Nutrition in Clinical Practice - American Gastroenterological

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

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