2018 Dietetic Internship Workshop
SNDA meeting recording (02/19/2021)
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Small Intestine Anatomy
Small Intestine Anatomy ▪ Duodenum > Jejunum > Ileum > Ileocecal valve
1. Pyloric sphincter (from stomach) TO duodenum
2. Jejunum
3. Ileum
4. Ileocecal valve from S.I to colon
Duodenum > Jejunum > Ileum > Ileocecal valve
▪ Maximum surface area for digestion and absorption
▪ Folds
▪ Villi
▪ Microvilli
▪ “brush border”
· Why is this surface area so important for digestion and absorption (increased surface area)
Motility
▪ Segmentation vs peristalsis
▪ Sphincters (control the rate at which food passes – if something is wrong could affect someone digestion and absorption and how it could affect nutrition that we want to give them)
Secretions
▪ Hormones (see Table 15.1)
▪ Bicarbonate – neutralizes gastric HCl
▪ Enzymes
Know digestion of macronutrients
▪ 1.5 L intestinal juices – water & mucus
▪ Fig 15.4, 15.5 and 15.6
mouth ulcerations ▪ Iron-deficiency anemia
Active transport utilizing Na/K+ pump at brush border
▪ Glucose, galactose, amino acids
Facilitated diffusion
▪ Fructose
Lipids enter lymph via passive diffusion
▪ First converted to micelles and packaged as chylomicrons
▪ Site-specific nutrient absorption, however able to adapt when needed
Large Intestine Functions
Large Intestine Functions: keeps things moving, allows us to defecate
▪ Motility, including defecation
▪ Primarily responsible for absorption of water, electrolytes & vitamins that remain
▪ No enzymatic absorption takes place
▪ Formation/storage of feces (waste products include insoluble fiber, bilirubin, and bacteria)
Intestinal flora ferment fiber
- There to help ferment some of the fibers that we cannot digest, and they produce SCFA, Vit. K, & Biotin
▪ Produce SCFA and lactate
▪ Maintaining optimal balance is area of ongoing research
▪ Synthesizes vitamin K & biotin
Nutrition Assessment (See Table 15.2)
▪ Anthropometrics – especially
▪ weight loss (help us figure out if their issue is causing poor intake/ digestion/ absorption
▪ History of GI surgery / current anatomy (want to know what they’re working with)
GI function/abdominal exam
▪ N/V, diarrhea, constipation, distention, pain, gas, bloating, cramping (when did it start, has it been going on for a long time? Or is it just when you eat food? Is it affecting how you eat?)
▪ Stool color, consistency, odor (Table 15.5) (assess quality of stool)
(ask) Food/fluid intake & eating pattern
▪ Specific restrictions or intolerances
▪ Diet (vege/vegan, low FODMAP, etc)
▪ Meal pattern/frequency ▪ Fiber intake/tolerance
Medications, supplements, herbs (Table 15.3)
▪ Labs: Electrolytes, serum proteins, vitamins/minerals
Stress/triggers (for IBS)
Pathophysiology of Lower GI Tract
Symptoms (may occur by themselves or may be underlying conditions)
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Diarrhea
- Compare to the patient’s baseline, what’s normal for them (N.A.) (we are looking for persistent change in pattern) (once a day is okay but if it’s happening repeatedly then we should be concerned) ( more than 200grams per day for adults or greater than 20grams per day for children) ( having stool measurements can be helpful but kind of just have to assess report and symptoms case by case)
▪ Increased frequency or water content of stools
▪ Affects consistency and/or volume
▪ Compare to patient’s baseline
▪ Acute ( < 2 weeks) versus chronic ( > 4 weeks)
- As acute expect to see dehydration, chronic could cause a more severe malnutrition
▪ Osmotic vs secretory (2 types) (see following slides)
Complications
▪ Dehydration & weight loss (because of increased stools and increased water at risk of dehydration and weight loss, primarily because of water loss but if its chronic could cause actually loss of lean body mass)
▪ Electrolyte and acid-base imbalances (loss of water)
▪ Abdominal pain & cramping (diarrhea is often associated with abdominal cramping and pain, which can affect intake as well)
▪ Presence of blood
▪ Malabsorption / Steatorrhea
Osmotic Diarrhea
▪ Normal: ~300 Osm/L (normal osmolarity of stomach is about 300L if it gets higher than that, that can be what causes osmotic diarrhea)
▪ Increased osmolarity drives water into GI lumen to normalize osmolarity (to dilute it, excess water in GI tract can result in diarrhea and watery stool)
May be caused by
▪ Maldigestion (e.g. lactose intolerance) (lactose sugars don’t get digested, which cause a lot of water to enter the G.I tract to dilute that)
▪ Excessive sorbitol, fructose or lactose
▪ Enteral feeding (rarely) (most are hyperosmolar, like most of our food)
▪ Laxative use
Tx - Remove causative agent
▪ Try isotonic enteral formula (i.e. Osmolite)
▪ Generally, resolves if pt is NPO
Secretory Diarrhea
▪ Underlying disease causes increased secretions
Bacterial, protozoa, viruses
▪ Often seen - Foodborne illnesses, like Clostridium difficile (C. Diff.) (people usually get this while they are in the hospital/ long term care- spreads from person to person and the problem with C. Diff is it doesn’t go away so once a person has it lives forever in their G.I track. When this person gets sick again, or immune system decreases C. Diff tends to flare up and cause S. Diarrhea) (if a person has diarrhea usually want to get a stool sample to see if person has C.Diff to rule that out)
▪ Traveler’s diarrhea (generally caused by bacteria and viruses)
Medications, including antibiotics (see Table 15.3)
▪ Increase GI motility or alter GI flora (which lead to S. Diarrhea)
▪ Other diseases, such as IBD, Celiac, HIV, cancer
▪ Does not resolve when NPO (because this is causing increased intestinal secretions, it would continue to happen, even though their volume might be going down if there not eating – still might see frequent smaller watery stool)
Treat underlying cause and symptoms
▪ Anti-diarrheal meds if not infectious or contraindicated (body is trying to flush out virus and we should let it. If it is a Food Born Illness, we know its bacterial and don’t give anti-diarrheal meds but if it’s caused by underlying condition or meds. That we can’t treat we can give)
▪ Fecal microbiota transplant
Nutrition Interventions for Diarrhea
1. Correct dehydration, electrolyte, acid/base balance (severe- intravenous in a hospital setting)
▪ Oral rehydration solutions ( Pedialyte, home formula – sugar, clean water, salt, sodium decarbonate ( if don’t have Pedialyte))
▪ Avoid high sugar beverages, caffeine, and EtOH (hyperosmolar) (clear liquids are hyperosmolar, which can increase diarrhea/ make worse)
Feed the gut (stimulate the GI tract for normal digestion, absorption, motility) (encourage eating normal food as much as tolerated)
▪ Soluble fiber and resistant starches to thicken stool
▪ BRAT diet, banana flakes, apple powder (easy to digest and tolerated, with not a lot of simple sugars and some fibers)
▪ Avoid foods high in simple sugars and sugar alcohols
▪ Avoid gas-producing foods
▪ Low residue (fiber) diet
Probiotics – repopulate healthy microbiota (yogurt, fermented foods)
▪ Minimal research so no organism or dose recommendations yet
Diarrhea with Enteral Nutrition (wouldn’t really do unless severe malabsorption)
Rule out other causes
- Look at medications are any made with sugar alcohols or hyperosmolar, are they on anti-biotics) (did the diarrhea start when the tube feeding started? Or have they been on tube feeding for a while and now they have diarrhea – if it’s not associated with the tube feeding starting or stopping tube feeding and you don’t see a pattern it’s probably not related).
▪ C diff
▪ Try another formula (Low fiber or high fiber formula just to see how they are tolerating it. Patient on high fiber, switch to low fiber or vice versa) (most fiber in formula is water soluble fiber which could be causing the looser stools) (isotonic formula) (peptide or MCT formula – already broken down, easy to digest)
▪ Low fiber vs high fiber
▪ Isotonic
▪ Peptide / MCT based
▪ Assess for malabsorption (diarrhea long-term, assess for malabsorption – if having enteral nutrition want to make sure there absorbing it, if there stools are the same color/ consistency as tube feeding, bad sign, not digesting anything – may have to assess if they need parental nutrition or more broken down formula) (loose stools but are digesting formula, maybe something they just have to deal with)
▪ Monitor hydration and skin
Preventing Diarrhea (assess these things)
▪ Improving access to clean water and safe sanitation
▪ Promoting hygiene education
▪ Exclusive breastfeeding
▪ Immunizing all children, esp rotavirus
▪ Keeping food and water clean
▪ Sanitary disposal of stool
Constipation - Definition
- Important to establish patients baseline and time frame – so again, ask clarifying questions – what do you mean? How often has this been going on? How many times a day do you have bowel movements? Etc..
Many subjective definitions
▪ Decrease in frequency of bowel movements
▪ Straining
▪ Hard stools
▪ Incomplete evacuation
▪ Establish baseline pattern & timeframe!
Rome Consensus Criteria (REVIEW)
▪ Symptoms >3 months (3-6 months, chronic)
▪ Define Criteria
May cause fullness, decreased appetite/intake
Constipation – Etiology
▪ Decreased motility/slowed colonic transit time
▪ Rectal outlet obstruction, adhesions, tumors
▪ Fecal impaction (obstruction in rectum, which could be a physical blockage- something that wasn’t digested (not food), adhesions (tissues of GI tract stick together), tumors) (rule of colon is to absorb water so if this isn’t happening, stool gets harder and harder to pass)
▪ IBS
▪ Neuro or inflammatory diseases like scleroderma, MS, Parkinson’s, para/quadriplegia (In lower half- often lack sensation to control muscles to pass stool, has to be monitored)
Side effect of medications, supplements
▪ Opioids
Diet & lifestyle (low in water, fiber, sedentary can contribute) (usually happens when change in lifestyle happens)
Constipation – Dx and Tx
Diagnosis
▪ Usually by report (patient saying “I have constipation” and asking those direct questions to determine if they meet criteria)
▪ May need radiographic or colonoscopy to find etiology
Treatment
▪ Underlying etiology
▪ Laxatives (to increase stool outputs, add more fluid), enemas, digital stimulation (stimulating anus to release stool)
▪ Surgery (tumor, adhesions)
Nutrition Interventions for Constipation
Recommend increased fiber intake (slowly because can cause diarrhea, gas and bloating) (encourage lots of water with fiber) (ONLY after cause has been discovered)
▪ Adults: 25-35 g/day
▪ Children >2: Age + 5 g/day
Encourage adequate fluid intake
▪ ~2L/day for adults
▪ Physical activity (stimulates gut motility and increases bowel movements)
▪ Don’t ignore the urge (holding can cause constipation because it becomes harder) (colon absorbing water from poo poo)
▪ Medications (laxative, anemia to help movement but body can come dependent so don’t recommend a lot)
Diverticulosis
▪ Herniations in colonic wall (sacs called diverticulum)
▪ Asymptomatic, seen on colonoscopy
Risk factors
- Diets or conditions that increase inflammation
▪ Inflammation
▪ Microbiome changes
▪ Abnormal motility
▪ Low fiber diet (contribute to inflammation)
▪ Frequent constipation
Diverticulitis
Acute inflammation of diverticula
▪ Contents can collect, and mucosa becomes infected
▪ Abd pain, GI bleed, fever, increased WBC
Tx – bowel rest (sips of clear liquids)
▪ Further complications may develop like abscess or perforation in G.I tissue
MNT for Diverticula
Prevention
▪ Anti-inflammatory diet – more plants (increased fiber), less meat
Acute flare
▪ Bowel rest → CL → Low-residue/fiber diet (as tolerated) ▪ Gradually resume, high fiber diet as acute symptoms resolve (to prevent flare ups from happening again)
▪ Soluble (attracts water, helps stool become gel like, easy to pass, stick together so less likely to get food stuck in diverticula) vs insoluble fiber (tough fibrous parts, add bulk to stool)
▪ Don’t need to avoid seeds, nuts, husks (insoluble fiber)
▪ As always – individual toleration
Lower GI Tract: Malabsorption
Pathophysiology of Lower GI Tract
Symptoms
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Malabsorption
▪ Incomplete absorption of nutrients due to maldigestion or damage to the anatomy and physiology
▪ Celiac, Crohn’s, PCM, dysfunction of accessory organs, GI surgeries, diarrhea (common causes)
Nutritional Implications
▪ A lot of Symptoms lead to inadequate intake (ex. If a patient has diarrhea may stop eating to reduce symptoms)
▪ Deficiencies
▪ Malnutrition (if severe enough can result in overall protein calorie malnutrition)
Fat Malabsorption
- It’s important to understand normal absorption for all of these so that we can identify what can be potentially causing the malabsorption and what interventions we can do to try to improve absorption of macronutrients. Fat has the most complications because we are dealing with hydrophobic lipids in the watery solution of our GI tract so we need to have…
▪ Bile to emulsify the fats to allow access to the lipase enzymes and adequate time in the GI tract for micelle formation (so when we have damage to pancreas or gallbladder, we often see fat malabsorption) (also if something increases transit time in GI tract (moving too quickly) can also lead to fat malabsorption)
Steatorrhea – fat in stool
▪ Frothy, greasy/oily (float), foul smelling stools
▪ Abdominal pain, cramping, diarrhea
▪ Fats & fat-soluble vitamins not absorbed
Lab tests available but limited use (Gold standard (fecal fat test) – collect stool sample for 72hrs and they eat exactly 100grams of fat and can measure how much fat is in the stool and determine if fat is not being absorbed. However, very impractical/ slow turn around long) (more specialized)
- In short term/ acute setting we will base it on the symptoms and then will probably just treat empirical by eliminating fat from diet or giving pancreatic enzymes and see if that works; if it works we know they weren’t absorbing fat)
Nutrition Interventions
▪ Restrict fat intake to 25-50g per day
▪ MCT (medium chained triglycerides are absorbed directly) oil (difficult to eat) (in formulas for malabsorption will usually give higher in MCT than LCT)
▪ Pancreatic enzymes
▪ Replete/supplement fat soluble vitamins (keep in mind, fat soluble vitamins are the ones that are stored so we really only need to do this if it’s a chronic fat malabsorption or if it’s been affecting intake). (also a lot of fatty foods contain protein so if there avoiding foods high in fat want to make sure they are getting lean protein)
Carbohydrate Malabsorption
Inability to digest di- or mono-saccharides
- So what happens is that the GI bacteria digest and produce gas (which then causes the gas and bloating symptoms and the undigested sugars lead to osmotic diarrhea)
▪ Osmotic diarrhea
Most common is lactose intolerance (some people can be fructose intolerant but less common and those individuals are usually not intolerable to fructose in fruit but really high doses such as high fructose syrup)
Nutrition Interventions
▪ Avoid poorly tolerated foods (milk products)
- Cheese, ice cream (usually well tolerated by people with low lactose intolerance)
▪ Enzyme supplements (Lactaid, lactase enzymes) (can give these to help with lactose products)
▪ Enhance tolerance by using small portions
Protein Malabsorption
Protein-losing enteropathy
▪ Occurs as result of other diseases, especially PCM (protein calorie malabsorption) could also be IBD or cancer
▪ Medical Tx: Underlying disease
(shift, command, 4)
- What happens – protein is not absorbed instead it is excreted in stool, which means less protein in blood and because blood concentration is now low, water leaves the blood and enters interstitial spaces causing edema
- Stage 4 edema (pit, shiny(tight))
- Medical Tx: Underlying disease (want to find some way to feed them but can be prone to refeeding syndrome so have to be careful of that).
• Due to reduced oncotic pressure Peripheral edema Assessment of Malabsorption
Assessment of Malabsorption
▪ Anatomy, previous surgeries
▪ Weight loss (because if there not absorbing what they are eating they are most likely going to be losing weight)
Vitamin and mineral deficiencies (there are blood labs that you can get but vary in how useful they can be) (better to look at signs and symptoms)
▪ Labs, clinical s/sx (more severe stage of vitamin and mineral deficiencies), diet history (can look at what types of foods they’ve been eating to give us a clue on what vitamins they potentially be deficient in and then supplement empirically and or just give them Vit. We think they can be low in (toxicity is very high so don’t really have to worry about that especially if we think they are lacking)
Stool characteristics (BEST WAY) (the best way to look for malabsorption- that’s where you’ll see it even before vit/ mineral deficiencies become a problem) (see Table 15.5)
▪ Odor
▪ Unusual color – green, yellow, white, orange
▪ Texture – greasy/oily, fluffy, frothy, floating
▪ Undigested foods ▪ Frequency – focus on changes & timeframe (Pay attention to when their pattern changed and how long!!)
▪ Output volume (how much stool they are putting out)
Protein-calorie malnutrition (If we expect malabsorption want to assess for P.C.M by using ASPEN A.N.D criteria)
Celiac Disease
Auto-immune response to peptides in gluten (wheat, rye, malt and barley)
▪ Gluten found in wheat, rye, malt, barley
Inflammatory response damages mucosa (body sees it as a virus and attacks it) (GI villi in GI tract, which causes them to become damaged and flat which reduces absorption compacity as well as damages the cells within the villi’s capacity to make enzymes)
▪ Damage & flattening of GI villi → reduced absorptive surface and loss of enzymes
Medical diagnosis
▪ Intestinal Biopsy (Gold standard)
▪ Gluten anti-bodies within the blood
▪ Serological testing
▪ Confirmed with reversal of symptoms on gluten-free diet
- If it bugs you DON’T EAT IT
Clinical Manifestations of Celiac Disease
▪ Malabsorption of all nutrients
▪ Steatorrhea/diarrhea
▪ Abdominal pain, cramping, gas
- Can also lead to other auto-immune diseases not related such as,
▪ Peripheral neuropathy
▪ Bone and joint pain
▪ Skin rash & mouth ulcerations
▪ Iron-deficiency anemia (common- as a result of lack of iron absorption and potential lack of iron due to damage from the mucosa)
Nutrition Interventions for Celiac Disease
Strict avoidance of gluten containing foods for life
Avoiding cross-contamination
Be aware of hidden sources (Oats don’t have gluten but are usually processed in facilities with gluten)
▪ Textured/hydrolyzed vegetable protein (TVP) (gluten provides that yummy chewy taste)
▪ Starch
▪ Malt/malt flavoring
▪ Condiments
▪ Natural flavors
▪ Seasoned snack foods
▪ Medications, cosmetics
- It’s KEY to educate client
- Eventually if they stick to a gluten free diet their anatomy should return to normal and malabsorption should resolve
- If a patient has developed severe malabsorption from prolonged undiagnosed or untreated celiacs disease that leads to malabsorption, we will have to treat underlying malabsorption – very similar to IBD
Irritable Bowel Syndrome
- Not a disease itself but a bunch of symptoms that occur together and can’t be attributed to a specific disease.
- Patients who have abdominal pain related to defecation or change in bowel habits one day per week for a month or more and we have ruled out every other potential cause then we would call it IBS)
Intermittent disturbance of bowel function
▪ Abd pain related to defecation or change in bowel habits at least 1 day per week for 1 month
▪ Rule out all other causes
4 types: Diarrhea, Constipation, Mixed, Unclassified
▪ Unknown cause
Irritable Bowel Syndrome
Symptoms
▪ Abdominal pain
▪ Diarrhea, constipation or both
▪ Gas, bloating, flatulence
▪ Acute or chronic (for some people can be every other day, ongoing or flare up and go away)
Medical Intervention – treat symptoms
- Because the cause is unknown (don’t have an underlying disease) we can’t address the underlying etiology but can try and treat the symptoms – manage the diarrhea/ constipation (that lead to gas and bloating)
Nutrition Intervention
▪ Elimination diet, then avoid trigger foods
- Fiber may exacerbate symptoms (low fiber diet)
▪ Establish regular eating pattern (finding foods they can tolerate, eating them consistently and getting regular good nutrition is the goal)
▪ Monitor for nutritional deficiencies (especially if they have to avoid whole food groups for certain types of food that contribute certain nutrients)
Low FODMAP Diet (See Table 15.14)
= Diet low in fermentable oligo-di-monosaccharides and Polyols
▪ Rationale: Foods high in FODMAPS are hyperosmotic, not well digested, and are fermented → gas/bloating & diarrhea
▪ Recommended: Follow diet for 6 weeks, high FODMAP foods are added back one at a time → avoid triggers (modified nutrition diet)
- Patient has to be very motivated to learn about the diet and keep track of what they are eating and symptoms
- Essentially have to look at a list to see what they can’t and can eat because very hard to distinction
- A very effective diet for managing symptoms though
Inflammatory Bowel Disease
- Another autoimmune disease, an inflammatory condition and includes two different conditions that are similar but not quite the same under this umbrella of IBD
1. Crohn’s disease
2. Ulcerative Colitis
Both of these are characterized by,
▪ Periods of “flares” and remission (comes and goes which makes it hard to manage)
▪ Cause unknown (but has a genetic component and environmental trigger)
Nutritional Implications
▪ High risk of developing malnutrition & specific deficiencies (espec. Crohns disease because of the damage it’s doing to GI tract)
Treatment
▪ Antibiotics, immunosuppressive meds, surgery
Crohn’s Disease
▪ "Crust Deep" - Effects All layers of mucosa involved
▪ Any part of GI (mouth to rectum)
▪ "Skipping" pattern (patches through GI tract)
▪ Thickened wall, cobblestone effect
▪ Fissures (crack that can go all the way through tissue), strictures (fat wrap)
▪ Surgery – resect severely damaged mucosa
- Know which parts have been removed and how it can affect their malabsorption (map)
- What nutrients we should be most concerned about. I.e., which areas have been removed
▪ Not a cure
Ulcerative Colitis
▪ "Upper cheese" - Involves 1st 2 layers of mucosa
▪ Only colon & rectum involved
▪ Continuous disease (not likely to cause skipping)
▪ Superficial ulcerations (In first two layers)
▪ Over time, edema → loss of haustra (little bubbles/ pockets along the colon)
▪ Colectomy (remove whole colon) cures disease An individual can live fine without a colon just have to monitor hydration/ water intake
Symptoms of IBD
(Compares conditions)
1. Crohn's Disease
▪ Abdominal pain with cramping
▪ Diarrhea
▪ Tenesmus (feel like you have to shit all the time)
▪ Anorexia, weight loss, malnutrition
▪ Delayed growth in adolescents (if undiagnosed)
▪ Joint pain
▪ Inflammation of other tissues
▪ Iron deficiency anemia
2. Ulcerative Colitis
▪ Abdominal/rectal pain
▪ Bloody or mucoid diarrhea
▪ Tenesmus
▪ Weight loss
▪ Fever Complications of IBD
Complications of IBD
▪ Toxic megacolon – ulcerated mucosa (colon becomes so swollen and huge it begins to poison the body)
▪ Fistulas (holes) healed with fibrotic tissue (scars) (majority associated with cronhs, scarring will result in malabsorption)
▪ Increased risk for malignant (cancer) disease Estimating Needs
Energy and protein needs increased during acute infection/inflammation
▪ Especially concerning in growing teens/children
Energy - Adjust based on weight/malnutrition hx
▪ Adults: start with MSJ x 1.2-1.3 or 25-30kcal/kg
▪ Children: as much as 80kcal/kg for teens, 120kcal/kg for infants (titrate up to make sure we are meeting their needs for growth) (want to monitor growth as well as length and height)
Protein – Adjust based on severity of disease/PCM
▪ 1.2-2g/kg adults in ICU
▪ 2-2.5g/kg children
Nutrition Interventions for IBD
▪ Interventions differ between acute flares and remissions
Enteral nutrition
▪ Supplemental, may need hydrolyzed formula (easy to digest and absorb, less work for GI tract)
Parenteral nutrition (severe damage or multiple resections and they need bowl rest) (generally we want to try and feed the gut bec. providing nutrition will help cells heal)
▪ Obstructions, fistulas, severe disease, major GI resections, bowel rest alone not usually indicated
Nutrition Interventions for IBD
Low-residue, lactose-free diets for reducing diarrhea/preventing obstruction
▪ Fat, fiber as tolerated (individualized) (important to know patient’s anatomy and where they are having the IBD- crohns more likely to have fat malabsorption and potentially need pancreatic enzymes while Ulcerative Colitis affects the colon where fiber has most of its affect, patient could not tolerate fiber)
▪ Small frequent meals
▪ Replete vitamins and minerals (If we expect any malabsorption)
▪ Due to avoidance of foods, malabsorption, increased losses, or to correct drug-nutrient interactions
▪ Pancreatic enzymes if needed
▪ Remission – maximize nutrition status to rebuild LBM and replete nutrient stores, normalize dietary patterns (build them up nutritionally so there body has like a buffer to get ready for the next flare up so they won’t get into severe malabsorption)
Lower GI Tract - Surgery
Surgery
Operative procedure used to diagnose, repair, or treat an organ or tissue
Classified by
▪ Seriousness (major or minor)
▪ Necessity (emergency of procedure or elective procedure – was the patient able to prepare)
▪ Specific purpose of procedure (0.33)
Bowel surgery
▪ Resection or diversion
▪ Know the anatomy & type of procedure
Small Intestine Anatomy
Small Intestine Anatomy ▪ Duodenum > Jejunum > Ileum > Ileocecal valve
1. Pyloric sphincter (from stomach) TO duodenum
2. Jejunum
3. Ileum
4. Ileocecal valve from S.I to colon
Duodenum > Jejunum > Ileum > Ileocecal valve
▪ Maximum surface area for digestion and absorption
▪ Folds
▪ Villi
▪ Microvilli
▪ “brush border”
· Why is this surface area so important for digestion and absorption (increased surface area)
Motility
▪ Segmentation vs peristalsis
▪ Sphincters (control the rate at which food passes – if something is wrong could affect someone digestion and absorption and how it could affect nutrition that we want to give them)
Secretions
▪ Hormones (see Table 15.1)
▪ Bicarbonate – neutralizes gastric HCl
▪ Enzymes
Know digestion of macronutrients
▪ 1.5 L intestinal juices – water & mucus
▪ Fig 15.4, 15.5 and 15.6
mouth ulcerations ▪ Iron-deficiency anemia
Active transport utilizing Na/K+ pump at brush border
▪ Glucose, galactose, amino acids
Facilitated diffusion
▪ Fructose
Lipids enter lymph via passive diffusion
▪ First converted to micelles and packaged as chylomicrons
▪ Site-specific nutrient absorption, however able to adapt when needed
Large Intestine Functions
Large Intestine Functions: keeps things moving, allows us to defecate
▪ Motility, including defecation
▪ Primarily responsible for absorption of water, electrolytes & vitamins that remain
▪ No enzymatic absorption takes place
▪ Formation/storage of feces (waste products include insoluble fiber, bilirubin, and bacteria)
Intestinal flora ferment fiber
- There to help ferment some of the fibers that we cannot digest, and they produce SCFA, Vit. K, & Biotin
▪ Produce SCFA and lactate
▪ Maintaining optimal balance is area of ongoing research
▪ Synthesizes vitamin K & biotin
Nutrition Assessment (See Table 15.2)
▪ Anthropometrics – especially
▪ weight loss (help us figure out if their issue is causing poor intake/ digestion/ absorption
▪ History of GI surgery / current anatomy (want to know what they’re working with)
GI function/abdominal exam
▪ N/V, diarrhea, constipation, distention, pain, gas, bloating, cramping (when did it start, has it been going on for a long time? Or is it just when you eat food? Is it affecting how you eat?)
▪ Stool color, consistency, odor (Table 15.5) (assess quality of stool)
(ask) Food/fluid intake & eating pattern
▪ Specific restrictions or intolerances
▪ Diet (vege/vegan, low FODMAP, etc)
▪ Meal pattern/frequency ▪ Fiber intake/tolerance
Medications, supplements, herbs (Table 15.3)
▪ Labs: Electrolytes, serum proteins, vitamins/minerals
Stress/triggers (for IBS)
Pathophysiology of Lower GI Tract
Symptoms (may occur by themselves or may be underlying conditions)
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Diarrhea
- Compare to the patient’s baseline, what’s normal for them (N.A.) (we are looking for persistent change in pattern) (once a day is okay but if it’s happening repeatedly then we should be concerned) ( more than 200grams per day for adults or greater than 20grams per day for children) ( having stool measurements can be helpful but kind of just have to assess report and symptoms case by case)
▪ Increased frequency or water content of stools
▪ Affects consistency and/or volume
▪ Compare to patient’s baseline
▪ Acute ( < 2 weeks) versus chronic ( > 4 weeks)
- As acute expect to see dehydration, chronic could cause a more severe malnutrition
▪ Osmotic vs secretory (2 types) (see following slides)
Complications
▪ Dehydration & weight loss (because of increased stools and increased water at risk of dehydration and weight loss, primarily because of water loss but if its chronic could cause actually loss of lean body mass)
▪ Electrolyte and acid-base imbalances (loss of water)
▪ Abdominal pain & cramping (diarrhea is often associated with abdominal cramping and pain, which can affect intake as well)
▪ Presence of blood
▪ Malabsorption / Steatorrhea
Osmotic Diarrhea
▪ Normal: ~300 Osm/L (normal osmolarity of stomach is about 300L if it gets higher than that, that can be what causes osmotic diarrhea)
▪ Increased osmolarity drives water into GI lumen to normalize osmolarity (to dilute it, excess water in GI tract can result in diarrhea and watery stool)
May be caused by
▪ Maldigestion (e.g. lactose intolerance) (lactose sugars don’t get digested, which cause a lot of water to enter the G.I tract to dilute that)
▪ Excessive sorbitol, fructose or lactose
▪ Enteral feeding (rarely) (most are hyperosmolar, like most of our food)
▪ Laxative use
Tx - Remove causative agent
▪ Try isotonic enteral formula (i.e. Osmolite)
▪ Generally, resolves if pt is NPO
Secretory Diarrhea
▪ Underlying disease causes increased secretions
Bacterial, protozoa, viruses
▪ Often seen - Foodborne illnesses, like Clostridium difficile (C. Diff.) (people usually get this while they are in the hospital/ long term care- spreads from person to person and the problem with C. Diff is it doesn’t go away so once a person has it lives forever in their G.I track. When this person gets sick again, or immune system decreases C. Diff tends to flare up and cause S. Diarrhea) (if a person has diarrhea usually want to get a stool sample to see if person has C.Diff to rule that out)
▪ Traveler’s diarrhea (generally caused by bacteria and viruses)
Medications, including antibiotics (see Table 15.3)
▪ Increase GI motility or alter GI flora (which lead to S. Diarrhea)
▪ Other diseases, such as IBD, Celiac, HIV, cancer
▪ Does not resolve when NPO (because this is causing increased intestinal secretions, it would continue to happen, even though their volume might be going down if there not eating – still might see frequent smaller watery stool)
Treat underlying cause and symptoms
▪ Anti-diarrheal meds if not infectious or contraindicated (body is trying to flush out virus and we should let it. If it is a Food Born Illness, we know its bacterial and don’t give anti-diarrheal meds but if it’s caused by underlying condition or meds. That we can’t treat we can give)
▪ Fecal microbiota transplant
Nutrition Interventions for Diarrhea
1. Correct dehydration, electrolyte, acid/base balance (severe- intravenous in a hospital setting)
▪ Oral rehydration solutions ( Pedialyte, home formula – sugar, clean water, salt, sodium decarbonate ( if don’t have Pedialyte))
▪ Avoid high sugar beverages, caffeine, and EtOH (hyperosmolar) (clear liquids are hyperosmolar, which can increase diarrhea/ make worse)
Feed the gut (stimulate the GI tract for normal digestion, absorption, motility) (encourage eating normal food as much as tolerated)
▪ Soluble fiber and resistant starches to thicken stool
▪ BRAT diet, banana flakes, apple powder (easy to digest and tolerated, with not a lot of simple sugars and some fibers)
▪ Avoid foods high in simple sugars and sugar alcohols
▪ Avoid gas-producing foods
▪ Low residue (fiber) diet
Probiotics – repopulate healthy microbiota (yogurt, fermented foods)
▪ Minimal research so no organism or dose recommendations yet
Diarrhea with Enteral Nutrition (wouldn’t really do unless severe malabsorption)
Rule out other causes
- Look at medications are any made with sugar alcohols or hyperosmolar, are they on anti-biotics) (did the diarrhea start when the tube feeding started? Or have they been on tube feeding for a while and now they have diarrhea – if it’s not associated with the tube feeding starting or stopping tube feeding and you don’t see a pattern it’s probably not related).
▪ C diff
▪ Try another formula (Low fiber or high fiber formula just to see how they are tolerating it. Patient on high fiber, switch to low fiber or vice versa) (most fiber in formula is water soluble fiber which could be causing the looser stools) (isotonic formula) (peptide or MCT formula – already broken down, easy to digest)
▪ Low fiber vs high fiber
▪ Isotonic
▪ Peptide / MCT based
▪ Assess for malabsorption (diarrhea long-term, assess for malabsorption – if having enteral nutrition want to make sure there absorbing it, if there stools are the same color/ consistency as tube feeding, bad sign, not digesting anything – may have to assess if they need parental nutrition or more broken down formula) (loose stools but are digesting formula, maybe something they just have to deal with)
▪ Monitor hydration and skin
Preventing Diarrhea (assess these things)
▪ Improving access to clean water and safe sanitation
▪ Promoting hygiene education
▪ Exclusive breastfeeding
▪ Immunizing all children, esp rotavirus
▪ Keeping food and water clean
▪ Sanitary disposal of stool
Constipation - Definition
- Important to establish patients baseline and time frame – so again, ask clarifying questions – what do you mean? How often has this been going on? How many times a day do you have bowel movements? Etc..
Many subjective definitions
▪ Decrease in frequency of bowel movements
▪ Straining
▪ Hard stools
▪ Incomplete evacuation
▪ Establish baseline pattern & timeframe!
Rome Consensus Criteria (REVIEW)
▪ Symptoms >3 months (3-6 months, chronic)
▪ Define Criteria
May cause fullness, decreased appetite/intake
Constipation – Etiology
▪ Decreased motility/slowed colonic transit time
▪ Rectal outlet obstruction, adhesions, tumors
▪ Fecal impaction (obstruction in rectum, which could be a physical blockage- something that wasn’t digested (not food), adhesions (tissues of GI tract stick together), tumors) (rule of colon is to absorb water so if this isn’t happening, stool gets harder and harder to pass)
▪ IBS
▪ Neuro or inflammatory diseases like scleroderma, MS, Parkinson’s, para/quadriplegia (In lower half- often lack sensation to control muscles to pass stool, has to be monitored)
Side effect of medications, supplements
▪ Opioids
Diet & lifestyle (low in water, fiber, sedentary can contribute) (usually happens when change in lifestyle happens)
Constipation – Dx and Tx
Diagnosis
▪ Usually by report (patient saying “I have constipation” and asking those direct questions to determine if they meet criteria)
▪ May need radiographic or colonoscopy to find etiology
Treatment
▪ Underlying etiology
▪ Laxatives (to increase stool outputs, add more fluid), enemas, digital stimulation (stimulating anus to release stool)
▪ Surgery (tumor, adhesions)
Nutrition Interventions for Constipation
Recommend increased fiber intake (slowly because can cause diarrhea, gas and bloating) (encourage lots of water with fiber) (ONLY after cause has been discovered)
▪ Adults: 25-35 g/day
▪ Children >2: Age + 5 g/day
Encourage adequate fluid intake
▪ ~2L/day for adults
▪ Physical activity (stimulates gut motility and increases bowel movements)
▪ Don’t ignore the urge (holding can cause constipation because it becomes harder) (colon absorbing water from poo poo)
▪ Medications (laxative, anemia to help movement but body can come dependent so don’t recommend a lot)
Diverticulosis
▪ Herniations in colonic wall (sacs called diverticulum)
▪ Asymptomatic, seen on colonoscopy
Risk factors
- Diets or conditions that increase inflammation
▪ Inflammation
▪ Microbiome changes
▪ Abnormal motility
▪ Low fiber diet (contribute to inflammation)
▪ Frequent constipation
Diverticulitis
Acute inflammation of diverticula
▪ Contents can collect, and mucosa becomes infected
▪ Abd pain, GI bleed, fever, increased WBC
Tx – bowel rest (sips of clear liquids)
▪ Further complications may develop like abscess or perforation in G.I tissue
MNT for Diverticula
Prevention
▪ Anti-inflammatory diet – more plants (increased fiber), less meat
Acute flare
▪ Bowel rest → CL → Low-residue/fiber diet (as tolerated) ▪ Gradually resume, high fiber diet as acute symptoms resolve (to prevent flare ups from happening again)
▪ Soluble (attracts water, helps stool become gel like, easy to pass, stick together so less likely to get food stuck in diverticula) vs insoluble fiber (tough fibrous parts, add bulk to stool)
▪ Don’t need to avoid seeds, nuts, husks (insoluble fiber)
▪ As always – individual toleration
Lower GI Tract: Malabsorption
Pathophysiology of Lower GI Tract
Symptoms
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Malabsorption
▪ Incomplete absorption of nutrients due to maldigestion or damage to the anatomy and physiology
▪ Celiac, Crohn’s, PCM, dysfunction of accessory organs, GI surgeries, diarrhea (common causes)
Nutritional Implications
▪ A lot of Symptoms lead to inadequate intake (ex. If a patient has diarrhea may stop eating to reduce symptoms)
▪ Deficiencies
▪ Malnutrition (if severe enough can result in overall protein calorie malnutrition)
Fat Malabsorption
- It’s important to understand normal absorption for all of these so that we can identify what can be potentially causing the malabsorption and what interventions we can do to try to improve absorption of macronutrients. Fat has the most complications because we are dealing with hydrophobic lipids in the watery solution of our GI tract so we need to have…
▪ Bile to emulsify the fats to allow access to the lipase enzymes and adequate time in the GI tract for micelle formation (so when we have damage to pancreas or gallbladder, we often see fat malabsorption) (also if something increases transit time in GI tract (moving too quickly) can also lead to fat malabsorption)
Steatorrhea – fat in stool
▪ Frothy, greasy/oily (float), foul smelling stools
▪ Abdominal pain, cramping, diarrhea
▪ Fats & fat-soluble vitamins not absorbed
Lab tests available but limited use (Gold standard (fecal fat test) – collect stool sample for 72hrs and they eat exactly 100grams of fat and can measure how much fat is in the stool and determine if fat is not being absorbed. However, very impractical/ slow turn around long) (more specialized)
- In short term/ acute setting we will base it on the symptoms and then will probably just treat empirical by eliminating fat from diet or giving pancreatic enzymes and see if that works; if it works we know they weren’t absorbing fat)
Nutrition Interventions
▪ Restrict fat intake to 25-50g per day
▪ MCT (medium chained triglycerides are absorbed directly) oil (difficult to eat) (in formulas for malabsorption will usually give higher in MCT than LCT)
▪ Pancreatic enzymes
▪ Replete/supplement fat soluble vitamins (keep in mind, fat soluble vitamins are the ones that are stored so we really only need to do this if it’s a chronic fat malabsorption or if it’s been affecting intake). (also a lot of fatty foods contain protein so if there avoiding foods high in fat want to make sure they are getting lean protein)
Carbohydrate Malabsorption
Inability to digest di- or mono-saccharides
- So what happens is that the GI bacteria digest and produce gas (which then causes the gas and bloating symptoms and the undigested sugars lead to osmotic diarrhea)
▪ Osmotic diarrhea
Most common is lactose intolerance (some people can be fructose intolerant but less common and those individuals are usually not intolerable to fructose in fruit but really high doses such as high fructose syrup)
Nutrition Interventions
▪ Avoid poorly tolerated foods (milk products)
- Cheese, ice cream (usually well tolerated by people with low lactose intolerance)
▪ Enzyme supplements (Lactaid, lactase enzymes) (can give these to help with lactose products)
▪ Enhance tolerance by using small portions
Protein Malabsorption
Protein-losing enteropathy
▪ Occurs as result of other diseases, especially PCM (protein calorie malabsorption) could also be IBD or cancer
▪ Medical Tx: Underlying disease
(shift, command, 4)
- What happens – protein is not absorbed instead it is excreted in stool, which means less protein in blood and because blood concentration is now low, water leaves the blood and enters interstitial spaces causing edema
- Stage 4 edema (pit, shiny(tight))
- Medical Tx: Underlying disease (want to find some way to feed them but can be prone to refeeding syndrome so have to be careful of that).
• Due to reduced oncotic pressure Peripheral edema Assessment of Malabsorption
Assessment of Malabsorption
▪ Anatomy, previous surgeries
▪ Weight loss (because if there not absorbing what they are eating they are most likely going to be losing weight)
Vitamin and mineral deficiencies (there are blood labs that you can get but vary in how useful they can be) (better to look at signs and symptoms)
▪ Labs, clinical s/sx (more severe stage of vitamin and mineral deficiencies), diet history (can look at what types of foods they’ve been eating to give us a clue on what vitamins they potentially be deficient in and then supplement empirically and or just give them Vit. We think they can be low in (toxicity is very high so don’t really have to worry about that especially if we think they are lacking)
Stool characteristics (BEST WAY) (the best way to look for malabsorption- that’s where you’ll see it even before vit/ mineral deficiencies become a problem) (see Table 15.5)
▪ Odor
▪ Unusual color – green, yellow, white, orange
▪ Texture – greasy/oily, fluffy, frothy, floating
▪ Undigested foods ▪ Frequency – focus on changes & timeframe (Pay attention to when their pattern changed and how long!!)
▪ Output volume (how much stool they are putting out)
Protein-calorie malnutrition (If we expect malabsorption want to assess for P.C.M by using ASPEN A.N.D criteria)
Celiac Disease
Auto-immune response to peptides in gluten (wheat, rye, malt and barley)
▪ Gluten found in wheat, rye, malt, barley
Inflammatory response damages mucosa (body sees it as a virus and attacks it) (GI villi in GI tract, which causes them to become damaged and flat which reduces absorption compacity as well as damages the cells within the villi’s capacity to make enzymes)
▪ Damage & flattening of GI villi → reduced absorptive surface and loss of enzymes
Medical diagnosis
▪ Intestinal Biopsy (Gold standard)
▪ Gluten anti-bodies within the blood
▪ Serological testing
▪ Confirmed with reversal of symptoms on gluten-free diet
- If it bugs you DON’T EAT IT
Clinical Manifestations of Celiac Disease
▪ Malabsorption of all nutrients
▪ Steatorrhea/diarrhea
▪ Abdominal pain, cramping, gas
- Can also lead to other auto-immune diseases not related such as,
▪ Peripheral neuropathy
▪ Bone and joint pain
▪ Skin rash & mouth ulcerations
▪ Iron-deficiency anemia (common- as a result of lack of iron absorption and potential lack of iron due to damage from the mucosa)
Nutrition Interventions for Celiac Disease
Strict avoidance of gluten containing foods for life
Avoiding cross-contamination
Be aware of hidden sources (Oats don’t have gluten but are usually processed in facilities with gluten)
▪ Textured/hydrolyzed vegetable protein (TVP) (gluten provides that yummy chewy taste)
▪ Starch
▪ Malt/malt flavoring
▪ Condiments
▪ Natural flavors
▪ Seasoned snack foods
▪ Medications, cosmetics
- It’s KEY to educate client
- Eventually if they stick to a gluten free diet their anatomy should return to normal and malabsorption should resolve
- If a patient has developed severe malabsorption from prolonged undiagnosed or untreated celiacs disease that leads to malabsorption, we will have to treat underlying malabsorption – very similar to IBD
Irritable Bowel Syndrome
- Not a disease itself but a bunch of symptoms that occur together and can’t be attributed to a specific disease.
- Patients who have abdominal pain related to defecation or change in bowel habits one day per week for a month or more and we have ruled out every other potential cause then we would call it IBS)
Intermittent disturbance of bowel function
▪ Abd pain related to defecation or change in bowel habits at least 1 day per week for 1 month
▪ Rule out all other causes
4 types: Diarrhea, Constipation, Mixed, Unclassified
▪ Unknown cause
Irritable Bowel Syndrome
Symptoms
▪ Abdominal pain
▪ Diarrhea, constipation or both
▪ Gas, bloating, flatulence
▪ Acute or chronic (for some people can be every other day, ongoing or flare up and go away)
Medical Intervention – treat symptoms
- Because the cause is unknown (don’t have an underlying disease) we can’t address the underlying etiology but can try and treat the symptoms – manage the diarrhea/ constipation (that lead to gas and bloating)
Nutrition Intervention
▪ Elimination diet, then avoid trigger foods
- Fiber may exacerbate symptoms (low fiber diet)
▪ Establish regular eating pattern (finding foods they can tolerate, eating them consistently and getting regular good nutrition is the goal)
▪ Monitor for nutritional deficiencies (especially if they have to avoid whole food groups for certain types of food that contribute certain nutrients)
Low FODMAP Diet (See Table 15.14)
= Diet low in fermentable oligo-di-monosaccharides and Polyols
▪ Rationale: Foods high in FODMAPS are hyperosmotic, not well digested, and are fermented → gas/bloating & diarrhea
▪ Recommended: Follow diet for 6 weeks, high FODMAP foods are added back one at a time → avoid triggers (modified nutrition diet)
- Patient has to be very motivated to learn about the diet and keep track of what they are eating and symptoms
- Essentially have to look at a list to see what they can’t and can eat because very hard to distinction
- A very effective diet for managing symptoms though
Inflammatory Bowel Disease
- Another autoimmune disease, an inflammatory condition and includes two different conditions that are similar but not quite the same under this umbrella of IBD
1. Crohn’s disease
2. Ulcerative Colitis
Both of these are characterized by,
▪ Periods of “flares” and remission (comes and goes which makes it hard to manage)
▪ Cause unknown (but has a genetic component and environmental trigger)
Nutritional Implications
▪ High risk of developing malnutrition & specific deficiencies (espec. Crohns disease because of the damage it’s doing to GI tract)
Treatment
▪ Antibiotics, immunosuppressive meds, surgery
Crohn’s Disease
▪ "Crust Deep" - Effects All layers of mucosa involved
▪ Any part of GI (mouth to rectum)
▪ "Skipping" pattern (patches through GI tract)
▪ Thickened wall, cobblestone effect
▪ Fissures (crack that can go all the way through tissue), strictures (fat wrap)
▪ Surgery – resect severely damaged mucosa
- Know which parts have been removed and how it can affect their malabsorption (map)
- What nutrients we should be most concerned about. I.e., which areas have been removed
▪ Not a cure
Ulcerative Colitis
▪ "Upper cheese" - Involves 1st 2 layers of mucosa
▪ Only colon & rectum involved
▪ Continuous disease (not likely to cause skipping)
▪ Superficial ulcerations (In first two layers)
▪ Over time, edema → loss of haustra (little bubbles/ pockets along the colon)
▪ Colectomy (remove whole colon) cures disease An individual can live fine without a colon just have to monitor hydration/ water intake
Symptoms of IBD
(Compares conditions)
1. Crohn's Disease
▪ Abdominal pain with cramping
▪ Diarrhea
▪ Tenesmus (feel like you have to shit all the time)
▪ Anorexia, weight loss, malnutrition
▪ Delayed growth in adolescents (if undiagnosed)
▪ Joint pain
▪ Inflammation of other tissues
▪ Iron deficiency anemia
2. Ulcerative Colitis
▪ Abdominal/rectal pain
▪ Bloody or mucoid diarrhea
▪ Tenesmus
▪ Weight loss
▪ Fever Complications of IBD
Complications of IBD
▪ Toxic megacolon – ulcerated mucosa (colon becomes so swollen and huge it begins to poison the body)
▪ Fistulas (holes) healed with fibrotic tissue (scars) (majority associated with cronhs, scarring will result in malabsorption)
▪ Increased risk for malignant (cancer) disease Estimating Needs
Energy and protein needs increased during acute infection/inflammation
▪ Especially concerning in growing teens/children
Energy - Adjust based on weight/malnutrition hx
▪ Adults: start with MSJ x 1.2-1.3 or 25-30kcal/kg
▪ Children: as much as 80kcal/kg for teens, 120kcal/kg for infants (titrate up to make sure we are meeting their needs for growth) (want to monitor growth as well as length and height)
Protein – Adjust based on severity of disease/PCM
▪ 1.2-2g/kg adults in ICU
▪ 2-2.5g/kg children
Nutrition Interventions for IBD
▪ Interventions differ between acute flares and remissions
Enteral nutrition
▪ Supplemental, may need hydrolyzed formula (easy to digest and absorb, less work for GI tract)
Parenteral nutrition (severe damage or multiple resections and they need bowl rest) (generally we want to try and feed the gut bec. providing nutrition will help cells heal)
▪ Obstructions, fistulas, severe disease, major GI resections, bowel rest alone not usually indicated
Nutrition Interventions for IBD
Low-residue, lactose-free diets for reducing diarrhea/preventing obstruction
▪ Fat, fiber as tolerated (individualized) (important to know patient’s anatomy and where they are having the IBD- crohns more likely to have fat malabsorption and potentially need pancreatic enzymes while Ulcerative Colitis affects the colon where fiber has most of its affect, patient could not tolerate fiber)
▪ Small frequent meals
▪ Replete vitamins and minerals (If we expect any malabsorption)
▪ Due to avoidance of foods, malabsorption, increased losses, or to correct drug-nutrient interactions
▪ Pancreatic enzymes if needed
▪ Remission – maximize nutrition status to rebuild LBM and replete nutrient stores, normalize dietary patterns (build them up nutritionally so there body has like a buffer to get ready for the next flare up so they won’t get into severe malabsorption)
Lower GI Tract - Surgery
Surgery
Operative procedure used to diagnose, repair, or treat an organ or tissue
Classified by
▪ Seriousness (major or minor)
▪ Necessity (emergency of procedure or elective procedure – was the patient able to prepare)
▪ Specific purpose of procedure (0.33)
Bowel surgery
▪ Resection or diversion
▪ Know the anatomy & type of procedure
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Small Intestine Anatomy
Small Intestine Anatomy ▪ Duodenum > Jejunum > Ileum > Ileocecal valve
1. Pyloric sphincter (from stomach) TO duodenum
2. Jejunum
3. Ileum
4. Ileocecal valve from S.I to colon
Duodenum > Jejunum > Ileum > Ileocecal valve
▪ Maximum surface area for digestion and absorption
▪ Folds
▪ Villi
▪ Microvilli
▪ “brush border”
· Why is this surface area so important for digestion and absorption (increased surface area)
Motility
▪ Segmentation vs peristalsis
▪ Sphincters (control the rate at which food passes – if something is wrong could affect someone digestion and absorption and how it could affect nutrition that we want to give them)
Secretions
▪ Hormones (see Table 15.1)
▪ Bicarbonate – neutralizes gastric HCl
▪ Enzymes
Know digestion of macronutrients
▪ 1.5 L intestinal juices – water & mucus
▪ Fig 15.4, 15.5 and 15.6
mouth ulcerations ▪ Iron-deficiency anemia
Active transport utilizing Na/K+ pump at brush border
▪ Glucose, galactose, amino acids
Facilitated diffusion
▪ Fructose
Lipids enter lymph via passive diffusion
▪ First converted to micelles and packaged as chylomicrons
▪ Site-specific nutrient absorption, however able to adapt when needed
Large Intestine Functions
Large Intestine Functions: keeps things moving, allows us to defecate
▪ Motility, including defecation
▪ Primarily responsible for absorption of water, electrolytes & vitamins that remain
▪ No enzymatic absorption takes place
▪ Formation/storage of feces (waste products include insoluble fiber, bilirubin, and bacteria)
Intestinal flora ferment fiber
- There to help ferment some of the fibers that we cannot digest, and they produce SCFA, Vit. K, & Biotin
▪ Produce SCFA and lactate
▪ Maintaining optimal balance is area of ongoing research
▪ Synthesizes vitamin K & biotin
Nutrition Assessment (See Table 15.2)
▪ Anthropometrics – especially
▪ weight loss (help us figure out if their issue is causing poor intake/ digestion/ absorption
▪ History of GI surgery / current anatomy (want to know what they’re working with)
GI function/abdominal exam
▪ N/V, diarrhea, constipation, distention, pain, gas, bloating, cramping (when did it start, has it been going on for a long time? Or is it just when you eat food? Is it affecting how you eat?)
▪ Stool color, consistency, odor (Table 15.5) (assess quality of stool)
(ask) Food/fluid intake & eating pattern
▪ Specific restrictions or intolerances
▪ Diet (vege/vegan, low FODMAP, etc)
▪ Meal pattern/frequency ▪ Fiber intake/tolerance
Medications, supplements, herbs (Table 15.3)
▪ Labs: Electrolytes, serum proteins, vitamins/minerals
Stress/triggers (for IBS)
Pathophysiology of Lower GI Tract
Symptoms (may occur by themselves or may be underlying conditions)
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Diarrhea
- Compare to the patient’s baseline, what’s normal for them (N.A.) (we are looking for persistent change in pattern) (once a day is okay but if it’s happening repeatedly then we should be concerned) ( more than 200grams per day for adults or greater than 20grams per day for children) ( having stool measurements can be helpful but kind of just have to assess report and symptoms case by case)
▪ Increased frequency or water content of stools
▪ Affects consistency and/or volume
▪ Compare to patient’s baseline
▪ Acute ( < 2 weeks) versus chronic ( > 4 weeks)
- As acute expect to see dehydration, chronic could cause a more severe malnutrition
▪ Osmotic vs secretory (2 types) (see following slides)
Complications
▪ Dehydration & weight loss (because of increased stools and increased water at risk of dehydration and weight loss, primarily because of water loss but if its chronic could cause actually loss of lean body mass)
▪ Electrolyte and acid-base imbalances (loss of water)
▪ Abdominal pain & cramping (diarrhea is often associated with abdominal cramping and pain, which can affect intake as well)
▪ Presence of blood
▪ Malabsorption / Steatorrhea
Osmotic Diarrhea
▪ Normal: ~300 Osm/L (normal osmolarity of stomach is about 300L if it gets higher than that, that can be what causes osmotic diarrhea)
▪ Increased osmolarity drives water into GI lumen to normalize osmolarity (to dilute it, excess water in GI tract can result in diarrhea and watery stool)
May be caused by
▪ Maldigestion (e.g. lactose intolerance) (lactose sugars don’t get digested, which cause a lot of water to enter the G.I tract to dilute that)
▪ Excessive sorbitol, fructose or lactose
▪ Enteral feeding (rarely) (most are hyperosmolar, like most of our food)
▪ Laxative use
Tx - Remove causative agent
▪ Try isotonic enteral formula (i.e. Osmolite)
▪ Generally, resolves if pt is NPO
Secretory Diarrhea
▪ Underlying disease causes increased secretions
Bacterial, protozoa, viruses
▪ Often seen - Foodborne illnesses, like Clostridium difficile (C. Diff.) (people usually get this while they are in the hospital/ long term care- spreads from person to person and the problem with C. Diff is it doesn’t go away so once a person has it lives forever in their G.I track. When this person gets sick again, or immune system decreases C. Diff tends to flare up and cause S. Diarrhea) (if a person has diarrhea usually want to get a stool sample to see if person has C.Diff to rule that out)
▪ Traveler’s diarrhea (generally caused by bacteria and viruses)
Medications, including antibiotics (see Table 15.3)
▪ Increase GI motility or alter GI flora (which lead to S. Diarrhea)
▪ Other diseases, such as IBD, Celiac, HIV, cancer
▪ Does not resolve when NPO (because this is causing increased intestinal secretions, it would continue to happen, even though their volume might be going down if there not eating – still might see frequent smaller watery stool)
Treat underlying cause and symptoms
▪ Anti-diarrheal meds if not infectious or contraindicated (body is trying to flush out virus and we should let it. If it is a Food Born Illness, we know its bacterial and don’t give anti-diarrheal meds but if it’s caused by underlying condition or meds. That we can’t treat we can give)
▪ Fecal microbiota transplant
Nutrition Interventions for Diarrhea
1. Correct dehydration, electrolyte, acid/base balance (severe- intravenous in a hospital setting)
▪ Oral rehydration solutions ( Pedialyte, home formula – sugar, clean water, salt, sodium decarbonate ( if don’t have Pedialyte))
▪ Avoid high sugar beverages, caffeine, and EtOH (hyperosmolar) (clear liquids are hyperosmolar, which can increase diarrhea/ make worse)
Feed the gut (stimulate the GI tract for normal digestion, absorption, motility) (encourage eating normal food as much as tolerated)
▪ Soluble fiber and resistant starches to thicken stool
▪ BRAT diet, banana flakes, apple powder (easy to digest and tolerated, with not a lot of simple sugars and some fibers)
▪ Avoid foods high in simple sugars and sugar alcohols
▪ Avoid gas-producing foods
▪ Low residue (fiber) diet
Probiotics – repopulate healthy microbiota (yogurt, fermented foods)
▪ Minimal research so no organism or dose recommendations yet
Diarrhea with Enteral Nutrition (wouldn’t really do unless severe malabsorption)
Rule out other causes
- Look at medications are any made with sugar alcohols or hyperosmolar, are they on anti-biotics) (did the diarrhea start when the tube feeding started? Or have they been on tube feeding for a while and now they have diarrhea – if it’s not associated with the tube feeding starting or stopping tube feeding and you don’t see a pattern it’s probably not related).
▪ C diff
▪ Try another formula (Low fiber or high fiber formula just to see how they are tolerating it. Patient on high fiber, switch to low fiber or vice versa) (most fiber in formula is water soluble fiber which could be causing the looser stools) (isotonic formula) (peptide or MCT formula – already broken down, easy to digest)
▪ Low fiber vs high fiber
▪ Isotonic
▪ Peptide / MCT based
▪ Assess for malabsorption (diarrhea long-term, assess for malabsorption – if having enteral nutrition want to make sure there absorbing it, if there stools are the same color/ consistency as tube feeding, bad sign, not digesting anything – may have to assess if they need parental nutrition or more broken down formula) (loose stools but are digesting formula, maybe something they just have to deal with)
▪ Monitor hydration and skin
Preventing Diarrhea (assess these things)
▪ Improving access to clean water and safe sanitation
▪ Promoting hygiene education
▪ Exclusive breastfeeding
▪ Immunizing all children, esp rotavirus
▪ Keeping food and water clean
▪ Sanitary disposal of stool
Constipation - Definition
- Important to establish patients baseline and time frame – so again, ask clarifying questions – what do you mean? How often has this been going on? How many times a day do you have bowel movements? Etc..
Many subjective definitions
▪ Decrease in frequency of bowel movements
▪ Straining
▪ Hard stools
▪ Incomplete evacuation
▪ Establish baseline pattern & timeframe!
Rome Consensus Criteria (REVIEW)
▪ Symptoms >3 months (3-6 months, chronic)
▪ Define Criteria
May cause fullness, decreased appetite/intake
Constipation – Etiology
▪ Decreased motility/slowed colonic transit time
▪ Rectal outlet obstruction, adhesions, tumors
▪ Fecal impaction (obstruction in rectum, which could be a physical blockage- something that wasn’t digested (not food), adhesions (tissues of GI tract stick together), tumors) (rule of colon is to absorb water so if this isn’t happening, stool gets harder and harder to pass)
▪ IBS
▪ Neuro or inflammatory diseases like scleroderma, MS, Parkinson’s, para/quadriplegia (In lower half- often lack sensation to control muscles to pass stool, has to be monitored)
Side effect of medications, supplements
▪ Opioids
Diet & lifestyle (low in water, fiber, sedentary can contribute) (usually happens when change in lifestyle happens)
Constipation – Dx and Tx
Diagnosis
▪ Usually by report (patient saying “I have constipation” and asking those direct questions to determine if they meet criteria)
▪ May need radiographic or colonoscopy to find etiology
Treatment
▪ Underlying etiology
▪ Laxatives (to increase stool outputs, add more fluid), enemas, digital stimulation (stimulating anus to release stool)
▪ Surgery (tumor, adhesions)
Nutrition Interventions for Constipation
Recommend increased fiber intake (slowly because can cause diarrhea, gas and bloating) (encourage lots of water with fiber) (ONLY after cause has been discovered)
▪ Adults: 25-35 g/day
▪ Children >2: Age + 5 g/day
Encourage adequate fluid intake
▪ ~2L/day for adults
▪ Physical activity (stimulates gut motility and increases bowel movements)
▪ Don’t ignore the urge (holding can cause constipation because it becomes harder) (colon absorbing water from poo poo)
▪ Medications (laxative, anemia to help movement but body can come dependent so don’t recommend a lot)
Diverticulosis
▪ Herniations in colonic wall (sacs called diverticulum)
▪ Asymptomatic, seen on colonoscopy
Risk factors
- Diets or conditions that increase inflammation
▪ Inflammation
▪ Microbiome changes
▪ Abnormal motility
▪ Low fiber diet (contribute to inflammation)
▪ Frequent constipation
Diverticulitis
Acute inflammation of diverticula
▪ Contents can collect, and mucosa becomes infected
▪ Abd pain, GI bleed, fever, increased WBC
Tx – bowel rest (sips of clear liquids)
▪ Further complications may develop like abscess or perforation in G.I tissue
MNT for Diverticula
Prevention
▪ Anti-inflammatory diet – more plants (increased fiber), less meat
Acute flare
▪ Bowel rest → CL → Low-residue/fiber diet (as tolerated) ▪ Gradually resume, high fiber diet as acute symptoms resolve (to prevent flare ups from happening again)
▪ Soluble (attracts water, helps stool become gel like, easy to pass, stick together so less likely to get food stuck in diverticula) vs insoluble fiber (tough fibrous parts, add bulk to stool)
▪ Don’t need to avoid seeds, nuts, husks (insoluble fiber)
▪ As always – individual toleration
Lower GI Tract: Malabsorption
Pathophysiology of Lower GI Tract
Symptoms
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Malabsorption
▪ Incomplete absorption of nutrients due to maldigestion or damage to the anatomy and physiology
▪ Celiac, Crohn’s, PCM, dysfunction of accessory organs, GI surgeries, diarrhea (common causes)
Nutritional Implications
▪ A lot of Symptoms lead to inadequate intake (ex. If a patient has diarrhea may stop eating to reduce symptoms)
▪ Deficiencies
▪ Malnutrition (if severe enough can result in overall protein calorie malnutrition)
Fat Malabsorption
- It’s important to understand normal absorption for all of these so that we can identify what can be potentially causing the malabsorption and what interventions we can do to try to improve absorption of macronutrients. Fat has the most complications because we are dealing with hydrophobic lipids in the watery solution of our GI tract so we need to have…
▪ Bile to emulsify the fats to allow access to the lipase enzymes and adequate time in the GI tract for micelle formation (so when we have damage to pancreas or gallbladder, we often see fat malabsorption) (also if something increases transit time in GI tract (moving too quickly) can also lead to fat malabsorption)
Steatorrhea – fat in stool
▪ Frothy, greasy/oily (float), foul smelling stools
▪ Abdominal pain, cramping, diarrhea
▪ Fats & fat-soluble vitamins not absorbed
Lab tests available but limited use (Gold standard (fecal fat test) – collect stool sample for 72hrs and they eat exactly 100grams of fat and can measure how much fat is in the stool and determine if fat is not being absorbed. However, very impractical/ slow turn around long) (more specialized)
- In short term/ acute setting we will base it on the symptoms and then will probably just treat empirical by eliminating fat from diet or giving pancreatic enzymes and see if that works; if it works we know they weren’t absorbing fat)
Nutrition Interventions
▪ Restrict fat intake to 25-50g per day
▪ MCT (medium chained triglycerides are absorbed directly) oil (difficult to eat) (in formulas for malabsorption will usually give higher in MCT than LCT)
▪ Pancreatic enzymes
▪ Replete/supplement fat soluble vitamins (keep in mind, fat soluble vitamins are the ones that are stored so we really only need to do this if it’s a chronic fat malabsorption or if it’s been affecting intake). (also a lot of fatty foods contain protein so if there avoiding foods high in fat want to make sure they are getting lean protein)
Carbohydrate Malabsorption
Inability to digest di- or mono-saccharides
- So what happens is that the GI bacteria digest and produce gas (which then causes the gas and bloating symptoms and the undigested sugars lead to osmotic diarrhea)
▪ Osmotic diarrhea
Most common is lactose intolerance (some people can be fructose intolerant but less common and those individuals are usually not intolerable to fructose in fruit but really high doses such as high fructose syrup)
Nutrition Interventions
▪ Avoid poorly tolerated foods (milk products)
- Cheese, ice cream (usually well tolerated by people with low lactose intolerance)
▪ Enzyme supplements (Lactaid, lactase enzymes) (can give these to help with lactose products)
▪ Enhance tolerance by using small portions
Protein Malabsorption
Protein-losing enteropathy
▪ Occurs as result of other diseases, especially PCM (protein calorie malabsorption) could also be IBD or cancer
▪ Medical Tx: Underlying disease
(shift, command, 4)
- What happens – protein is not absorbed instead it is excreted in stool, which means less protein in blood and because blood concentration is now low, water leaves the blood and enters interstitial spaces causing edema
- Stage 4 edema (pit, shiny(tight))
- Medical Tx: Underlying disease (want to find some way to feed them but can be prone to refeeding syndrome so have to be careful of that).
• Due to reduced oncotic pressure Peripheral edema Assessment of Malabsorption
Assessment of Malabsorption
▪ Anatomy, previous surgeries
▪ Weight loss (because if there not absorbing what they are eating they are most likely going to be losing weight)
Vitamin and mineral deficiencies (there are blood labs that you can get but vary in how useful they can be) (better to look at signs and symptoms)
▪ Labs, clinical s/sx (more severe stage of vitamin and mineral deficiencies), diet history (can look at what types of foods they’ve been eating to give us a clue on what vitamins they potentially be deficient in and then supplement empirically and or just give them Vit. We think they can be low in (toxicity is very high so don’t really have to worry about that especially if we think they are lacking)
Stool characteristics (BEST WAY) (the best way to look for malabsorption- that’s where you’ll see it even before vit/ mineral deficiencies become a problem) (see Table 15.5)
▪ Odor
▪ Unusual color – green, yellow, white, orange
▪ Texture – greasy/oily, fluffy, frothy, floating
▪ Undigested foods ▪ Frequency – focus on changes & timeframe (Pay attention to when their pattern changed and how long!!)
▪ Output volume (how much stool they are putting out)
Protein-calorie malnutrition (If we expect malabsorption want to assess for P.C.M by using ASPEN A.N.D criteria)
Celiac Disease
Auto-immune response to peptides in gluten (wheat, rye, malt and barley)
▪ Gluten found in wheat, rye, malt, barley
Inflammatory response damages mucosa (body sees it as a virus and attacks it) (GI villi in GI tract, which causes them to become damaged and flat which reduces absorption compacity as well as damages the cells within the villi’s capacity to make enzymes)
▪ Damage & flattening of GI villi → reduced absorptive surface and loss of enzymes
Medical diagnosis
▪ Intestinal Biopsy (Gold standard)
▪ Gluten anti-bodies within the blood
▪ Serological testing
▪ Confirmed with reversal of symptoms on gluten-free diet
- If it bugs you DON’T EAT IT
Clinical Manifestations of Celiac Disease
▪ Malabsorption of all nutrients
▪ Steatorrhea/diarrhea
▪ Abdominal pain, cramping, gas
- Can also lead to other auto-immune diseases not related such as,
▪ Peripheral neuropathy
▪ Bone and joint pain
▪ Skin rash & mouth ulcerations
▪ Iron-deficiency anemia (common- as a result of lack of iron absorption and potential lack of iron due to damage from the mucosa)
Nutrition Interventions for Celiac Disease
Strict avoidance of gluten containing foods for life
Avoiding cross-contamination
Be aware of hidden sources (Oats don’t have gluten but are usually processed in facilities with gluten)
▪ Textured/hydrolyzed vegetable protein (TVP) (gluten provides that yummy chewy taste)
▪ Starch
▪ Malt/malt flavoring
▪ Condiments
▪ Natural flavors
▪ Seasoned snack foods
▪ Medications, cosmetics
- It’s KEY to educate client
- Eventually if they stick to a gluten free diet their anatomy should return to normal and malabsorption should resolve
- If a patient has developed severe malabsorption from prolonged undiagnosed or untreated celiacs disease that leads to malabsorption, we will have to treat underlying malabsorption – very similar to IBD
Irritable Bowel Syndrome
- Not a disease itself but a bunch of symptoms that occur together and can’t be attributed to a specific disease.
- Patients who have abdominal pain related to defecation or change in bowel habits one day per week for a month or more and we have ruled out every other potential cause then we would call it IBS)
Intermittent disturbance of bowel function
▪ Abd pain related to defecation or change in bowel habits at least 1 day per week for 1 month
▪ Rule out all other causes
4 types: Diarrhea, Constipation, Mixed, Unclassified
▪ Unknown cause
Irritable Bowel Syndrome
Symptoms
▪ Abdominal pain
▪ Diarrhea, constipation or both
▪ Gas, bloating, flatulence
▪ Acute or chronic (for some people can be every other day, ongoing or flare up and go away)
Medical Intervention – treat symptoms
- Because the cause is unknown (don’t have an underlying disease) we can’t address the underlying etiology but can try and treat the symptoms – manage the diarrhea/ constipation (that lead to gas and bloating)
Nutrition Intervention
▪ Elimination diet, then avoid trigger foods
- Fiber may exacerbate symptoms (low fiber diet)
▪ Establish regular eating pattern (finding foods they can tolerate, eating them consistently and getting regular good nutrition is the goal)
▪ Monitor for nutritional deficiencies (especially if they have to avoid whole food groups for certain types of food that contribute certain nutrients)
Low FODMAP Diet (See Table 15.14)
= Diet low in fermentable oligo-di-monosaccharides and Polyols
▪ Rationale: Foods high in FODMAPS are hyperosmotic, not well digested, and are fermented → gas/bloating & diarrhea
▪ Recommended: Follow diet for 6 weeks, high FODMAP foods are added back one at a time → avoid triggers (modified nutrition diet)
- Patient has to be very motivated to learn about the diet and keep track of what they are eating and symptoms
- Essentially have to look at a list to see what they can’t and can eat because very hard to distinction
- A very effective diet for managing symptoms though
Inflammatory Bowel Disease
- Another autoimmune disease, an inflammatory condition and includes two different conditions that are similar but not quite the same under this umbrella of IBD
1. Crohn’s disease
2. Ulcerative Colitis
Both of these are characterized by,
▪ Periods of “flares” and remission (comes and goes which makes it hard to manage)
▪ Cause unknown (but has a genetic component and environmental trigger)
Nutritional Implications
▪ High risk of developing malnutrition & specific deficiencies (espec. Crohns disease because of the damage it’s doing to GI tract)
Treatment
▪ Antibiotics, immunosuppressive meds, surgery
Crohn’s Disease
▪ "Crust Deep" - Effects All layers of mucosa involved
▪ Any part of GI (mouth to rectum)
▪ "Skipping" pattern (patches through GI tract)
▪ Thickened wall, cobblestone effect
▪ Fissures (crack that can go all the way through tissue), strictures (fat wrap)
▪ Surgery – resect severely damaged mucosa
- Know which parts have been removed and how it can affect their malabsorption (map)
- What nutrients we should be most concerned about. I.e., which areas have been removed
▪ Not a cure
Ulcerative Colitis
▪ "Upper cheese" - Involves 1st 2 layers of mucosa
▪ Only colon & rectum involved
▪ Continuous disease (not likely to cause skipping)
▪ Superficial ulcerations (In first two layers)
▪ Over time, edema → loss of haustra (little bubbles/ pockets along the colon)
▪ Colectomy (remove whole colon) cures disease An individual can live fine without a colon just have to monitor hydration/ water intake
Symptoms of IBD
(Compares conditions)
1. Crohn's Disease
▪ Abdominal pain with cramping
▪ Diarrhea
▪ Tenesmus (feel like you have to shit all the time)
▪ Anorexia, weight loss, malnutrition
▪ Delayed growth in adolescents (if undiagnosed)
▪ Joint pain
▪ Inflammation of other tissues
▪ Iron deficiency anemia
2. Ulcerative Colitis
▪ Abdominal/rectal pain
▪ Bloody or mucoid diarrhea
▪ Tenesmus
▪ Weight loss
▪ Fever Complications of IBD
Complications of IBD
▪ Toxic megacolon – ulcerated mucosa (colon becomes so swollen and huge it begins to poison the body)
▪ Fistulas (holes) healed with fibrotic tissue (scars) (majority associated with cronhs, scarring will result in malabsorption)
▪ Increased risk for malignant (cancer) disease Estimating Needs
Energy and protein needs increased during acute infection/inflammation
▪ Especially concerning in growing teens/children
Energy - Adjust based on weight/malnutrition hx
▪ Adults: start with MSJ x 1.2-1.3 or 25-30kcal/kg
▪ Children: as much as 80kcal/kg for teens, 120kcal/kg for infants (titrate up to make sure we are meeting their needs for growth) (want to monitor growth as well as length and height)
Protein – Adjust based on severity of disease/PCM
▪ 1.2-2g/kg adults in ICU
▪ 2-2.5g/kg children
Nutrition Interventions for IBD
▪ Interventions differ between acute flares and remissions
Enteral nutrition
▪ Supplemental, may need hydrolyzed formula (easy to digest and absorb, less work for GI tract)
Parenteral nutrition (severe damage or multiple resections and they need bowl rest) (generally we want to try and feed the gut bec. providing nutrition will help cells heal)
▪ Obstructions, fistulas, severe disease, major GI resections, bowel rest alone not usually indicated
Nutrition Interventions for IBD
Low-residue, lactose-free diets for reducing diarrhea/preventing obstruction
▪ Fat, fiber as tolerated (individualized) (important to know patient’s anatomy and where they are having the IBD- crohns more likely to have fat malabsorption and potentially need pancreatic enzymes while Ulcerative Colitis affects the colon where fiber has most of its affect, patient could not tolerate fiber)
▪ Small frequent meals
▪ Replete vitamins and minerals (If we expect any malabsorption)
▪ Due to avoidance of foods, malabsorption, increased losses, or to correct drug-nutrient interactions
▪ Pancreatic enzymes if needed
▪ Remission – maximize nutrition status to rebuild LBM and replete nutrient stores, normalize dietary patterns (build them up nutritionally so there body has like a buffer to get ready for the next flare up so they won’t get into severe malabsorption)
Lower GI Tract - Surgery
Surgery
Operative procedure used to diagnose, repair, or treat an organ or tissue
Classified by
▪ Seriousness (major or minor)
▪ Necessity (emergency of procedure or elective procedure – was the patient able to prepare)
▪ Specific purpose of procedure (0.33)
Bowel surgery
▪ Resection or diversion
▪ Know the anatomy & type of procedure
Small Intestine Anatomy
Small Intestine Anatomy ▪ Duodenum > Jejunum > Ileum > Ileocecal valve
1. Pyloric sphincter (from stomach) TO duodenum
2. Jejunum
3. Ileum
4. Ileocecal valve from S.I to colon
Duodenum > Jejunum > Ileum > Ileocecal valve
▪ Maximum surface area for digestion and absorption
▪ Folds
▪ Villi
▪ Microvilli
▪ “brush border”
· Why is this surface area so important for digestion and absorption (increased surface area)
Motility
▪ Segmentation vs peristalsis
▪ Sphincters (control the rate at which food passes – if something is wrong could affect someone digestion and absorption and how it could affect nutrition that we want to give them)
Secretions
▪ Hormones (see Table 15.1)
▪ Bicarbonate – neutralizes gastric HCl
▪ Enzymes
Know digestion of macronutrients
▪ 1.5 L intestinal juices – water & mucus
▪ Fig 15.4, 15.5 and 15.6
mouth ulcerations ▪ Iron-deficiency anemia
Active transport utilizing Na/K+ pump at brush border
▪ Glucose, galactose, amino acids
Facilitated diffusion
▪ Fructose
Lipids enter lymph via passive diffusion
▪ First converted to micelles and packaged as chylomicrons
▪ Site-specific nutrient absorption, however able to adapt when needed
Large Intestine Functions
Large Intestine Functions: keeps things moving, allows us to defecate
▪ Motility, including defecation
▪ Primarily responsible for absorption of water, electrolytes & vitamins that remain
▪ No enzymatic absorption takes place
▪ Formation/storage of feces (waste products include insoluble fiber, bilirubin, and bacteria)
Intestinal flora ferment fiber
- There to help ferment some of the fibers that we cannot digest, and they produce SCFA, Vit. K, & Biotin
▪ Produce SCFA and lactate
▪ Maintaining optimal balance is area of ongoing research
▪ Synthesizes vitamin K & biotin
Nutrition Assessment (See Table 15.2)
▪ Anthropometrics – especially
▪ weight loss (help us figure out if their issue is causing poor intake/ digestion/ absorption
▪ History of GI surgery / current anatomy (want to know what they’re working with)
GI function/abdominal exam
▪ N/V, diarrhea, constipation, distention, pain, gas, bloating, cramping (when did it start, has it been going on for a long time? Or is it just when you eat food? Is it affecting how you eat?)
▪ Stool color, consistency, odor (Table 15.5) (assess quality of stool)
(ask) Food/fluid intake & eating pattern
▪ Specific restrictions or intolerances
▪ Diet (vege/vegan, low FODMAP, etc)
▪ Meal pattern/frequency ▪ Fiber intake/tolerance
Medications, supplements, herbs (Table 15.3)
▪ Labs: Electrolytes, serum proteins, vitamins/minerals
Stress/triggers (for IBS)
Pathophysiology of Lower GI Tract
Symptoms (may occur by themselves or may be underlying conditions)
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Diarrhea
- Compare to the patient’s baseline, what’s normal for them (N.A.) (we are looking for persistent change in pattern) (once a day is okay but if it’s happening repeatedly then we should be concerned) ( more than 200grams per day for adults or greater than 20grams per day for children) ( having stool measurements can be helpful but kind of just have to assess report and symptoms case by case)
▪ Increased frequency or water content of stools
▪ Affects consistency and/or volume
▪ Compare to patient’s baseline
▪ Acute ( < 2 weeks) versus chronic ( > 4 weeks)
- As acute expect to see dehydration, chronic could cause a more severe malnutrition
▪ Osmotic vs secretory (2 types) (see following slides)
Complications
▪ Dehydration & weight loss (because of increased stools and increased water at risk of dehydration and weight loss, primarily because of water loss but if its chronic could cause actually loss of lean body mass)
▪ Electrolyte and acid-base imbalances (loss of water)
▪ Abdominal pain & cramping (diarrhea is often associated with abdominal cramping and pain, which can affect intake as well)
▪ Presence of blood
▪ Malabsorption / Steatorrhea
Osmotic Diarrhea
▪ Normal: ~300 Osm/L (normal osmolarity of stomach is about 300L if it gets higher than that, that can be what causes osmotic diarrhea)
▪ Increased osmolarity drives water into GI lumen to normalize osmolarity (to dilute it, excess water in GI tract can result in diarrhea and watery stool)
May be caused by
▪ Maldigestion (e.g. lactose intolerance) (lactose sugars don’t get digested, which cause a lot of water to enter the G.I tract to dilute that)
▪ Excessive sorbitol, fructose or lactose
▪ Enteral feeding (rarely) (most are hyperosmolar, like most of our food)
▪ Laxative use
Tx - Remove causative agent
▪ Try isotonic enteral formula (i.e. Osmolite)
▪ Generally, resolves if pt is NPO
Secretory Diarrhea
▪ Underlying disease causes increased secretions
Bacterial, protozoa, viruses
▪ Often seen - Foodborne illnesses, like Clostridium difficile (C. Diff.) (people usually get this while they are in the hospital/ long term care- spreads from person to person and the problem with C. Diff is it doesn’t go away so once a person has it lives forever in their G.I track. When this person gets sick again, or immune system decreases C. Diff tends to flare up and cause S. Diarrhea) (if a person has diarrhea usually want to get a stool sample to see if person has C.Diff to rule that out)
▪ Traveler’s diarrhea (generally caused by bacteria and viruses)
Medications, including antibiotics (see Table 15.3)
▪ Increase GI motility or alter GI flora (which lead to S. Diarrhea)
▪ Other diseases, such as IBD, Celiac, HIV, cancer
▪ Does not resolve when NPO (because this is causing increased intestinal secretions, it would continue to happen, even though their volume might be going down if there not eating – still might see frequent smaller watery stool)
Treat underlying cause and symptoms
▪ Anti-diarrheal meds if not infectious or contraindicated (body is trying to flush out virus and we should let it. If it is a Food Born Illness, we know its bacterial and don’t give anti-diarrheal meds but if it’s caused by underlying condition or meds. That we can’t treat we can give)
▪ Fecal microbiota transplant
Nutrition Interventions for Diarrhea
1. Correct dehydration, electrolyte, acid/base balance (severe- intravenous in a hospital setting)
▪ Oral rehydration solutions ( Pedialyte, home formula – sugar, clean water, salt, sodium decarbonate ( if don’t have Pedialyte))
▪ Avoid high sugar beverages, caffeine, and EtOH (hyperosmolar) (clear liquids are hyperosmolar, which can increase diarrhea/ make worse)
Feed the gut (stimulate the GI tract for normal digestion, absorption, motility) (encourage eating normal food as much as tolerated)
▪ Soluble fiber and resistant starches to thicken stool
▪ BRAT diet, banana flakes, apple powder (easy to digest and tolerated, with not a lot of simple sugars and some fibers)
▪ Avoid foods high in simple sugars and sugar alcohols
▪ Avoid gas-producing foods
▪ Low residue (fiber) diet
Probiotics – repopulate healthy microbiota (yogurt, fermented foods)
▪ Minimal research so no organism or dose recommendations yet
Diarrhea with Enteral Nutrition (wouldn’t really do unless severe malabsorption)
Rule out other causes
- Look at medications are any made with sugar alcohols or hyperosmolar, are they on anti-biotics) (did the diarrhea start when the tube feeding started? Or have they been on tube feeding for a while and now they have diarrhea – if it’s not associated with the tube feeding starting or stopping tube feeding and you don’t see a pattern it’s probably not related).
▪ C diff
▪ Try another formula (Low fiber or high fiber formula just to see how they are tolerating it. Patient on high fiber, switch to low fiber or vice versa) (most fiber in formula is water soluble fiber which could be causing the looser stools) (isotonic formula) (peptide or MCT formula – already broken down, easy to digest)
▪ Low fiber vs high fiber
▪ Isotonic
▪ Peptide / MCT based
▪ Assess for malabsorption (diarrhea long-term, assess for malabsorption – if having enteral nutrition want to make sure there absorbing it, if there stools are the same color/ consistency as tube feeding, bad sign, not digesting anything – may have to assess if they need parental nutrition or more broken down formula) (loose stools but are digesting formula, maybe something they just have to deal with)
▪ Monitor hydration and skin
Preventing Diarrhea (assess these things)
▪ Improving access to clean water and safe sanitation
▪ Promoting hygiene education
▪ Exclusive breastfeeding
▪ Immunizing all children, esp rotavirus
▪ Keeping food and water clean
▪ Sanitary disposal of stool
Constipation - Definition
- Important to establish patients baseline and time frame – so again, ask clarifying questions – what do you mean? How often has this been going on? How many times a day do you have bowel movements? Etc..
Many subjective definitions
▪ Decrease in frequency of bowel movements
▪ Straining
▪ Hard stools
▪ Incomplete evacuation
▪ Establish baseline pattern & timeframe!
Rome Consensus Criteria (REVIEW)
▪ Symptoms >3 months (3-6 months, chronic)
▪ Define Criteria
May cause fullness, decreased appetite/intake
Constipation – Etiology
▪ Decreased motility/slowed colonic transit time
▪ Rectal outlet obstruction, adhesions, tumors
▪ Fecal impaction (obstruction in rectum, which could be a physical blockage- something that wasn’t digested (not food), adhesions (tissues of GI tract stick together), tumors) (rule of colon is to absorb water so if this isn’t happening, stool gets harder and harder to pass)
▪ IBS
▪ Neuro or inflammatory diseases like scleroderma, MS, Parkinson’s, para/quadriplegia (In lower half- often lack sensation to control muscles to pass stool, has to be monitored)
Side effect of medications, supplements
▪ Opioids
Diet & lifestyle (low in water, fiber, sedentary can contribute) (usually happens when change in lifestyle happens)
Constipation – Dx and Tx
Diagnosis
▪ Usually by report (patient saying “I have constipation” and asking those direct questions to determine if they meet criteria)
▪ May need radiographic or colonoscopy to find etiology
Treatment
▪ Underlying etiology
▪ Laxatives (to increase stool outputs, add more fluid), enemas, digital stimulation (stimulating anus to release stool)
▪ Surgery (tumor, adhesions)
Nutrition Interventions for Constipation
Recommend increased fiber intake (slowly because can cause diarrhea, gas and bloating) (encourage lots of water with fiber) (ONLY after cause has been discovered)
▪ Adults: 25-35 g/day
▪ Children >2: Age + 5 g/day
Encourage adequate fluid intake
▪ ~2L/day for adults
▪ Physical activity (stimulates gut motility and increases bowel movements)
▪ Don’t ignore the urge (holding can cause constipation because it becomes harder) (colon absorbing water from poo poo)
▪ Medications (laxative, anemia to help movement but body can come dependent so don’t recommend a lot)
Diverticulosis
▪ Herniations in colonic wall (sacs called diverticulum)
▪ Asymptomatic, seen on colonoscopy
Risk factors
- Diets or conditions that increase inflammation
▪ Inflammation
▪ Microbiome changes
▪ Abnormal motility
▪ Low fiber diet (contribute to inflammation)
▪ Frequent constipation
Diverticulitis
Acute inflammation of diverticula
▪ Contents can collect, and mucosa becomes infected
▪ Abd pain, GI bleed, fever, increased WBC
Tx – bowel rest (sips of clear liquids)
▪ Further complications may develop like abscess or perforation in G.I tissue
MNT for Diverticula
Prevention
▪ Anti-inflammatory diet – more plants (increased fiber), less meat
Acute flare
▪ Bowel rest → CL → Low-residue/fiber diet (as tolerated) ▪ Gradually resume, high fiber diet as acute symptoms resolve (to prevent flare ups from happening again)
▪ Soluble (attracts water, helps stool become gel like, easy to pass, stick together so less likely to get food stuck in diverticula) vs insoluble fiber (tough fibrous parts, add bulk to stool)
▪ Don’t need to avoid seeds, nuts, husks (insoluble fiber)
▪ As always – individual toleration
Lower GI Tract: Malabsorption
Pathophysiology of Lower GI Tract
Symptoms
▪ Diarrhea
▪ Constipation
▪ Malabsorption
Conditions
▪ Celiac disease
▪ Inflammatory Bowel Disease
▪ Diverticulitis
Surgery
Malabsorption
▪ Incomplete absorption of nutrients due to maldigestion or damage to the anatomy and physiology
▪ Celiac, Crohn’s, PCM, dysfunction of accessory organs, GI surgeries, diarrhea (common causes)
Nutritional Implications
▪ A lot of Symptoms lead to inadequate intake (ex. If a patient has diarrhea may stop eating to reduce symptoms)
▪ Deficiencies
▪ Malnutrition (if severe enough can result in overall protein calorie malnutrition)
Fat Malabsorption
- It’s important to understand normal absorption for all of these so that we can identify what can be potentially causing the malabsorption and what interventions we can do to try to improve absorption of macronutrients. Fat has the most complications because we are dealing with hydrophobic lipids in the watery solution of our GI tract so we need to have…
▪ Bile to emulsify the fats to allow access to the lipase enzymes and adequate time in the GI tract for micelle formation (so when we have damage to pancreas or gallbladder, we often see fat malabsorption) (also if something increases transit time in GI tract (moving too quickly) can also lead to fat malabsorption)
Steatorrhea – fat in stool
▪ Frothy, greasy/oily (float), foul smelling stools
▪ Abdominal pain, cramping, diarrhea
▪ Fats & fat-soluble vitamins not absorbed
Lab tests available but limited use (Gold standard (fecal fat test) – collect stool sample for 72hrs and they eat exactly 100grams of fat and can measure how much fat is in the stool and determine if fat is not being absorbed. However, very impractical/ slow turn around long) (more specialized)
- In short term/ acute setting we will base it on the symptoms and then will probably just treat empirical by eliminating fat from diet or giving pancreatic enzymes and see if that works; if it works we know they weren’t absorbing fat)
Nutrition Interventions
▪ Restrict fat intake to 25-50g per day
▪ MCT (medium chained triglycerides are absorbed directly) oil (difficult to eat) (in formulas for malabsorption will usually give higher in MCT than LCT)
▪ Pancreatic enzymes
▪ Replete/supplement fat soluble vitamins (keep in mind, fat soluble vitamins are the ones that are stored so we really only need to do this if it’s a chronic fat malabsorption or if it’s been affecting intake). (also a lot of fatty foods contain protein so if there avoiding foods high in fat want to make sure they are getting lean protein)
Carbohydrate Malabsorption
Inability to digest di- or mono-saccharides
- So what happens is that the GI bacteria digest and produce gas (which then causes the gas and bloating symptoms and the undigested sugars lead to osmotic diarrhea)
▪ Osmotic diarrhea
Most common is lactose intolerance (some people can be fructose intolerant but less common and those individuals are usually not intolerable to fructose in fruit but really high doses such as high fructose syrup)
Nutrition Interventions
▪ Avoid poorly tolerated foods (milk products)
- Cheese, ice cream (usually well tolerated by people with low lactose intolerance)
▪ Enzyme supplements (Lactaid, lactase enzymes) (can give these to help with lactose products)
▪ Enhance tolerance by using small portions
Protein Malabsorption
Protein-losing enteropathy
▪ Occurs as result of other diseases, especially PCM (protein calorie malabsorption) could also be IBD or cancer
▪ Medical Tx: Underlying disease
(shift, command, 4)
- What happens – protein is not absorbed instead it is excreted in stool, which means less protein in blood and because blood concentration is now low, water leaves the blood and enters interstitial spaces causing edema
- Stage 4 edema (pit, shiny(tight))
- Medical Tx: Underlying disease (want to find some way to feed them but can be prone to refeeding syndrome so have to be careful of that).
• Due to reduced oncotic pressure Peripheral edema Assessment of Malabsorption
Assessment of Malabsorption
▪ Anatomy, previous surgeries
▪ Weight loss (because if there not absorbing what they are eating they are most likely going to be losing weight)
Vitamin and mineral deficiencies (there are blood labs that you can get but vary in how useful they can be) (better to look at signs and symptoms)
▪ Labs, clinical s/sx (more severe stage of vitamin and mineral deficiencies), diet history (can look at what types of foods they’ve been eating to give us a clue on what vitamins they potentially be deficient in and then supplement empirically and or just give them Vit. We think they can be low in (toxicity is very high so don’t really have to worry about that especially if we think they are lacking)
Stool characteristics (BEST WAY) (the best way to look for malabsorption- that’s where you’ll see it even before vit/ mineral deficiencies become a problem) (see Table 15.5)
▪ Odor
▪ Unusual color – green, yellow, white, orange
▪ Texture – greasy/oily, fluffy, frothy, floating
▪ Undigested foods ▪ Frequency – focus on changes & timeframe (Pay attention to when their pattern changed and how long!!)
▪ Output volume (how much stool they are putting out)
Protein-calorie malnutrition (If we expect malabsorption want to assess for P.C.M by using ASPEN A.N.D criteria)
Celiac Disease
Auto-immune response to peptides in gluten (wheat, rye, malt and barley)
▪ Gluten found in wheat, rye, malt, barley
Inflammatory response damages mucosa (body sees it as a virus and attacks it) (GI villi in GI tract, which causes them to become damaged and flat which reduces absorption compacity as well as damages the cells within the villi’s capacity to make enzymes)
▪ Damage & flattening of GI villi → reduced absorptive surface and loss of enzymes
Medical diagnosis
▪ Intestinal Biopsy (Gold standard)
▪ Gluten anti-bodies within the blood
▪ Serological testing
▪ Confirmed with reversal of symptoms on gluten-free diet
- If it bugs you DON’T EAT IT
Clinical Manifestations of Celiac Disease
▪ Malabsorption of all nutrients
▪ Steatorrhea/diarrhea
▪ Abdominal pain, cramping, gas
- Can also lead to other auto-immune diseases not related such as,
▪ Peripheral neuropathy
▪ Bone and joint pain
▪ Skin rash & mouth ulcerations
▪ Iron-deficiency anemia (common- as a result of lack of iron absorption and potential lack of iron due to damage from the mucosa)
Nutrition Interventions for Celiac Disease
Strict avoidance of gluten containing foods for life
Avoiding cross-contamination
Be aware of hidden sources (Oats don’t have gluten but are usually processed in facilities with gluten)
▪ Textured/hydrolyzed vegetable protein (TVP) (gluten provides that yummy chewy taste)
▪ Starch
▪ Malt/malt flavoring
▪ Condiments
▪ Natural flavors
▪ Seasoned snack foods
▪ Medications, cosmetics
- It’s KEY to educate client
- Eventually if they stick to a gluten free diet their anatomy should return to normal and malabsorption should resolve
- If a patient has developed severe malabsorption from prolonged undiagnosed or untreated celiacs disease that leads to malabsorption, we will have to treat underlying malabsorption – very similar to IBD
Irritable Bowel Syndrome
- Not a disease itself but a bunch of symptoms that occur together and can’t be attributed to a specific disease.
- Patients who have abdominal pain related to defecation or change in bowel habits one day per week for a month or more and we have ruled out every other potential cause then we would call it IBS)
Intermittent disturbance of bowel function
▪ Abd pain related to defecation or change in bowel habits at least 1 day per week for 1 month
▪ Rule out all other causes
4 types: Diarrhea, Constipation, Mixed, Unclassified
▪ Unknown cause
Irritable Bowel Syndrome
Symptoms
▪ Abdominal pain
▪ Diarrhea, constipation or both
▪ Gas, bloating, flatulence
▪ Acute or chronic (for some people can be every other day, ongoing or flare up and go away)
Medical Intervention – treat symptoms
- Because the cause is unknown (don’t have an underlying disease) we can’t address the underlying etiology but can try and treat the symptoms – manage the diarrhea/ constipation (that lead to gas and bloating)
Nutrition Intervention
▪ Elimination diet, then avoid trigger foods
- Fiber may exacerbate symptoms (low fiber diet)
▪ Establish regular eating pattern (finding foods they can tolerate, eating them consistently and getting regular good nutrition is the goal)
▪ Monitor for nutritional deficiencies (especially if they have to avoid whole food groups for certain types of food that contribute certain nutrients)
Low FODMAP Diet (See Table 15.14)
= Diet low in fermentable oligo-di-monosaccharides and Polyols
▪ Rationale: Foods high in FODMAPS are hyperosmotic, not well digested, and are fermented → gas/bloating & diarrhea
▪ Recommended: Follow diet for 6 weeks, high FODMAP foods are added back one at a time → avoid triggers (modified nutrition diet)
- Patient has to be very motivated to learn about the diet and keep track of what they are eating and symptoms
- Essentially have to look at a list to see what they can’t and can eat because very hard to distinction
- A very effective diet for managing symptoms though
Inflammatory Bowel Disease
- Another autoimmune disease, an inflammatory condition and includes two different conditions that are similar but not quite the same under this umbrella of IBD
1. Crohn’s disease
2. Ulcerative Colitis
Both of these are characterized by,
▪ Periods of “flares” and remission (comes and goes which makes it hard to manage)
▪ Cause unknown (but has a genetic component and environmental trigger)
Nutritional Implications
▪ High risk of developing malnutrition & specific deficiencies (espec. Crohns disease because of the damage it’s doing to GI tract)
Treatment
▪ Antibiotics, immunosuppressive meds, surgery
Crohn’s Disease
▪ "Crust Deep" - Effects All layers of mucosa involved
▪ Any part of GI (mouth to rectum)
▪ "Skipping" pattern (patches through GI tract)
▪ Thickened wall, cobblestone effect
▪ Fissures (crack that can go all the way through tissue), strictures (fat wrap)
▪ Surgery – resect severely damaged mucosa
- Know which parts have been removed and how it can affect their malabsorption (map)
- What nutrients we should be most concerned about. I.e., which areas have been removed
▪ Not a cure
Ulcerative Colitis
▪ "Upper cheese" - Involves 1st 2 layers of mucosa
▪ Only colon & rectum involved
▪ Continuous disease (not likely to cause skipping)
▪ Superficial ulcerations (In first two layers)
▪ Over time, edema → loss of haustra (little bubbles/ pockets along the colon)
▪ Colectomy (remove whole colon) cures disease An individual can live fine without a colon just have to monitor hydration/ water intake
Symptoms of IBD
(Compares conditions)
1. Crohn's Disease
▪ Abdominal pain with cramping
▪ Diarrhea
▪ Tenesmus (feel like you have to shit all the time)
▪ Anorexia, weight loss, malnutrition
▪ Delayed growth in adolescents (if undiagnosed)
▪ Joint pain
▪ Inflammation of other tissues
▪ Iron deficiency anemia
2. Ulcerative Colitis
▪ Abdominal/rectal pain
▪ Bloody or mucoid diarrhea
▪ Tenesmus
▪ Weight loss
▪ Fever Complications of IBD
Complications of IBD
▪ Toxic megacolon – ulcerated mucosa (colon becomes so swollen and huge it begins to poison the body)
▪ Fistulas (holes) healed with fibrotic tissue (scars) (majority associated with cronhs, scarring will result in malabsorption)
▪ Increased risk for malignant (cancer) disease Estimating Needs
Energy and protein needs increased during acute infection/inflammation
▪ Especially concerning in growing teens/children
Energy - Adjust based on weight/malnutrition hx
▪ Adults: start with MSJ x 1.2-1.3 or 25-30kcal/kg
▪ Children: as much as 80kcal/kg for teens, 120kcal/kg for infants (titrate up to make sure we are meeting their needs for growth) (want to monitor growth as well as length and height)
Protein – Adjust based on severity of disease/PCM
▪ 1.2-2g/kg adults in ICU
▪ 2-2.5g/kg children
Nutrition Interventions for IBD
▪ Interventions differ between acute flares and remissions
Enteral nutrition
▪ Supplemental, may need hydrolyzed formula (easy to digest and absorb, less work for GI tract)
Parenteral nutrition (severe damage or multiple resections and they need bowl rest) (generally we want to try and feed the gut bec. providing nutrition will help cells heal)
▪ Obstructions, fistulas, severe disease, major GI resections, bowel rest alone not usually indicated
Nutrition Interventions for IBD
Low-residue, lactose-free diets for reducing diarrhea/preventing obstruction
▪ Fat, fiber as tolerated (individualized) (important to know patient’s anatomy and where they are having the IBD- crohns more likely to have fat malabsorption and potentially need pancreatic enzymes while Ulcerative Colitis affects the colon where fiber has most of its affect, patient could not tolerate fiber)
▪ Small frequent meals
▪ Replete vitamins and minerals (If we expect any malabsorption)
▪ Due to avoidance of foods, malabsorption, increased losses, or to correct drug-nutrient interactions
▪ Pancreatic enzymes if needed
▪ Remission – maximize nutrition status to rebuild LBM and replete nutrient stores, normalize dietary patterns (build them up nutritionally so there body has like a buffer to get ready for the next flare up so they won’t get into severe malabsorption)
Lower GI Tract - Surgery
Surgery
Operative procedure used to diagnose, repair, or treat an organ or tissue
Classified by
▪ Seriousness (major or minor)
▪ Necessity (emergency of procedure or elective procedure – was the patient able to prepare)
▪ Specific purpose of procedure (0.33)
Bowel surgery
▪ Resection or diversion
▪ Know the anatomy & type of procedure
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