting
associated with initial and repeat courses of
cancer chemotherapy.
http://www.medicines.org.au/files
/mfpakynz.pdf
cont...
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MEDICAL UPDATE - CONT... BY LAUREN REECE & FEL IC I TY R ITORN I
DAA GASTRO IG NEWSLETTER ISSUE 04
JOURNAL ARTICLES:
ESPEN guidelines on chronic intestinal failure in
adults
Chronic Intestinal Failure (CIF) is the longlasting
reduction of gut function, below the minimum
necessary for the absorption of macronutrients
and/or water and electrolytes such that intravenous
supplementation is required to maintain health
and/or growth. These guidelines provide
comprehensive recommendations for safe and
effective management of adult patients with CIF.
Pironi L; Arends J; Bozzetti F; Cuerda C; Gillanders
L; Jeppesen PB; Joly F; Kelly D; Lal S; Staun M;
Szczepanek K; Van Gossum A; Wanten G;
Schneider SM; Home Artificial Nutrition & Chronic
Intestinal Failure Special Interest Group of ESPEN.
ESPEN guidelines on chronic intestinal failure in
adults. [cited May 2016] Clinical Nutrition.
35(2):247307, 2016 Apr.
Available http://www.ncbi.nlm.nih.gov/pubmed
Gastroparesis and Malnutrition
This article outline a systematic approach to
consider in complex patients with gastroparesis.
Strategies include nutritional screening, diet
recommendations, medical therapies, nutrition
monitoring and enteral/parenteral nutrition.
Bharadwaj S; Meka K; Trandon P; Rathur A; Rivas
J; Vallabh H; Jevenn A; Guirguis J; Sunesara I;
Nischnick A; Ukleja A. The management of
gastroparesis associated malnutrition [cited May
2016] Journal of Digestive Diseases 2016 Apr
PMID: 27111029
Iron Deficiency, Zinc Magnesium, Vitamin
Deficiencies in Chrohn’s disease: Substitute
or Not?
A review article focuses on at risk nutrients in
Chrohn’s disease and provides recommendations
for treatment of deficiencies.
Kruis W; Ngygen GP. Iron Deficiency, Zinc
Magnesium, Vitamin Deficiencies in Chrohn’s
disease: Substitute or Not? [cited May 2016]
Digestive Diseases. 34;12:105111, 2016 Apr
FODMAPs Systematic Review and MetaAnalysis
A review to determine the evidence for a low
FODMAP diet in the treatment of functional
gastrointestinal symptoms. Six RCT and 16
nonrandomized interventions were assessed.
Low FODMAP diets were found to reduce IBS
SSS scores and symptom severity and increase
scores on the IBSQOL.
Marsh A; Eslick EM; Eslick GD. Does a diet low in
FODMAPS reduce symptoms associated with
functional gastrointestinal disorders?A
comprehensive systematic review and
metaanalysis. [cited May 2016] European
Journal of Nutrition 55;3:897906, 2016 Apr
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cont...
MEDICAL UPDATE - CONT... BY LAUREN REECE & FEL IC I TY R ITORN I
DAA GASTRO IG NEWSLETTER ISSUE 04
Should Perioperative Immunonutrition be
Standard Care?
This review discusses the positive postoperative
outcomes associated with immunonutrtion, the cost
effectiveness, the current guidelines and future
directions of care.
Bharadwaj S; Trivaz B; Tandon P; AlkmaB;
Hanouneh I; Steiger E. Should perioperative
immunonutrition for elective surgery be the current
standard of care? [cite May 2016] Gastroenterology
Report 2016 Apr,
doi: 10.1093/gastro/gow008
Gastroparesis and Malnutrition
This article outline a systematic approach to
consider in complex patients with gastroparesis.
Strategies include nutritional screening, diet
recommendations, medical therapies, nutrition
monitoring and enteral/parenteral nutrition.
Bharadwaj S; Meka K; Trandon P; Rathur A; Rivas
J; Vallabh H; Jevenn A; Guirguis J; Sunesara I;
Nischnick A; Ukleja A. The management of
gastroparesis associated malnutrition [cited May
2016] Journal of Digestive Diseases 2016 Apr
PMID: 27111029
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NUTRITION IN ACTION CASE STUDY: ANSWERS
DAA GASTRO IG NEWSLETTER ISSUE 04
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Q1. What energy and protein requirements would you be aiming to reach during hishospital stay?
Energy: 105 – 147 kj/kg/day
Protein: 1.2 – 1.5 g/kg/day
Carbohydrates: 36 g/kg/day
Fat: 2 g/kg/day
References: ESPEN Guidelines on nutrition in acute pancreatitis; Meier R, Beglinger C, Layer
P, et al. Clinical Nutrition (2002); 21(2), 173 183ESPEN Guidelines on Enteral Nutrition:
Pancreas; Meier R, Ockenga J, Pertkiewicz M, Pap A, et al. Clinical Nutrition (2006); 25, 275
284
Q2. What macronutrient(s) would you be taking into account when selecting anappropriate oral nutrition supplement?
Reference suggestion: See page 179 of the ESPEN Guidelines on nutrition in acute
pancreatitis; Meier R, Beglinger C, Layer P, et al. Clinical Nutrition (2002); 21(2).
By day 3 when you go to review Mr. APP’s progress, the doctors had upgraded him to a free
fluid diet.
Q3. List 4 clinical/biochemical signs of resolving pancreatitis?
1. Creactive protein (CRP) trending downwards
2. Reduced abdominal pain on ingestion of oral intake
3. Reduced feelings of nausea, absence of vomiting
4. Normalisation of bowel habits
References: Oxford Handbook of Clinical Medicine; Longmore M, et al. 2001 Oxford Handbook
of Nutrition and Dietetics, WebsterGandy J, et al. 2012
On day 4, during handover meeting, you hear Mr. APP had a rough night. He vomited 500mls of
bile and his abdomen has become severely distended. He is now nil by mouth (NBM) with a
nasogastric tube (NGT) insitu on free drainage.
NUTRITION IN ACTION - CONT CASE STUDY: ANSWERS
DAA GASTRO IG NEWSLETTER ISSUE 04
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Q4. What could potentially be causing this vomiting and abdominal distension?
A reactive ileus usually associated with severe pancreatitis.
Reference: Diagnosis and Management of Acute Pancreatitis; Baker S. Critical Care and
Resuscitation 2004; 6: 1727
You return to review Mr. APP on day 6. He is still NBM, with a mild reduction in NGT output
from 2L on day 4, 1.2L on day 5 and 500mls by 1500 when you review him on day 6. The
doctors have documented no improvement in abdominal distension, ongoing nausea, NGT to
remain on free drainage and to continue NBM.
Q5. Would you recommend parenteral nutrition? Please explain your reasoning as towhy or why not.
Reference suggestion: See page 186187 of the Guidelines for the Provision and Assessment
of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Journal of
Parenteral and Enteral Nutrition; 201 (40:2).