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git > 24 Feb Nutrition > Flashcards

24 Feb Nutrition Flashcards

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1
Q

B12 def due to omeprazole use

A

B12 is ingested bound to animal protein and must be liberated in the stomach by PEPSIN.
Pepsin is activated from pepsinogen by Gastric Acid.
Pts in long term PPI develop b12 def due to achlorhydria.

Dx : B12 levels
If inconclusive:
Methylmalonic acid levels
Homocyteine levels

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2
Q

First sign of B12 def

A

Symmetric Lower extremity paresthesia due to myelinated peripheral nerve damage.

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3
Q

Alarm signs for pathologic constipation

A

Delayed passage of meconium
Fever/vomiting
Ribbon stools
Poor growth
Severe abd distension

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4
Q

Constipation around 6months and ttt

A

Functional constipation due to dietary change(weaning) solid foods with low fibre and decreased fluid content.

Exam :
unremarkable with normal growth
(Maybe some abd distension , LLQ firmness or palpable stool)

Ttt:
🥾Dietary change with non digestible osmotically active carbs -sorbitol , Apple prune pear juice/puree
🥾polyethylene glycol (refractory)

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5
Q

Indication forBariatric surgery

A

BMI >- 35
BMI > - 30 with T2DM
BMI >- 30 with failure to lose weight or uncontrolled comorbidities

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6
Q

Options for pts unable to lose weight through lifestyle modification.

A

Weight loss medications :
🥁Pts who are overweight (BMi 25-29.9) With comorbidities
🚜Orlistat , semaglutide , tirzepatide
👠Naltrexone/bupropion, phentermine, topiramate.

Bariatric surgery :
🚨BMi >- 35 or BMI >-30 with DM and comorbidities.
🚨Medication failure not a criteria req for surgery
🚨Wt loss medication plus Surgery can also b pursued.

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7
Q

Pathogenesis and cause of Dumping Syndrome

A

Destruction or bypass of pyloric sphincter
Rapid emptying of hypertonic gastric contents.

Cause :
➡️Esophageal /Gastric resection or Reconstruction
➡️Vagal Nerve injury (Nissen fundoplication)

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8
Q

S/S of dumping syndrome

A

👐15-30 min after meals
👐Abd pain , diarrhea , nausea
👐Hypotension /Tachycardia
👐Dizziness /confusion , Fatigue , diaphoresis

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9
Q

Ttt of dumping Syndrome

A

Clinical dx
Dietary modification is best ttt.
Small freq meals
Replacement of simple sugars with complex carbs
Incorporation of high fibre and protein rich foods

Symptoms diminish over time
Minority of pts benefit from a trial of octreotide or reconstructive surgery.

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10
Q

How to identify dumping syndrome ina scenario

A

Post gastrectomy pt with GI symptoms nausea diarrhea abd cramps and vasomotor S/S : palpitations , diaphoresis

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11
Q

2 types if Dysphagia

A

🦵🏾Oropharyngeal :
Food stuck in throat , nasal regurg , coughing , choking

🦵🏾Esophageal dysphagia :
Food stuck in chest

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12
Q

Common cause Of oropharyngeal Dysphagia

A

Stroke
Advanced dementia
Oropharyngeal malignancy
Neuromuscular dx ( Myasthenia)

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13
Q

How to evaluate Dysphagia

A

💩Diff initiating swallow
Coughing, choking, nasal regurg (oropharyngeal)
⬇️
Do VideoFluoroscopic barium swallow

💩Diff with food passing thru esophagus
Food gets stuck in Chest (esophageal)

↪️If dysphagia with solids and liquids at onset (achalasia ).
⬇️
Do Barium swallow and then manometry with endoscopy

↪️If dysphagia of solids progressing to liquids (malignancy)
⬇️

Do Upper GI endoscopy (with/wo Barium swallow beforehand)

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14
Q

Cause of blood streaked stool in a well appearing child of age <6mo

A

FPIAP (If stools are loose with mucus)
Anal fissure (if constipated)

DD meckel diverticulum. Rarely presents before 6mo. And chikdren are mostly ill appearing.

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15
Q

Chemotherapy induced diarrhea

A

Secretory (Nocturnal diarrhea)
Watery voluminous and persistent despite periods of fasting.

Ttt: Oral hydration
Loperamide

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16
Q

Workup fro chemo induced diarrhea

A

CBC , serum chemistry
Stool for CDI , fecal occult.

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17
Q

Postbariatric anastomotic leak CF

A

Happens due to breakdown of either gastronejunal or jejunojenunal anastomosis

CF:
Usually in the first week post op
Fever
Abd pain
Tachypnea
Tachycardia
HR >120/min (most sensitive predictor)

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18
Q

Dx of anstomotic leak

A

Dx
Oral contrast enhanced Abd CT scan
Upper GI series

Ttt:
Urgent surgical repair

Esophagoduodenoscopy is Contraindicated as it can worsen the leak and cause perforation.

19
Q

SIBO risk factors

A

➗anatomic abnormalities (strictures , surgery , Small bowel diverticulosis)
➗motility disorders (diabetes, scleroderm, opioid use)
➗immunodef (IgA def)
➗chronic Pancreatitis
➗gastric hypochlorhydria , PPI use

20
Q

Mechanism of SIBO

A

The prox small intestine contains minimal bacteria colonization due to Gastric Acidity and peristalsis.
In roux en Y Gastric bypass , a blind loop of intestine allows for excessive bacterial growth.

Condition that alter motility(Systemic Sclerosis , DM) , anatomy (strictures) , Gastric / Pancreatic secretions (atrophic Gastritis , chronic Pancreatitis ) predispose to SIBO.

21
Q

Nutritional Deficiencies of SIBO

A

Nutritional def ;
B12 , fat soluble vitamin def
Macrocytic anemia

Folic acid and vit K maybe elevated due to inc production from enteric bacteria.

22
Q

Test to confirm SIBo

A

Lactulose and glucose breath test( that measures the production of Hydrogen and methane by intestinal flora )

Gold standard:
Endoscopy with jejunal aspirate and culture shows inc bacterial burden (>103 colony forming units)

23
Q

Ttt of SIBO

A

Empiric Ab (rifaximin)

24
Q

CI to breast feeding

A

⚫️Galactosemia in newborn
⚫️Maternal HIV infection in dev countries where formula is available
⚫️Herpetic breast lesions , active varicella
⚫️Most chemo and radio ttt
⚫️Active TB until no longer contagious (2w of anti TB ttt)
⚫️Active substance use dx without enrollment in a methadone or buprenorphine ttt program

Conc of methadone in Breast milk are low and BF is encouraged regardless of prescribed dose

Newborns of mothers taking methadone during pregnancy are at inc risk for Neonatal abstinence syndrome (withdrawal from in utero exposure to opioids)

25
Q

Manifestations of folate def

A

☑️Megaloblastic anemia
☑️Low / normal Ret count : inability to increase RBC production to respond to anemia
☑️Pancytopenia : if severe def
☑️Hyperhomocysteinemia : decreased matabolism of homocysteine

No neurologic manifestations
Normal methylmalonic acid (high in b12)

26
Q

Cause of iron def anemia in infants.

A

Maternal Iron def
Prematurity
Early introduction of cows milk before age 12mo

27
Q

Supplements for exclusively breasfed infants

A

Iron and vitamin D
Iron unti 1 yr esp in premature babies.

B12 for exclusively breasfed infants whose mothers are vegan

28
Q

Lactose intolerance dx

A

🔘Positive hydrogen breath test
(Indicating impaired absorption and bacterial carb metabolism)
🔘Positive stool test for reducing substances
🔘Low stool pH
🔘Increased stool osmotic Gap
High osmotic gap >125 mOsm/kg due to umetabolized lactose and organic acids.
Osmotic Gap 290-(2xstool Na + stool K)
Is >75 in all forms of osmotic diarrhea.
🔘No steatorrhea

29
Q

Nutrition of critically ill patients

A

Enteral nutrition initiating within <-48hrs
Via NG or orogastric tube
If risk of aspiration tube is advanced to postpyloric duodenum.
Normal Bowel sounds or evidence of bowel function(passing flatus or stool) not req for EN.

TPN used only if contraindication to EN(eg intestinal discontinuity, prolonged ileus ) as it carries risk of infection.

Dextrose solutions lack protein and cannot also maintain gut integrity.

30
Q

Benefits of EN in critically ill patients

A

🔘Prevent malnourishment and improve outcomes.
🔘Reduced infections (pneumonia)
🔘Maintain gut integrity and decreased bacterial translocation
🔘Prevent atrophy of gut and mucosa associated lymphoid tissue
🔘dec Mortality

31
Q

Enteral nutrition method

A

☑️Given within 24hrs in burn patients.
(Delay if pt is hemodynamically unstable as gut perfusion in inadequte )
☑️Start at low rate (trackle feeding) progressively inc as the patient tolerates.
☑️Burns patients have increased protein catabolism with moderate to severe burns , high protein , high calorie formulas are used

32
Q

Factitious diarrhea due to laxatives features

A

✔️Metabolic alkalosis
✔️Hypokalemia
✔️Positive stool screen for Diphenolic (bisacodyl) or polyethylene
✔️Colonoscopy showd melanosis coli
Histo shows pigment in Macrophages of lamina Propria

33
Q

What is Roux en Y gastric by pass

A

Bypasses stomach by creating small gastric pouch, Gastrojejunal anastomosis and jejunojejunal anastomosis

Weight loss is due to small gastric pouch
And induced malabsorption as nutrients can only be absorbed in common limb.

34
Q

Stomach/anastomotic stenosis S/S

A

Happens in first year after surgery due to local tissue ischemia and Ulceration.

Progressive narrowing of GJ anastomosis that leads to obstruction of gastric pouch outflow.

Progressive S/S :
Nausea, post prandial vomiting, GERD , dysphagia to the point of not tolerating liquids.

Dx :
EGD to visualize GJ anastomosis during which balloon dilation is performed to open the narrowing

     If balloon dilation fails … surgical revision is done.
35
Q

What is Refeeding syndrome

A

Reintroduction of Nutrition in pts with chronic malnourishment.
Dec Phosphate
Dec Mg
Dec K
LFT abnormalities
Muscle weakness
Arrhythmia
CCF
Rhabdomyolysis
Paresthesia seizure

36
Q

Mech of Refeeding syndrome

A

🔻Starvation results in dec PO4 , although serum levels remain Normal due to Transcellular shifts.

🔻Reintroduction if Carbs(tube feeding) causes increased Insulin secretion

🔻Insulin stimulates uptake of electrolytes PO4, K , Mg and inc PO4 utilization during glycolysis.

🔻This causes phosphate utilization
And massive fluid and electrolyte shifts.

37
Q

Subphrenic abscess CF

A

RUQ pain
Recurrent Fever leukocytosis
Abd SS : pain vomit
SOB , hiccups , Rt sided effusion
After laproscopic appendectomy.

Dx : CT scan abd

Ttt: Drainage and IV AB

38
Q

Risk for post Op intraabd abscess

A

Laparoscopy (more than laparotomy )

39
Q

CF of psoas abscess

A

🔳 subacute fever and Abd pain/flank pain that may radiate to groin or hip

🔳 anorexia weight loss

🔳 abd pain with hip extension (psoas sign)

40
Q

Dx of psoas abscess

A

🟤CT scan abd and pelvis

🟤Leukocytosis , elevated inf markers

🟤Blood and abscess cultures

41
Q

Ttt of psoas abscess

A

Drainage

BS AB

42
Q

Pt with skin furuncle presents with fever, abd pain radiating to groin

A

Psoas abscess

43
Q

Psoas abcess RF

A

HIV
IV drug abuse
Diabetes crohn dx

Either occurs from hematologic seeding from a distant infection or from direct extension of intraabd infection (diverticulitis , vertebral OM)

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