Heather Janicki RD CNSC Objectives Nutritional considerations of the patient with inflammatory bowel disease IBD Oral and nutrition support for the IBD patient Complications of IBD patients ID: 930939
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Slide1
Nutrition in Inflammatory Bowel Disease and the Role of Parenteral Nutrition
Heather Janicki, RD, CNSC
Slide2Objectives
Nutritional considerations of the patient with inflammatory bowel disease (IBD)Oral and nutrition support for the IBD patient
Complications of IBD patients
Slide3Inflammatory Bowel Disease (IBD)
Inflammatory disorder of the gastrointestinal tractSymptoms include:
Pain
Nausea
Fever
Diarrhea
Symptoms can lead to impaired nutritional status through
Loss of appetiteReduced nutrient intakeAltered nutrient metabolism
Slide4Unknown Etiology
Higher prevalence in Western lifestyle
Refined carbohydrates, meat and animal fat and low fibre intake
Slide5Inflammatory Bowel Disease
Inflammatory Bowel Disease Crohn’s disease (CD)
Characterized by transmural inflammation of the GI tract, appearing anywhere from mouth to anus
Ulcerative colitis (UC)
Chronic inflammation of the colon
http://images.onhealth.com/images/slideshow/crohns-disease-s5-illustration-of-crohns-disease-and-ulcerative-colitis.jpg
Slide6Crohn’s Disease
Nutritional deficiencies and malnutrition have been well documentedUp to 80% of patients may have some degree of malnutrition
65-75% of inpatients and over 50% of outpatients with CD experience significant weight loss
Result of:
Decreased oral intake/ fear of eating
Abdominal pain
Diarrhea/ nausea
StricturesMalabsorption (previous resections)
Slide7Crohn’s DiseaseFurther complications affecting nutrition therapy
FistulasBowel perforations or abscessBowel stricture or obstructionPrevious resections or surgeries leading to short bowel syndrome
Slide8Crohn’s Disease
Nutrition needsEnergy requirement
Elevated resting energy expenditure during active inflammation
Protein requirement: 1-1.5 g/ kg, up to 2 g/ kg with malnutrition
Increased with active inflammation or losses due to fistulas etc.
Increased in post operative period
Fibre
No proven regimen for fibre intake although common for CD patients to follow low fibre diet
No controlled trials show a benefit in a low fibre diet for symptom improvement, decreased admissions or incidence of small bowel obstructions
Slide9Crohn’s Disease
MicronutrientsIron deficiency anemia- secondary to blood loss and malabsorption
35-40% estimated incidence of osteopenia
Corticosteroids, malabsorption
Up to 1500 mg calcium per day, 800-1000 IU of vitamin D per day, vitamin K
Vitamin B 12, fat soluble vitamins (A,D,E,K) if terminal ileum disease
Folate- methotrexate use
Zinc deficiency- high output
enterocutaneous
fistulas or diarrhea
Ileostomy patients
May require additional fluid and sodium
Slide10Micronutrient Absorption
Length
Absorption
Stomach & Pylorus
Alcohol
Increases bioavailability
of calcium, iron, B12
Duodenum
30 cm (12 inch)
Iron, calcium,
magnesium, zinc
Jejunum
2-3 meters
Vit
C, thiamine, riboflavin,
pyridoxine, folic acid
Ileum
3-4 meters
Vit
A,D,E,K, fat, cholesterol, bile salts,
vit
B12
Large Bowel
1.5 meters
Water,
sodium, potassium, oxalates,
SCFA,
vit
K
Slide11Ulcerative Colitis (UC)
Protein-energy malnutrition is less common than CD as small bowel is not affected
Nutrition needs
Energy requirements
Elevated resting energy expenditure during active inflammation
Protein requirements: 1-1.5 g/ kg, up to 2 g/ kg with malnutrition
Increased with active inflammation and in post operative period
Potential role of increased fibre dietShort chain fatty acids (butyrate) produced in the colon from fermentation of dietary fibre by colonic microorganisms
Serve as fuel for the
colonocytes
and promote water and sodium absorption
Slide12Ulcerative Colitis
MicronutrientsUp to 80% may develop iron deficiency anemia secondary to blood loss and malabsorption
Higher incidence than CD
25-32% estimated incidence of osteopenia
Corticosteroids, malabsorption
Up to 1500 mg calcium per day, 800-1000 IU of vitamin D per day
Recurrent
pouchitis or management of UC, probiotic VSL -3 (3-6 g/ d) may offer some benefit in preventing relapse
Research is still in the early stages
Slide13Nutrition Assessment
DiagnosisHistory of presenting illness including nutrition and weight loss history
Past medical and surgical history
Medications
Nutritionally relevant blood work
Anthropometrics- height/ weight, significant changes
Diet history, food intolerances and allergies, access to food
Slide14Refeeding Syndrome
Screen for patients at moderate to severe malnutrition Severe weight lossAggressive feeding of dextrose can cause electrolyte abnormalities and multiple serious complicationsIf electrolyte levels are low (K, Mg, PO4) replete before starting PNMonitor closely
Start with 100 grams dextrose/ day,
lower calories
Low sodium, may need lower volume to start
Monitor K, Mg, PO4 closely. May need higher end of range in PN or additional boluses.
Slide15Nutrition Therapy
Determine appropriate route of feeding (oral, enteral and/ or parenteral), what to feed and how aggressive to feed
Supplementation required (vitamins, minerals, protein)
Any diet restrictions required
Monitoring
Amount of prescribed nutrition received
Tolerance to nutrition regime, bowel care
Changing clinical picture and requirementsEducation needs
Slide16Benefits of Nutrition Therapy
Prevents or treats malnutrition and micronutrient deficienciesHelps prevent/ reduce loss of lean body mass
Improves GI tract structure and functions
Improves wound healing
Decreased hospital admission and length of stay
Consequences of Malnutrition
Growth failure in pediatrics
Weight lossBone diseaseMicronutrient deficiencies
Slide17Oral Diet in IBDNo diet restrictions, especially when in disease remission
Based on individual toleranceDuring flare upMay have a temporary intolerance to lactoseSome may prefer low fibre foodsCrohn’s patients with strictures
Avoid high fibre foods- nuts, seeds, tough fruit/ vegetable skins, corn, popcorn, celery
Patients with ileostomies
May require additional fluid and sodium
Slide18Enteral Nutrition (EN)
Commonly given via a nasogastric tube or can be provided orally
Polymeric formulas:
Contains whole proteins, carbohydrates
etc
and are palatable
Semi-elemental or elemental formulas
Contains nutrients that are partially or fully broken downRequire little to no digestion prior to absorptionStudies have not shown any difference between formulas
Slide19Enteral Nutrition
Indicated in both CD and UC to meet nutritional needs
EN may be the first line of therapy in some children to promote remission of CD
Given exclusively for 6-8 weeks, mostly as polymeric
Lower recurrence rates in patients treated with EN versus normal diet
EN provided as 50% of calories
Adult patients: may be less effective as a sole treatment compared to corticosteroids
in CDEvidence is limited to support the use of EN as primary therapy for treatment of UC
Can be used in active flares, similar rates of remission and need for surgery compared to PN
Slide20Enteral Nutrition
Mechanism of how EN improves outcomes in CD is unclear. Theories include:
Altered or reduced gut microbiota
Avoidance of food additives- emulsifiers, colourings
etc
Prevention/ correction of malnutrition- improved wound healing and gut permeability
Benefits:
Maintain gut integrityNo long term adverse effectsCost efficient
Fewer complications than parenteral nutrition
Slide21Enteral Nutrition
Long-term challenges:Access-
Naso
gastric tube versus G- tube
Palatability, length of time without solid food
Cost of EN formulas
High relapse rate when patient returns to normal diet
? Weaning period of 2-4 weeks may help relapseEN provided as 50% of calories
Slide22Parenteral Nutrition
Infusion of dextrose, amino acids, IV fat emulsion (IVFE), electrolytes, vitamins and trace elements through an IVGoal: prevent or correct nutritional deficiencies and malnutrition when the function of the GI tract is inadequate or bowel rest indicated2 types
Central Parenteral Nutrition (CPN) often referred to as Total Parenteral Nutrition (TPN)
Peripheral Parenteral Nutrition (PPN)
Slide23Parenteral Nutrition
ObjectivesMaintain or replace lean body mass, macronutrient and micronutrient deficiencies when enteral/ oral feeding is contraindicatedProvide fluids with care to prevent over-hydration or dehydrationAdvance to oral/ enteral feeds as soon as possible
Minimize complications
Slide24Parenteral Nutrition
Not recommended for primary or maintenance therapy in CD or UC
Historically used for patients on bowel rest
Bowel rest- limit intestinal exposure to proinflammatory agents, allow for mucosal healing and reduce risk of surgical interventions
No conclusive role for TPN or bowel rest.
May reduce bowel movement frequency and stool weight
May reduce need for surgery in CD but not UC patients
No difference at one year remission rates for PN and bowel rest, EN or supplementary PN with unrestricted food
Slide25Parenteral Nutrition
Indications
Essential in very severe cases
When enteral nutrition is not tolerated
Inability to maintain weight and nutrition status on oral and/ or enteral nutrition
Short bowel syndrome
Small bowel obstruction
High output fistulas when EN is not feasibleIntractable diarrhea/vomitingProlonged ileus
NPO > 7 days
Slide26Fistulas
Enterocutaneous fistulas:
Abnormal communication between the intestine and the skin
Often occur 7-10 days after surgery
Enteral nutrition indicated:
low output fistulas (<500 mL/d)
Proximal fistula if able to feed distally
Distal ileal or colonic fistulas
Parenteral nutrition indicated:
Pancreatic fistula
Jejunal/
ileal
high output fistula
Any fistula when distal access is not possible
Slide27Short Bowel Syndrome
Inadequate absorption of the small bowel resulting from loss of bowel length and/ or function
< 200 cm of small bowel remaining
>70-90 cm of small bowel with intact colon can usually regain autonomy from PN
130-150 cm if colon is removed
Factors affecting adaptation of the bowel
Length of remaining bowel/ health of the bowel
Section of bowel resected
Slide28Short Bowel Syndrome
Primary goal is to regain/ maintain as much gut function possibleFirst phase- post operative- significant fluid loses and hypersecretion of gastric fluids
Second phase- gut adaptation period up to 2 years post operative
Must determine the length of bowel remaining, terminal ileum and amount of colon remaining
Vitamin/ mineral levels should be monitored. At baseline, 3 months post surgery and then annually
At risk for fat soluble vitamin deficiencies, vitamin B12 and zinc
Slide29Parenteral Nutrition
ContraindicationsFunctional GI TractPreviously well nourishedTPN for less than 7 days in well nourished patientsPoor prognosis
Risks exceed benefit
Slide30Parenteral Nutrition
ComplicationsPN can be life saving/ sustaining but can also be associated with serious complicationsMacronutrient (hyperglycemia, azotemia etc.)Fluid and electrolyte, acid base imbalance
Micronutrient ( may require extra zinc, selenium, TPN contains no iron, excess manganese, copper)
Hepatobiliary (parenteral nutrition associated liver disease)
Metabolic bone disease
Infections
Slide31Parenteral Nutrition
MonitoringBloodwork- electrolytes, triglyceride, glucose, liver/ renal functionWeight- dehydration, fluid retentionIns and outs
Medical condition- continually re-assess for need for PN
Line infection/ complications
Slide32Summary
Crohn’s Disease
Ulcerative Colitis
Induce remission
Maintain remission
Post op.
Induce remission
Maintain remission
Post op.
Pouchitis
Enteral Nutrition
Children:++
Adults: +
++
+
No effect
No effect
No effect
Not tested
TPN
+
No effect
Not tested
No effect
No effect
No effect
Not tested
Probiotics
No effect
No effect
No effect
+
+
Not tested
++
Slide33Questions
Slide34References
Mueller, C., McClave, S., & Kuhn, J. M. (2012).
The A.S.P.E.N. adult nutrition support core curriculum
. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.
(
n.d.
). Retrieved September 10, 2017, from http://www.uptodate.com/contents/nutrition-and-dietary-interventions-in-adults-with-inflammatory-bowel-disease
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