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IFM Study > GI APM > Flashcards

GI APM Flashcards

1
Q

What does DIGIN stand for?

A 
Digestion/Absorption
Intestinal Permeability
Gastrointestinal Microflora
Inflammation/Immune Regulation
Nervous System - Gut Feelings
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2
Q

What are the 5 R’s?

A

Remove, replace, reinoculate, repair, re-balance

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3
Q

What can you treat Entamoeba Histolytica with?

A

Nitazoxanide 500 mg bid x 10 days, Oregano Oil 200 mg tid x 10 days

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4
Q

What GI condition is associated with RLS?

A

SIBO

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5
Q

What are some alarming GI symptoms/criteria that might warrant a further specific diagnostic testing first before applying a functional medicine approach?

A 
Age over 50
Fever, chills, unintended weight loss
Family history of GI malignancy
Severe unresponsive diarrhea
Severe or unrelenting abdominal pain
Lower GI bleeding
Nocturnal Symptoms
Physical findings - abdominal mass, skin abnormalities, lymphadenopathy, arthritis
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6
Q

What digestive enzyme is secreted in saliva and what does it digest?

A

Amylase - starches

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7
Q

What digestive enzyme is secreted in stomach and what does it digest?

A

HCL/acid, Pepsin - proteins into polypeptides

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8
Q

What digestive enzymes are secreted in small intestine and what does it digest?

A

Pancreatic amylase/lipase - starches, fats
Trypsin and other enzymes - polypeptides into amino acids
Brush border enzymes - starches

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9
Q

What digestive enzyme is secreted in large intestine and what does it digest?

A

Bacterial enzymes - fiber

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10
Q

What are some impairments in Digestion and Absorption?

A 
Mastication so do good mouth exam
Hypochlorhydria
Pancreatic insufficiency
Bile insufficiency
Brush Border injury - lacking enzymes or inadequate brush border enyzmes
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11
Q

What are some causes of poor digestion?

A

1) Poor dietary habits in regard to food selection, timing, food prep and chewing.
2) Altered bowel transit time
3) Villous Atrophy - decrease brush border enzymes and transporters which affect absorption
4) Dysbiosis - affects brush border enzymes
5) Altered gut/Neuroendocrine signaling
6) Low endogenous levels of stomach acid, pancreatic enzymes, saliva and bile
7) Pharmaceutical agents - acid blocking, laxatives, nutrient inhibition

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12
Q

What are consequences of poor digestion?

A

1) Reduced bioavailability of nutrients and bio active ingredients to tissues(GI and systemic symptoms) - potential deficiency related outcome, reduced metabolic efficiency, alterned genomic activation, altered epigenetic signaling
2) Increased availability of undigested and/or un-neutralized food particles(mostly GI symptoms) - Increased allergenicity/immunogenicity, increased inflammatory triggers, increase burden for detoxification, increased fermentation and putrefaction via gut microbiota

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13
Q

Define maldigestion.

A

Refers to defective hydrolysis of nutrients.

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14
Q

Define malabsorption.

A

Refers to impaired mucosal absorption.

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15
Q

What gets digested absorbed in the proximal small intestine(duodenum)?

A

Fat, Sugars, peptides/amino acids,

Iron, Folate, Calcium, Water, Electrolytes

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16
Q

What gets digested absorbed in the middle small intestine(jejunum)?

A

Sugars, peptides/amino acids

Calcium, Water, Electrolytes

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17
Q

What gets digested absorbed in the distal small intestine(ileum)?

A

Bile Salts, B12, Water, Electrolytes

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18
Q

What gets digested absorbed large intestine(colon)?

A

Water, electrolytes, MCT oil, amino acids

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19
Q

What are some causes of Conjugated Bile Acid Deficiency?

A

Liver disease, biliary obstruction, SIBO, ileal disease, CCK deficiency

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20
Q

What are the malabsorbed substrates in Conjugated Bile Acid Deficiency?

A

Fat, Fat soluble vitamins, calcium, magnesium

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21
Q

What are causes of pancreatic insufficiency?

A

Congenital, chronic pancreatitis, pancreatic tumors, hyperacidity(inactivating pancreatic enzymes)

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22
Q

What are malabsorbed substrates of pancreatic insufficiency?

A

Fat, protein, CHO, fat soluble vitamins, B12

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23
Q

What are the causes of reduced mucosal digestion?

A

Mucosal disease(Crohn’s, Celiac), brush border enzyme deficiency(ex:lactase)

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24
Q

What are the malabsorbed substrates in reduced mucosal digestion?

A

CHO, protein

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25
Q

What are causes of intraluminal consumption of nutrients?

A

SIBO, parasitic infection(ex:D. latum)

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26
Q

What are the malabsorbed substrates of intraluminal consumption of nutrients?

A

B12, macronutrients

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27
Q

What are some mechanisms of maldigestion?

A

Conjugated Bile Acid Deficiency, Pancreatic Insufficiency, Reduced Mucosal Digestion and Intraluminal consumption of nutrients.

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28
Q

What are some mechanisms of malabsorption?

A

Reduced Mucosal Absorption, Decreased transport, Decreased Gastric Acid, IF, Rapid Gastric Emptying or Decreased Gastric Mixing.

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29
Q

What are causes of Reduced Mucosal Absorption?

A

Mucosal Disease(Crohn’s or Celiac), intestinal surgery, infections, malignancy

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30
Q

What are causes of Decreased Transport?

A

Lymphatic disease, venous stasis(ex. CHF)

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31
Q

What are causes of Decreased Gastric Acid, IF?

A

Atrophic gastritis, pernicious anemia, prior gastric resection

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32
Q

What are causes of Rapid Gastric Emptying and Decreased Gastric Mixing?

A

Gastroparesis, prior surgery, autonomic dysfunction

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33
Q

What substrates are malabsorbed in Reduced mucosal absorption?

A

Fat, CHO, protein, vitamins and minerals

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34
Q

What substrates are malabsorbed in Decreased transport?

A

Fat, protein

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35
Q

What substrates are malabsorbed in Decreased gastric acid, IF?

A

B12

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36
Q

What substrates are malabsorbed in Rapid gastric emptying, decreased gastric mixing?

A

Fat, protein

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37
Q

How does prior gastric surgery affect absorption?

A

Involves the pylorus and/or including vagatomy - accelerates gastric emptying and decreased time for absorption in the small bowel.

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38
Q

How does gastroparesis affect absorption?

A

decreased gastric mixing and impaired protein and fat assimilation.

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39
Q

What are some signs of fat malabsorption?

A

Pale, voluminous, greasy diarrhea

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40
Q

What are signs of protein malabsorption?

A

Edema, muscle atrophy, amenorrhea

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41
Q

What are signs of CHO malabsorption?

A

Abdominal bloating, flatus, diarrhea

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42
Q

What are signs of B12 malabsorption?

A

Macrocytic anemia, SSCD spinal cord

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43
Q

What are signs of folate malabsorption?

A

Macrocytic anemia

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44
Q

What are signs of B vitamin malabsorption?

A

Cheilosis, glossitis, stomatitis, acrodermatitis

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45
Q

What are signs of Iron malabsorption?

A

Microcytic anemia

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46
Q

What are signs of Calcium and Vitamin D malabsorption?

A

Osteomalacia, bone pain, fractures, tetany

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47
Q

What are signs of Vitamin A malabsorption?

A

Follicular hyperkeratosis, night blindness

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48
Q

What are signs of Vitamin K malabsorption?

A

Bleeding diathesis, hematoma

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49
Q

What are some signs of pancreatic exocrine insufficiency?

A

Steatorrhea, diarrhea, gas, bloating, stomach pain, weight loss; compounded conditions that increase fat malabsorption - crohns, SIBO, short bowel syndrome, GB dysfunction

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50
Q

What are some diseases associated with Enzyme Insufficiencies?

A

Chronic pancreatitis, CF, Diabetes esp insulin dependent, celiac, Gi surgery/bypass, gastric ulcers, obstructions of pancreatic duct, Crohns, Autoimmune dz, Zollinger Ellison Syndrome, anemia, bone loss, neurological problems.

51
Q

What contributes to Enzyme Deficiency?

A

Damaged microvilli, toxicity, stress, nutritional insufficiency, imbalanced pH, inhibitors in food, free radical oxidation, alcohol abuse

52
Q

How does nutritional deficiency worsen enzyme deficiency?

A

Digestive enzymes not working well leads to nutritional insufficiency which then worsens digestive enzymes effectiveness as need nutrients for them to work well

53
Q

How does damaged microvilli contribute to enzyme deficiency?

A

Affects disaccharides and decreased digestion of gluten which leads to inflammation; results in deficiency in brush border enyzme which leads to decreased CCK and digestive enzymes.

54
Q

What other common enzyme insufficiencies aside from pancreatic is there?

A

Lactose intolerance, fructose intolerance and sucrose intolerance.

55
Q

What are some facts about fructose malabsorption?

A

Hereditary fructose intolerance affects 1 in 20,000-30,000 people; Up to 1/3 of us not tolerant; Americans consumed 38.9 lbs of it in 2017 and 60.2 lbs sucrose.
More common in women
83% of people with fructose malabsorption have IBS dx as it can look like it with constipation, diarrhea, abdominal spasms, nausea and flatulence

56
Q

What are some facts about Pancreatic Elastase?

A

It evaluates exocrine pancreatic function and reflects overall enzyme production of amylase, lipase and protease.
It is a proteolytic enzyme secreted by human pancreas
Not affected by supplemental enzymes(but check lab)
It is 90-100% sensitive and 93-98% specific

57
Q

What are some basics for supporting enzyme function?

A

Rest and digest
Mastication
Food choices
Digestive Enzyme Supplementation

58
Q

What are some spices that increase amylase production?

A

Ginger, curcumin, mint, fennel

59
Q

What are some spices that increase lipase production?

A

Cucurmin increases it by 80%, mint and fennel

60
Q

What are some spices that increase disaccharidase enzymes(sucrase, lactase, maltase)?

A

Coriander, onion by >300%; ginger, ajowan, fennel, cumin, asafedita, curcumin, capsacin and piperine increase at least 1 disaccharidase.

61
Q

What increase bile secretion?

A

Mint and fennel

62
Q

What are some selection criteria for digestive enzyme supplements?

A

Resistance of the enzyme to the GI tract conditions, mostly pH
Activity of enzyme in digestive tract where its action is expected in order to impart the desired benefits
Turnover rate of the enzyme or its activity
Effectiveness of enzyme on the target substrate
Level of purity and absence of toxic compounds
Good manufacturing practices

63
Q

What is DPP4?

A

Protease enzyme that helps with gluten and dairy

64
Q

What does alpha galactosidase do?

A

Digestive enzyme supplement that helps with digestion of beans

65
Q

What does Pancreatic enzyme replacement therapies(PERT) go by in terms of units?

A

They go by units of lipase but they all have amylase and protease.

66
Q

Which PERT requires acid suppression?

A

Brand Viokase

67
Q

How are PERTs dosed?

A

Based on body weight

68
Q

What are PERTS based on ?

A

Porcine based

69
Q

What is Pancreatin?

A

It has protease, lipase, amylase supplement. Animal derived. Dose ranges 500-2500 units/kg/meal.

70
Q

What digestive enzyme is non animal based?

A

Aspergillus Derived Digestive Enzymes.

71
Q

What are some food derived digestive enzymes?

A

Bromelain(pineapple) 250-500 mg with food and digests protein. Taken between meals, it decreases inflammation
Papain(Papaya) - typically chewable, 100-250 mg

72
Q

What is a normal pancreatic elastase level?

A

> 350 microgram/g

73
Q

What does a level of 200-350 microgram/g pancreatic elastase indicate?

A

Declining pancreatic function, consider supplementation

74
Q

What does a level of 100-200 microgram/g of pancreatic elastase indicate?

A

Moderate pancreatic insufficiency.

Supplement with broad array of pancreatic enzymes

75
Q

What does a level of less than 100 microgram/g of pancreatic elastase indicate?

A

Severe pancreatic insufficiency

Supplement with broad array of pancreatic enzymes

76
Q

In which patients would you test pancreatic elastase?

A

Unexplained diarrhea, weight loss, other signs of malabsorption, abdominal pain

77
Q

What can exocrine pancreatic insufficiency occur secondary to?

A

Chronic pancreatitis, diabetes, celiac, inflammatory bowel dz, CF, alcohol consumption, gallstone dz

78
Q

Is pancreatic elastase more reliable with formed or unformed stool?

A

Formed stool. If unformed it is not as reliable and results in low levels.

79
Q

What increases risks for hypochlorhydria?

A 
Surgery
AI gastritis
Aging
Stress
Fasting
H PYlori
PPIs, H2 Blockers, Antacid abuse
Severe iron deficiency
Viral or bacterial infection
Debilitating chronic condition(takes 600-800 cls per day to concentrate H+ ions)
80
Q

What are consequences of hypochlorhydria?

A 
SIBO
Parasite
H Pylori
Chronic candida
Iron deficiency
Other mineral deficiency(Ca, Mg, Zn, Fe, Cr, Mo, Mn, Cu) - osteroporosis or anemia
B12 deficiency(indirectly)
81
Q

What can you take to support gastric acidity?

A 
Best to take with protein containing meal:
Betaine
Bitters
Vinegars
Umeboshi plums
Digestive enzymes with acid PH range
Stress mgmt
Accupuncture
82
Q

What are some signs of Bile Acid Insufficiency?

A 
Incomplete digestion/absorption of fats
Steatorrhea
Diarrhea
Bitter taste in mouth after meals
N/V
Queasy after fatty meal
Constant feeling of fullness
Deferred pain to head, abdomen, under shoulder blades, etc
83
Q

What supports fat digestion and absorption?

A

Lipase containing digestive enzymes
Bile salts
Cholagogues/Choleretics

84
Q

What can maintain motility?

A 
F/V, ancient grains, beans, seeds, water
Probiotic foods, fermented foods
Psyllium, pectin
Flax, flaxseed oil
Cod liver oil
Natural colonic laxatives
Addressing root causes
85
Q

What are some natural colonic laxatives?

A

Aloe vera, senna, buckthorn, rhubarb. (Don’t use anthraquinones longterm as they are stimulant laxatives. )

86
Q

What are non pharmacologic prokinetics?

A 
Iberogast
Ginger root
Tryptophan
Mag citrate, dietary magnesium
Ascorbic acid, sodium ascorbate
Vitamin D
Swedish bitters
D limonene
Triphala
Chinese herbs
Accupuncture/pressure
Deep breathing, stress reduction
Exercise
87
Q

What do you want to remove as part of the 5R?

A

Foods that pt are sensitive, intolerant or allergic to
Pathogenic microflora(bacteria, fungi, parasite)
Environmental stressors such as pollutants
Stress

88
Q

What do you want to replace as part of the 5R?

A

Factors that are inadequate or lacking

89
Q

What do you want to reinoculate as part of the 5R?

A

Desirable gut microflora(pre/pro/synbiotics) to obtain a more desirable balance to the intestinal milieu

90
Q

What do you want to repair as part of the 5R?

A

Providing nutritional support for healing and regeneration of the gut mucosa

91
Q

What do you want to rebalance as part of the 5R?

A

Providing support for restorative processes in patient’s life

92
Q

What are some clinical approaches to “remove”?

A

Oligoantigenic elimination diet
Botanical antimicrobrials or bacteriostatic/cidal phytonutrients
Antibiotics/Antifungals

93
Q

What are some clinical approaches to “replace”?

A 
Digestive factors
HCL
Pancreatic Enzymes
Bile salts
Fiber to support transit and general GI fxn
94
Q

What are some clinical approaches to “reinoculate”?

A

Probiotics
Prebiotics
Synbiotics

95
Q

What are some clinical approaches to “repair”?

A

Nutrients for GI repair and healing
Mucosal lining support
Mucosal secretion protectants
Support for GALT fxn
Antioxidants known to function in GI(ex catechins)
Nutritional and phytonutritional antiinflammatories(cucurmin, EPA, DHA)

96
Q

What are some clinical approaches to “rebalance”?

A 
Scheduling and relaxation
Mindful eating and better choices
HRV, biofeedback
Yoga, meditation, prayer, breathing and other centering practices
Psychotherapy
97
Q

What should you hold if have yeast in GI tract?

A

Prebiotics as can act as fertilizers for eat; Probiotics are okay.

98
Q

What are some nutrients important for GI repair?

A

Glutamine, arginine, vitamin A, D, C, B5, E, zinc and carotenoids

99
Q

What helps mucosal lining support?

A

Phosphytidylcholine

100
Q

What are mucosal secretion protectants?

A

PC, plantain, polysaccharides

101
Q

What supports GALT fxn?

A

Lactoferrin, lactoperoxidase, whey, Immunoglobulins

102
Q

What are some triggers and mediators to cause gut dysregulation?

A

Diminished HCL, Bile acids, gastric/pancreatic/brush border enzymes
CCK hypersensitivity
Food allergies/intolerances/sensitivities
Psych/emot stress
Travel
Hypoxia(ischemia, low O2 sat)

103
Q

What is the autoimmune triad?

A

Genetic predisoposition, trigger, leaky gut

104
Q

What are different types of Elimination Diets?

A

Comprehensive
6 food elimination(SFED) wheat, eggs, dairy, legumes/peanuts, soy, seafood/fish
4 food elimination - wheat, eggs, dairy, legumes/peanuts
Simplified(caveman) - eating lamb, rice, pear, sweet potato
Single food group elimination
Sugar
FODMAP
PALEO

105
Q

What botanicals tx yeast?

A 
Oregano
Thyme
Garlic
Goldenseal
In general use in combination
106
Q

What are botanical tx for parasites?

A 
Oregano
Thyme
Goldenseal
Artemis
Tx 4-6 weeks
107
Q

What increases sIgA?

A

Presence of harmful antigens - bacteria, parasites, fungi, viruses, abnl cell Ag, allergenic proteins

108
Q

What decreases sIgA?

A

Mental/physical stress, inadequate nutrition

109
Q

What increases Calprotectin and Lactoferrin?

A 
IBD
Postinfectious IBS
Cancer GI tract
GI infections
Nsaid enteropathy
Food allergy
Chronic pancreatitis
110
Q

What is better at predicting relapse in IBD, calprotectin or lactoferrin?

A

Both are similiar in prediction of relapse(better in UC then CD); similiar at distinguishing IBD from IBS; both sensitive

111
Q

What conditions is Pancreatic elastase commonly decreased in?

A

Autism
Osteoporosis
Mood d/o
Diabetes

112
Q

What are the 3 putrefactive SCFA?

A

Valerate, isovalerate, isobutyrate(products of anaerobic fermentation of proteins)

113
Q

What are good SCFA?

A

Butyrate, acetate and proprionate(fermentation of fibers)

114
Q

What conditions cause putrefactive SCFA?

A

Hypochlorhydria, PPI
Low protein digesting enzymes by pancreas
Poor abs of protein d/t inflammation of gut lining
Dysbiosis:SIBO

115
Q

What does level <50 calprotectin mean?

A

No chance of IBD

116
Q

What does level of 50-120 calprotectin mean?

A

Some GI inflammation, IBD, inefction, polyps, neoplasia, nsaids

117
Q

What does level of >120 and >200 calprotectin mean?

A

Significant inflammation - needs referral

Active disease, relapse imminent in treated patients

118
Q

What does the relationship look like for calprotectin and lactoferrin in response to inflammation?

A

Calprotectin - linear

Lactoferrin - hockey stick

119
Q

What is Eosinophil Protein X tell you?

A

Feces test to evaluate disease activity and predicting relapse in IBD, but not as good as fecal calprotectin in predicting treatment outcome.

120
Q

Which test is better for diagnosing Celiac?

A

IgG DGP(better than IgA DGP) - has better sensitivity and specificity

121
Q

Positive Anti-tTg IgA, normal total IgA means?

A

presume celiac

122
Q

Negative anti tTg IgA, low total IgA, negative anti dgp IgA, positive anti tTG IgG, positive anti dGP IgG?

A

Celiac with IgA deficiency

123
Q

Positive anti dGP IgA and +/- anti dGP IgG with other negative ab?

A

Possible celiac disease(seen in under 3)

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