A Casebased Approach to Gastroenterology Kimberly Carter MS PAC Division of Gastroenterology University of Pennsylvania KimberlyCarter2uphsupennedu Nutrition Why should we care Nutrition is an essential component of healthcare and is apart of most of what we do as GI specialist ID: 934664
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Slide1
Nutrition 101: When, What, How to Feed
A Case-based Approach to Gastroenterology
Kimberly Carter, MS, PA-C
Division of Gastroenterology
University of Pennsylvania
Kimberly.Carter2@uphs.upenn.edu
Nutrition: Why should we care….
Slide3Nutrition is an essential component of healthcare and is apart of most of what we do as GI specialists.
Slide4Objective
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.
Slide5Slide6Nutrition in GI Disease:
Nutritional Status
Slide7Nutritional Assessment
Food and Nutrition related historyMedical, Surgical, and Social historyAnthropometric measurementsNutrition 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.
Slide8Food and Nutrition Related History
Dietary intake: 24 hour recallUse of dietary supplementsEating difficulties : poor dentition, taste disturbances, dysphagiaGastrointestinal complaints: Nausea, vomiting, abdominal pain, diarrhea, constipation
Slide9Medical History
Critical illness or chronic diseasePancreatic insufficiencyIBDCeliac disease
Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency.
Journal of Parenteral and Enteral Nutrition
. 2002;26(5):S29-S33.
Slide10Surgical History
Major abdominal surgery, traumaPrevious GI surgeryFistula, 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.
Slide11Social History
Living environmentCaregiverFunctional statusAlcohol or substance abuseMental health
Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency.
Journal of Parenteral and Enteral Nutrition
. 2002;26(5):S29-S33.
Slide12Anthropometric Measurements
HeightWeightUsual Body Weight (UBW)Weight loss
10 lbs. weight loss over 6 months is noteworthy
>10% of UBW
BMI
<
18.5 underweight
Slide13Nutrition focused PE findings
Loss of muscle mass and subcutaneous fatEdema 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.
Slide14Physical Signs
Signs
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 B6Magenta TongueVitamin B2Loss of DTRsVitamins 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).
Slide15Poor nutrient intake and excessive losses may contribute to malnutrition.
Slide16Case 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
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
Slide18Assessment: Is this patient malnourished?
Slide19Nutrition in GI Disease:
Nutrition Support
Slide20Nutrition Intervention
Oral nutrition supplementsEnteral NutritionParenteral Nutrition
Slide21Nutrition Support
Slide22Enteral Nutrition Support
Functioning GI tractShort vs. Long TermNG/NJ vs. PEG/PEJGastric: Bolus feedings
Jejunal
: Continuous feedings
Disease Specific Formulas
Slide23Parenteral Nutrition Support
Non-functioning GI tractCentral or PICCEN vs. PN (Complications)
Slide24Nutrition Support
Multi-disciplinary teamRefeeding Syndrome
Slide25Case 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.
Slide26Prognosis of Short Gut Syndrome (SGS)
Presence of residual underlying diseaseLength of remaining small intestinePresence 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
Slide27Clinical Consequences SGS
Table 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
Slide28Bowel Adaptation SGS
Gastric hypersecretionIncreased
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
Slide29Short Gut Syndrome Medical Nutrition Therapy (MNT)
Table 2. General Management Strategies for SBS
Fluids
Avoid drinking water without food
Spread fluid intake throughout the day
Sip liquids
Restrict hypotonic fluids
Drink
oral rehydration solution containing salt and
carbohydrates
Diet
Eat small, frequent meals balanced in nutrient content
Add salt to the diet (only for patient with colon in continuity)
Increase quantity of food intake
Follow 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
Slide30Short Gut Syndrome MNT
Hypomotility agentsRotating antibioticsEnzyme replacement
Slide31Short Gut Syndrome
Site
Nutrient
(s) absorbed
Stomach
Cu, I
Duodenum
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, folateShortgutsupport.com
Slide32Nutrition in GI Disease:
Nutritional Therapy
Slide33Case 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 negativeEndoscopic evaluation unremarkable
Micronutrient deficiencies: Calcium, Zinc, Vitamin D, B12
Slide34Nutrition and RYGB Malabsorption
Many patients stop supplements after bariatric surgeryLook for other micronutrient deficienciesOften subtle deficiencies are asymptomatic
Slide35Nutrition and Malabsorption
HypoalbuminemiaSteatorrheaFe deficiency anemiaB 12 deficiency
Thiamine deficiency
Slide36Nutritional Therapy
60-120 grams of protein dailyLong-term vitamin/mineral supplementationPeriodic 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.
Slide37Biochemical Monitoring
6, 12, 18, 24 months then annuallyFe, 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.
Slide38Dietary modifications
Consume small frequent mealsAvoid ingestion of liquids within 30 min of solid foodAvoid simple sugarsIncrease intake of fiber and complex carbohydrates
Increase protein intake
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.
Slide39Case 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
Slide40Nutrition and IBD
Nutrient deficiencies Hypoalbuminemia Fe
B12
Vitamin D
Folic acid
Calcium
Magnesium
Slide41Nutritional Therapy
Vitamin/Mineral RepletionElimination DietLactose FreeLow ResidueProbiotic
Slide42Case Study # 5
23-year-old female with history of Type I DM presents with bloating, flatulence, and diarrhea in the setting of anemiaPositive celiac serology with duodenal biopsy c/w villous atrophy
Slide43Nutrition and Celiac Disease
Micronutrient deficienciesPancreatic insufficiency
Slide44Gluten-free diet
Eliminates wheat, rye, and barleyRice, corn, millet, potato, buckwheat, and soybeans are safeCommon gluten free foods
fresh fish, meats, milk, cheese, fruits,
vegetables
Gluten-free substitutes are often expensive and may be difficult to access
Slide45Management of Celiac Disease
C
Consultation with a skilled
dietitian
E
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.
Slide46Nutrition in GI Disease:
Nutritional Therapy
Slide47Nutrition and IBS
Multifactorial: visceral hypersensitivity, gut flora, diet
Slide48Nutritional Therapy
Lactose Free dietProbioticsFiber Supplements (Psyllium)FODMAP Diet
Slide49FODMAP
Fermentable OligoDiMonosaccharides and Polyols
Poor absorption
Osmotic effect
B
acterial fermentation
Simren M. Diet as a Therapy for irritable bowel
s
yndrome: progress at last.
Gastroenterology
. 2014;146(1):10-12.
Slide50Absorption of FODMAPs
Presence or absence of enzymesSmall 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.
Slide51FODMAP Diet
Fedewa
A,
Rao
S. Dietary Fructose Intolerance,
Fructan
Intolerance and FODMAPS
.
Current Gastroenterology Reports
. 2014;16(1):370.
Slide52FODMAP Approach
Barrett, J. Extending our knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms.
Nutrition in Clinical Practice
. 2013;28(3):300-306
Slide53FODMAP Approach
Provides therapeutic strategy to manage symptoms.Use of dietitian is paramount.Address long-term efficacy and safety of dietary intervention.
Slide54Nutrition and GERD
Chronic acid exposureReflux triggering foodsSpicy
Acidic
Citrus
Fried/Fatty
Caffeine, coffee, cola
Spearmint/Peppermint
Chocolate
Alcohol
Slide55Nutritional Therapy
Dietary/Behavioral ModificationsAvoidance of reflux triggering foodsSmall 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
Slide56Nutrition and Gastroparesis
Hypomotility disorderEtiology: Idiopathic, post-viral, diabetic
Slide57Nutritional Therapy
Dietary/Behavioral ModificationsSeveral small frequent mealsAvoid high fat and fiber foods
Chew food slowly/thoroughly
Sit upright
Active
Digestive Enzymes/Probiotics
Slide58Nutrition and Eosinophilic
EsophagitisChronic allergic diseaseElimination diet
Slide59Nutritional Therapy
Six-Food-Elimination DietMilkEggs
Nuts
Wheat
Fish/Shellfish
Soy
Slide60Therapeutic Approach
Treat underlying etiologyDietVitamin/Mineral supplementation
Nutrition support
Pharmacotherapy
If underlying etiology is irreversible-target symptoms
Anti-diarrheal
PERT
Slide61In Summary
Recognize nutrition is apart of most of what we do as GI specialistsUnderstand the impact of GI disease on nutritional status Utilize a nutrition assessment to dictate intervention
Consult with a dietitian
Work with multi-disciplinary team