Condition Specific Nutrition Support

Question 1

In an intensive care setting, which of the following complications associated with malnutrition is most likely to occur as a result of the failure to begin nutrition support early in the treatment regimen?

1: Decreased systemic vascular resistance
2: Increased white cell production
3: Increased myocardial contraction
4: Increased serum levels of protein-bound drugs

Answer 1

4: Increased serum levels of protein-bound drugs

Protein stores in the body, including plasma proteins, decline as a result of malnutrition. Insufficient protein availability can lead to increased serum levels of protein-bound drugs. This alteration in the pharmacokinetics can lead to dangerous elevations in serum drug concentrations; therefore, an evaluation to initiate nutrition support should begin promptly.

Question 2

Which of the following is the inpatient glycemic target for critically ill patients?

1: 80-110 mg/dL
2: 140-180 mg/dL
3: 181-210 mg/dL
4: 211-240 mg/dL

.

Answer 2

2: 140-180 mg/dL

For the critically ill patient, blood glucose levels should be maintained between 140-180mg/dL. Lower glucose targets may be appropriate in selected patients. Targets <110mg/dL are not recommended

Question 3

Under conditions of sepsis and stress, which of the following metabolic alterations are most likely to occur?

1: Increased glucose production and increased glucose uptake
2: Increased glucose production and decreased glucose uptake
3: Decreased glucose production and decreased glucose uptake
4: Decreased glucose production and increased glucose uptake

Answer 3

2: Increased glucose production and decreased glucose uptake

The metabolic response to sepsis and stress is characterized by an increase in glucose production and a decrease in glucose uptake. Stress hormones induce insulin resistance and hyperglycemia is commonly observed with nutrition support. It is recommended that glucose levels be adequately controlled to avoid polyuria and electrolyte disturbances.

Question 4

Which of the following immunomodulating nutrients may be harmful in patients with severe sepsis?

1: Arginine
2: Selenium
3: Nucleic acids
4: Omega-3 fatty acids

Answer 4

1: Arginine

Arginine is a major substrate for nitric oxide production. Under normal conditions, small quantities of nitric oxide have a beneficial effect on immune function and tissue oxygenation. Thus, arginine is considered an “immune-enhancing” agent. However, nitric oxide can also be detrimental by leading to coagulation abnormalities and altered hemodynamic status. In this case, arginine could be considered harmful. Because of these effects, there is still much debate over the value of arginine in nutrition support for critically ill patients.

Question 5

Which of the following best describes enteral glutamine supplementation in the critically ill patient not in multi organ failure?

1: Enteral glutamine decreases mortality
2: Enteral glutamine decreases ventilator days
3: Enteral glutamine decreases hospital length of stay
4: Enteral glutamine decreases nosocomial infections

Answer 5

4: Enteral glutamine decreases nosocomial
infections

Glutamine supplementation is supposed to reduce mortality and nosocomial infections in critically ill patients. However the “reducing deaths due to oxidative stress” (REDOX) trials did not provide evidence supporting this. A recent meta-analysis investigated the impact of glutamine-supplemented nutrition on the outcomes of critically ill patients and found that glutamine supplementation conferred no overall mortality and length of hospital stay benefit in critically ill patients. However, glutamine supplementation did reduce nosocomial infections among critically ill patients.

Question 6

Which of the following are counter-regulatory hormones responsible for the hypercatabolism observed in critically ill trauma patients?

1: Glycogen, insulin, norepinephrine
2: Glucagon, epinephrine, cortisol
3: Glycerol, serotonin, thymoglobulin
4: Glycerin, leptin, adenosine

Answer 6

2: Glucagon, epinephrine, cortisol

The inflammation following a traumatic injury provokes a release of systemic catabolic hormones like epinephrine, glucagon, and cortisol from the hypothalamus. These hormones are responsible for glycogenolysis, gluconeogenesis, proteolysis, and free fatty acid release. The goal of this metabolic response by the patient is to maintain survival, homeostasis, and promote recovery. Therapeutic intervention is geared toward blunting the inflammatory response without making the patient susceptible to immunosuppression. Timely resuscitation, including restoration of perfusion, oxygenation, and hemodynamic stability, is the top priority. The early initiation of nutrition is an important component of supportive therapy in the care of the trauma patient

Question 7

In patients with burns, providing caloric support above energy expenditure has been found to

1: significantly decrease hospital length of stay.
2: improve wound healing and graft success.
3: decrease fat accumulation and steatosis.
4: have no effect on preservation of lean body mass.

Answer 7

4: have no effect on preservation of lean body mass.

The metabolic stress that occurs in burn injury generates a hypercatabolic state that increases energy expenditure. Although patients with burns have increased needs, feeding in excess of energy expenditure may cause hyperglycemia, hepatic steatosis, and prolonged ventilator dependence. One study of critically ill burn patients showed that caloric delivery beyond 1.2 x measured resting energy expenditure did not conserve lean body mass but was associated with increased fat mass accumulation

Question 8

In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in

1: metabolic acidosis.
2: metabolic alkalosis.
3: respiratory acidosis.
4: respiratory alkalosis.

Answer 8

3: respiratory acidosis.

The increased metabolism of glucose (oxidation and lipogenesis) increases CO2 production. This may result in increased blood pCO2 if pulmonary insufficiency is significant. According to the Henderson-Hasselbach equation, this will result in a decrease in pH. If compensatory retention and increase in bicarbonate ion do not occur, the pH may remain < 7.35. This is a condition of respiratory acidosis. The increased CO2 production is greatest when overfeeding occurs (2 x BEE). Lipogenesis, the synthesis of fat from glucose, produces 6 to 8 times more CO2 than the oxidative process (energy production).

Question 9

Which of the following is true of essential fatty acid deficiency (EFAD) in patients with cystic fibrosis (CF)?

1: Routine supplementation of omega-3 fatty acids is essential in the management of CF
2: EFAD usually does not manifest in CF patients until the second decade.
3: CF patients without pancreatic insufficiency rarely develop EFAD
4: EFA profiles have been shown to improve in CF patients after lung transplantation

Answer 9

4: EFA profiles have been shown to improve in CF patients after lung transplantation

Disruption in the exocrine function of the pancreas leads to malabsorption of fat, protein, and fat-soluble vitamins in CF patients. Essential fatty acid deficiency may contribute to inflammatory pathways contributing to the pulmonary and gastrointestinal symptoms associated with CF. The overt signs of EFAD (scaly dermatitis, alopecia, thrombocytopenia, and growth failure) are uncommon in patients with CF. EFAD correlates with poor growth and pulmonary status. EFA status is usually evaluated by measuring the triene: tetraene ratio. Although supplementation with omega 3 fatty acids are sometimes used in the management of CF, results from clinical trials have shown mixed results and further trials are needed to determine the efficacy of routine EFA supplementation in the management of CF.

Question 10

Which of the following is the best choice for feeding a pancreatic insufficient infant with cystic fibrosis?

1: Protein hydrolysate formula with medium chain triglyceride (MCT)
2: Free amino acid formula with MCT
3: Human milk
4: Standard infant formula

Answer 10

3: Human milk

Human milk is the optimal choice over standard formula for any infant due to multiple beneficial components including immunologic properties, growth factors, and both pre- and probiotics. Human milk or standard infant formula with appropriate enzyme dosing is recommended. Protein hydrolysate or free amino acid formulas containing MCT are not indicated for infants with cystic fibrosis (CF) unless there is another medical reason such as bowel resection resulting in malabsorption or liver abnormalities

Question 11

Which of the following blood chemistries will most effectively indicate the response to the protein component of nutrition support in a patient on hemodialysis?

1: Albumin
2: Prealbumin
3: Urea nitrogen appearance
4: Normalized protein equivalent of total nitrogen

Answer 11

4: Normalized protein equivalent of total nitrogen

Albumin has a half life of 21 days. Prealbumin has a half life of 72 hours. Serum prealbumin is a valid and clinically useful measure of protein energy nutritional status in maintenance dialysis patients. Prealbumin is more sensitive than albumin as an indicator of nutritional status. Normalized protein equivalent of total nitrogen (nPNA) as a component of urea kinetics is normalized to a function of weight. Urea nitrogen appearance (UNA) is the net appearance of urea nitrogen in body fluids/outputs (urine, dialysate, fistula drainage).

Question 12

For a patient requiring nutrition support therapy, which of the following may be necessary for a patient with acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT)?
1: Low potassium
2: Increased phosphorus
3: Low protein
4: Increased fluid

Answer 12

4: Increased fluid

CRRT can remove upwards of 20 liters of volume per day. This massive volume removal can result in severe hypokalemia and hypophosphatemia if potassium and phosphorus are restricted. As such, the nutrition support regimen should be generous in potassium and phosphorus. Protein requirements can be as high as 2.5 grams per kilogram per day depending on comorbidities and other acute conditions. A nutrition support regimen need not be restricted in fluid for patients receiving CRRT. However, increased fluid provision from nutrition support is not necessary.

Question 13

For acute renal failure patients requiring parenteral nutrition support, recommendations include

1: balanced mixture of essential (EAA) and non-essential amino acids (NEAA).
2: essential amino acids (EAA) plus dextrose.
3: non-essential amino acids (NEAA).
4: dextrose alone, no amino acids.

Answer 13

1: balanced mixture of essential (EAA) and non-essential amino acids (NEAA).

Previous studies supported the use of small doses of EAA plus dextrose rather than dextrose alone. More recent investigations comparing EAA administration with administration of a balance mix of EAA and NEAA showed no difference in mortality, nitrogen balance or BUN. Additionally, when EAA formulations are used for longer than 2 to 3 week, hyperammonemia and metabolic encephalopathy can occur.

Question 14

What is the glomerular filtration rate (GFR) of a patient with end-stage renal disease?
1: >90 mL/min/1.73 M2
2: 30-59 mL/min/1.73 M2
3: 15-29 mL/min/1.73 M2
4: <15 mL/min/1.73 M2

Answer 14

4: <15 mL/min/1.73 M2

Stage 1, Kidney damage with normal or high GFR: >90 mL/minute/1.73 M2. Stage 2, Kidney damage with mild low GFR: 60-89 mL/minute/1.73 M2. Stage 3, Moderate low GFR: 30-59 mL/minute/1.73 M2. Stage 4, Severe low GFR: 15-29 mL/minute/1.73 M2. Stage 5, Kidney failure: <15 (or dialysis) mL/minute/1.73 M2.

Question 15

Increased mortality in maintenance hemodialysis patients has been associated with

1: low baseline body fat percentage and low muscle mass.
2: elevated albumin and decreased CRP values.
3: increased body mass index.
4: decreased serum cholesterol.

Answer 15

1: low baseline body fat percentage and low muscle mass.

Lower muscle mass reflects poor nutrition status and inflammation. Low fat mass reflects low body stores of energy and demonstrates poor coping with catabolic stress as caused by dialysis. A BMI between 30 Kg/m^2 and 34.9 Kg/m^2 as demonstrated by Dialysis Outcomes and Practice Patterns Study is considered protective in dialysis patients. A BMI of less than 25 Kg/m^2 is not considered beneficial for patients on HD.

Question 16

Which of the following has NOT been shown to delay weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease who are receiving enteral nutrition?

1: Refeeding syndrome
2: Tube feeding syndrome
3: Underfeeding
4: Overfeeding

Answer 16

2: Tube feeding syndrome

Both overfeeding and underfeeding have been associated with prolonged ventilator dependence. Refeeding syndrome is characterized by a serum depletion of phosphorus, magnesium, and potassium as a result of aggressively refeeding malnourished patients. The hypophosphatemia associated with refeeding syndrome can intensify respiratory dysfunction and diaphragmatic weakness, leading to difficulty in ventilator weaning. Tube feeding syndrome is the development of azotemia, hypernatremia and dehydration related to the use of high protein tube feedings and inadequate fluid provision.

Question 17

What is the recommended dietary protein intake in acutely ill adult patients receiving continuous renal replacement therapy (CRRT)?

1: 0.5-0.8 g/kg per day
2: 1.2-1.5 g/kg per day
3: 1.5-2 g/kg per day
4: 2.5-3 g/kg per day

Answer 17

3: 1.5-2 g/kg per day

The delivery of adequate protein to acutely ill patients requiring dialysis is critical secondary to hypercatabolism, obligatory use of protein as a preferred fuel source during the stress response, and the likelihood of significant protein losses in CRRT effluent. In general, centrally-infused protein losses into CRRT effluent range from 10-17% and should be taken into consideration when determining protein requirements. Consensus in the literature for daily protein delivery in patients undergoing CRRT is 1.5-2 g protein/kg per day. While doses as high as 2.5g protein/kg per day have been advocated to promote positive nitrogen balance, disadvantages of high-protein delivery may include the exacerbation of uremia, increased demand on hepatic and renal function, and increased costs.

Question 18

What are the protein requirements for a stable patient receiving peritoneal dialysis (PD)?

1: 0.6-0.8 grams per kilogram per day
2: 1.2-1.3 grams per kilogram per day
3: 1.5-1.8 grams per kilogram per day
4: 2.0-2.2 grams per kilogram per day

Answer 18

2: 1.2-1.3 grams per kilogram per day

Protein losses through the peritoneum take place routinely while on PD. KDOQI guidelines recommend 1.2-1.3 gm protein/kg/day in clinically stable patients. Unless the patient has demonstrated stable protein status with 1.2 gms/kg/day, 1.3 gms/kg per day must be used.

Question 19

Which of the following is NOT a cause of protein-energy malnutrition in a patient with liver disease?
1: Malabsorption
2: Decreased caloric intake
3: Abnormal fuel metabolism
4: Reduced energy expenditure

Answer 19

4: Reduced energy expenditure

Protein-energy malnutrition with liver disease is multifactorial. Reduced caloric intake from anorexia and early satiety, fat malabsorption from altered bile acid circulation, and increased protein and fat oxidation are the main etiologies. Energy expenditure may be increased in those patients with infections and ascites.

Question 20

Protein-energy malnutrition is most common in which of the following types of liver disease?
1: Viral hepatitis
2: Cirrhosis
3: Hepatic steatosis
4: Nonalcoholic steatohepatitis (NASH)

.

Answer 20

2: Cirrhosis

Protein-energy malnutrition is prevalent in all forms of cirrhosis; severe muscle wasting may be clinically apparent. Patients with compensated viral diseases, such as hepatitis B and C, usually are not severely malnourished compared to those with alcoholic liver disease/cirrhosis. Hepatic steatosis may occur as the first stage of hepatic insufficiency as the result of alcohol consumption. Malnutrition is much less common in patients with nonalcholic steatohepatitis

Question 21

Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for

1: hyperkalemia.
2: azotemia.
3: hypermagnesium.
4: hypoglycemia.

Answer 21

2: azotemia.

Loop diuretics are known to cause electrolyte abnormalities as a result of increased urine output. Specific disturbances include excess potassium and magnesium excretion which can result in hypokalemia and hypomagnesemia. Loop diuretics are not associated with hypoglycemia. Azotemia can occur related to volume depletion.

Question 22

Hypoglycemia, requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease?
1: Hepatic steatosis
2: Well-compensated cirrhosis
3: Decompensated cirrhosis
4: Fulminant hepatic failure

Answer 22

4: Fulminant hepatic failure

Hypoglycemia is seen in the majority of patients with fulminant hepatic failure and may result from impaired glycogenolysis, glycogenesis, gluconeogenesis and hyperinsulinemia requiring aggressive glucose administration. Patients are usually in a hypercatabolic state with an increase in energy expenditure and can become rapidly malnourished.

Question 23

In cirrhotic patients, which of the following should be implemented to assist in avoiding fasting-associated starvation during the night?
1: Late evening snack
2: Nocturnal tube feeding
3: Branched-chain amino acids supplement
4: Nocturnal parenteral nutrition

Answer 23

1: Late evening snack

Cirrhotic patients have depleted glycogen stores and utilize more fat as fuel during periods of prolonged starvation. This accelerated starvation phenomenon can be seen in an overnight fast of 12 to 18 hours. A late evening snack may help prevent fasting-associated starvation. Provided the patient is able to consume adequate oral intake, tube feeding and branched-chain amino acids would have no role. Parenteral nutrition is not indicated with a functional gut.

Question 24

Which of the following is an important indicator of protein-energy malnutrition in chronic liver disease?

1: Jaundice
2: Muscle wasting
3: Elevated liver function tests
4: Hepatic encephalopathy

Answer 24

2: Muscle wasting

Muscle wasting and subcutaneous fat loss are important clinical indicators of protein-energy malnutrition. As part of the physical examination, anthropometric measurements, such as triceps skin fold and mid-arm circumference can be used. Although these measurements may be affected by fluid retention, they can be useful to assess subcutaneous fat and muscle mass. Mid-arm circumference and hand grip strength appear to be sensitive markers of body cell mass depletion. Hepatic encephalopathy, jaundice, and elevated liver function tests are not markers of malnutrition.

Question 25

Treatment for patients with overt hepatic encephalopathy who have impairments in cognitive and neuromuscular function include all EXCEPT:

1: Correction of electrolyte abnormalities
2: Treatment with lactulose or other FDA approved medication
3: Meal pattern of 3 meals and 3 snacks
4: Diet low in total protein

Answer 25

1: Correction of electrolyte abnormalities

The long standing tradition of protein restrictions for patients with advanced liver disease has no solid scientific basis and recent studies do not support this approach. Protein requirements should be determined in the same manner as for the general ICU patient. Since patients with advanced liver disease enter into starvation mode with decreased glucose oxidation and increased protein and fat catabolism, a diet should be divided into three meals and three snacks with one snack provided at bedtime. a temporary protein restriction may be utilized until cause of the encephalopathy is diagnosed and eliminated. In hepatorenal syndrome a modest reduction in protein can be made on a temporary basis until renal function improves. Primary sclerosing cholangitis, alcoholic liver disease and hepatocellular carcinoma do not require protein restrictions.

Question 26

The highest prevalence and severity of weight loss is found in patients with which of the following types of cancer?
1: Lung and colon
2: Breast and ovarian
3: Prostate and testicular
4: Pancreatic and gastric

Answer 26

4: Pancreatic and gastric

A large multicenter cooperative study of patients with 12 types of cancer found that over half of cancer patients present with weight loss at the time of diagnosis. The lowest prevalence of weight loss was found in patients with sarcomas, breast, and hematologic cancers. Patients with prostate, colon, and lung cancers had an intermediate prevalence of weight loss. The highest prevalence of weight loss came from patients with pancreatic and gastric cancers.

Question 27

Which of the following best describes the benefit of megestrol acetate in patients with cancer-associated cachexia?

1: Increase in lean muscle mass
2: Decreases the risk of thromboembolic events
3: Improves blood glucose control in diabetes mellitus
4: Improves appetite and ameliorates weight loss

Answer 27

4: Improves appetite and ameliorates weight loss

Megestrol acetate is a synthetic progestational agent that promotes weight gain and helps to stimulate appetite. Progestagens induce the release of Neuropeptide Y from the hypothalamus and downregulate the synthesis and release of proinflammatory cytokines. The change in weight is thought to be largely due to increased adipose tissue and edema. Megestrol acetate can exacerbate underlying diabetes mellitus, and rarely leads to adrenal suppression. It may also be associated with a small increase in the risk of deep venous thrombosis.

Question 28

In the first 1 - 3 months after a bone marrow transplant the nutritional needs of a patient are best met with

1: 20-25 kcal/kg daily with >= 1.5 g protein per kg body weight.
2: 20-25 kcal/kg daily with 80% of total calories from carbohydrate.
3: 30-35 kcal/kg daily with >= 1.5 g protein per kg body weight.
4: 30-35 kcal/kg daily with 80% of total calories from carbohydrate.

Answer 28

3: 30-35 kcal/kg daily with >= 1.5 g protein per kg body weight.

Energy needs will vary with the individual but usually, energy requirements are estimated at 1.5 x basal energy expenditure (BEE), or approximately 30 to 35 kcal per kilogram. Protein intake should be aimed at 1.5 g per kilogram during the first 1 to 3 months after transplantation.

Question 29

Supplementation with which of the following nutrients is routinely restricted during the early stages following hematopoietic stem cell transplantation (HSCT)?
1: calcium
2: Folate
3: Iron
4: Vitamin B12

Answer 29

3. Iron

Blood product support is usually required before, during and following HSCT with resultant iron overload. Iron overload may adversely affect overall survival post-HSCT by increasing the likelihood of acute graft-versus-host disease, blood stream infection, and sinusoidal obstruction syndrome of the liver.

Question 30

Which of the following acute changes in the serum chemistry profile would be expected in a patient who is experiencing tumor lysis syndrome(TLS)?

1: Hypercalcemia and hypomagnesemia
2: Hyperkalemia and hyperphosphatemia
3: Hypernatremia and hypermagnesemia
4: Hypocalcemia and hyperphosphatemia

Answer 30

2: Hyperkalemia and hyperphosphatemia

Tumor lysis syndrome (TLS) is caused by massive tumor cell lysis with the release of large amounts of potassium (hyperkalemia), phosphate (hyperphosphatemia), and nucleic acids into the systemic circulation. Catabolism of the nucleic acids to uric acid leads to hyperuricemia. TLS most often occurs after the initiation of cytotoxic therapy.

Question 31

Which of the following best describes the treatment of diarrhea in inflammatory bowel disease?

1: Cholestyramine is effective treatment for steatorrhea
2: Patients with diarrhea should be treated with prebiotics
3: Start antidiarrheal agents once infectious etiology is ruled out
4: Withhold pharmacological therapy until diarrhea exceeds 1 L/day

Answer 31

3: Start antidiarrheal agents once infectious etiology is ruled out

Antidiarrheals should not be given to patients with inflammatory bowel disease until the possibility of an infectious etiology of the diarrhea has been ruled out. Otherwise, there is a risk of developing toxic megacolon that can result in mortality and morbidity. Cholestyramine, used to treat bile salt malabsorption, can be used with antidiarrheal agents for patients who have undergone extensive bowel resection. There are no definite guidelines on when treatment for diarrhea should begin. However, stool output greater than 500 mL/day for 2 consecutive days should be evaluated with intervention started to reduce the risk of volume depletion and electrolyte deficiencies. There is currently a growing interest in the role of prebiotics and probiotics in the management of patients with inflammatory bowel disease. However, there are no evidence-based recommendations for using prebiotics and probiotics as standard therapy with diarrhea.

Question 32

A patient with Crohn’s disease that involves the distal ileum should be closely monitored for malabsorption of
1: iron.
2: calcium.
3: vitamin B12.
4: folic acid.

Answer 32

3: vitamin B12.

Crohn’s disease can appear anywhere from the mouth to the most distal bowel. As a result, patients with Crohn’s disease can become deficient in a whole host of nutrients. Iron and calcium are absorbed in the duodenum. Folic acid is absorbed in the proximal jejunum. Vitamin B12 is absorbed in the distal ileum.

Question 33

Which of the following is a major contributing factor in the development of metabolic bone disease in patients with inflammatory bowel disease?

1: Corticosteroid use
2: Aluminum toxicity
3: Vitamin B12 deficiency
4: Oxalic acid deficiency
.

Answer 33

1: Corticosteroid use

Osteopenia and osteoporosis are metabolic bone disease complications associated with inflammatory bowel disease. Although it is controversial whether or not the primary contributor is corticosteroid therapy, a correlation has been shown between corticosteroid dose and degree of osteopenia. Supplementation of calcium and vitamin D reduces osteopenia in patients on long-term steroids. Malnutrition, vitamin D deficiency, corticosteroid therapy, magnesium deficiency, and chronic inflammation, commonly found in patients with inflammatory bowel disease, are also associated with the development of metabolic bone disease. Hypercalciuria, aluminum toxicity and magnesium deficiency may be associated with parenteral nutrition-associated metabolic bone disease and could be a factor for patients with inflammatory bowel disease who require long-term parenteral nutrition. Aluminum toxicity and malabsoption are probably minor contributors to the problem in patients with inflammatory bowel disease. Vitamin B12 and oxalic acid play no known role in metabolic bone disease.

Question 34

In patients with severe acute pancreatitis, the use of enteral nutrition via nasojejunal feeding tube rather than parenteral nutrition is associated with

1: an increased incidence of hyperglycemia.
2: a lower risk of developing infectious complications.
3: a greater incidence of negative nitrogen balance.
4: a decreased frequency of pancreatic stimulation.

Answer 34

2: a lower risk of developing infectious complications.

Severe acute pancreatitis has historically been considered an indication for parenteral nutrition in an effort to avoid enterally induced pancreatic stimulation; however, more recent research has demonstrated that enteral nutrition is well tolerated in severe acute pancreatitis. In a study of 38 patients with severe acute pancreatitis, enteral nutrition beyond the ligament of Treitz was compared with parenteral nutrition. Those who received enteral nutrition were less likely to develop infectious complications, maintained equal nitrogen balance and had a reduced incidence of hyperglycemia compared to those who received parenteral nutrition. The enteral feedings were well tolerated without adverse effects on the disease course. It is suggested that the enteral route be used preferentially, rather than parenteral nutrition, for the patient with severe acute pancreatitis. The 2013 American College of Gastroenterology Guidelines for Management of Acute Pancreatitis recommends administration of enteral nutrition as the preferred route of nutrition support to prevent infectious complications, unless EN is not available, tolerated or patient is not meeting nutritional requirements via EN alone.

Question 35

A patient with chronic heart failure on high-dose furosemide is started on enteral nutrition for an inability to consume adequate oral nutrition. Despite a slow advancement to goal feeding rate, he suffers from electrolyte imbalance and peripheral neuritis. Deficiency of which vitamin should be suspected in the cause of his symptoms?

1: Thiamine
2: Vitamin B12
3: Folate
4: Riboflavin

Answer 35

1: Thiamine

Furosemide and digoxin may decrease thiamin uptake by cardiac cells in patients with heart failure. Thiamin deficiency in the form of wet beriberi is characterized by an enlarged heart, nonspecific electrolyte alterations, profound vasodilation, and peripheral neuritis. Symptoms of heart failure secondary to wet beriberi have been shown to improve fairly rapidly in response to thiamin supplementation in tablet or injection form.

Question 36

Gastric hypersecretions following significant small bowel resection can become problematic. Which of the following medications have shown to be the most successful in suppressing gastric hypersecretions?

1: Cholestyramine
2: Loperamide
3: Histamine2 receptor antagonists
4: Proton pump inhibitors

Answer 36

4: Proton pump inhibitors

Both histamine2-receptor antagonists (H2-blockers) and proton pump inhibitors (PPIs) have been used to treat gastric hypersecretion; however, PPIs suppress significantly more acid than H2-blockers. Fifty centimeters of jejunum are necessary to absorb PPIs. For patients with severe SBS, PPI in liquid forms may be better as the other forms of the PPI(capsules and enteric coated tablets) may be excreted before it has had time to work. Cholestyramine is used for diarrhea associated with excess fecal bile acids. Loperamide is used to slow intestinal transit

Question 37

Which of the following metabolic complications is most likely to occur in patients with short bowel syndrome with small bowel bacterial overgrowth?

1: Metabolic acidosis
2: Respiratory alkalosis
3: Metabolic alkalosis
4: Respiratory acidosis

Answer 37

1: Metabolic acidosis

Intestinal resection, especially involving removal of the ileocecal valve, with the colon intact predisposes patients to small bowel bacterial overgrowth (SBBO). In SBS the more than the “usual” amount of carbohydrate presented to the colon as a result of malabsorption can lead to an increase in d-lactate production by colonic bacteria. This cycle is exacerbated as d-lactate producing bacteria thrive in an acidic environment, which is common in SBS as a result of many factors including metabolism of more carbohydrate leads to production of lactate that leads to more acid and decrease the pH. Acidemia itself also impairs D-lactate metabolism due to a decrease in pyruvate dehydrogenase (PDH) activity. This may be a factor in the neurologic and encephalopathy seen in d- lactic acidosis.

Question 38

Patients with short bowel syndrome would benefit most from octreotide injections in the presence of

1: absence of an ileocecal valve.
2: short bowel secondary to mesenteric ischemia.
3: short bowel secondary to inflammatory bowel disease.
4: refractory diarrhea not controlled with standard antidiarrheal agents.

Answer 38

4: refractory diarrhea not controlled with standard antidiarrheal agents.

Octreotide reduces the production of a variety of GI secretions and slows jejunal transit. However, its effects are often short lasting and have not been shown to improve absorption or lead to the elimination of the need for parenteral nutrition. Due to an increased risk for cholelithiasis, expense and the potential for octreotide to inhibit bowel adaptation, use of octreotide should be reserved for patients with large volume stool losses in whom fluid and electrolyte management is problematic and should be avoided in the early adaptation stage.

Question 39

Which of the following diets should be recommended to patients with a short bowel syndrome (ileal resection) and colon in continuity?

1: High fat
2: High oxalate
3: High simple carbohydrate
4: High complex carbohydrate

Answer 39

4: High complex carbohydrate

A diet high in complex carbohydrates (50% to 60%) and low in fat (20% to 30%) has been shown to reduce fecal calorie loss and to increase overall energy absorption in short bowel syndrome (SBS) patients with at least a portion of their colon present. This diet reduces steatorrhea , magnesium and calcium lossess and decreases oxalate absorption. Normally oxalate binds to calcium and is excreted in the stool, but in fat malabsorption calcium binds to free fatty acids thus leaving oxalate free to be absorbed. To decrease risk of oxalate nephrolithiasis, SBS patients who have a colon should restrict dietary oxalate intake and consume high calcium foods or calcium citrate supplements. Regardless of bowel anatomy, the provision of complex carbohydrates in the diet of SBS patients is preferred because they reduce the osmotic load and may exert a positive effect on the adaptation process. In the intestine, starch is broken down more slowly than simple sugars, thus improving tolerance. In addition, some starches will be converted to SCFA by colonic bacterial fermentation and used as energy. Concentrated sugars should be avoided because they generate a high osmotic load and potentiate stool output

Question 40

Calcium Oxalate Nephrolithiasis can occur in patients with short bowel syndrome (SBS) with a remnant colon who

1: eat a diet with 20-30% fat.
2: do not maintain adequate hydration.
3: have ileal resection < 100cm.
4: take 500 mg calcium 2-3 times per day.

Answer 40

2: do not maintain adequate hydration.

Nephrolithiasis from calcium oxalate stones is multifactorial but is primarily due to accelerated oxalate absorption in the colon. Normally, dietary oxalate binds to calcium and is excreted in the stool. However, in the setting of steatorrhea, calcium binds to fatty acids, leaving oxalate free to pass into the colon to be absorbed and then filtered by the kidney. In the kidney, oxalate binds to calcium, resulting in oxalate nephropathy. Volume depletion increases the risk of nephrolithiasis. Maintaining adequate hydration to support a urine output > 1200 mL/day is the most important intervention to prevent this complication. Oral calcium supplements of 800 to 1200 mg/day, in divided doses not exceeding 500 mg, are used in an effort to compete with fatty acids in the lumen to bind oxalate.

Question 41

Which of the following types of fistulas will result in the greatest degree of nutritional loss?
1: Distal low output
2: Distal high output
3: Proximal low output
4: Proximal high output

Answer 41

4: Proximal high output

The higher the fistula occurs in the gastrointestinal tract, the greater the output and the higher the risk of metabolic derangements, as seen with proximal high output fistulas. Fluids and electrolytes will need to be managed and replaced carefully. Protein and calorie requirements may be elevated due to nutrient losses via fistula drainage and/or sepsis. Enteral nutrition may be possible in low output fistulas (< 500 mL/d), esophageal, gastric, duodenal or proximal jejunal fistulas with distal enteral access, can be fed with a fiber containing formula. To minimize fistula output in distal ileal or colonic fistulas a fiber free or low fiber formula should be used and the site should be as high up as possible to increase the surface area for absorption.