Lower GI Flashcards
(101 cards)
1
Q
Which foods should be avoided after ileostomy?
A
For the first 6-8 weeks:
V&F: bean sprouts, coconut, dried fruit, mushrooms, snow peas, vegetable skins, popcorn
Protein: legumes such as beans, meat casings, tough or stringy meat, whole nuts and seeds
After 6 to 8 weeks, once your stoma has healed, you can introduce the foods listed above into your diet. Do this one type of food at a time. This will help you see the effects of each food on your ileostomy output.
2
Q
WHat are good fluid choices after ileostomy?
A
- water
- milk or milk alternatives
- 100% fruit juices, diluted
- herbal or weak tea.
3
Q
Try limiting these foods to help decrease odour with ileostomy
A
- asparagus
- broccoli
- eggs
- fish
- garlic
- onion
- spiced foods.
4
Q
Try adding these foods to help decrease odour with ileostomy
A
- buttermilk
- fresh parsley
- yogurt.
5
Q
Which diet/habit adjustments can you undertake with gas after ileostomy
A
Try limiting these foods to reduce gas: • cruciferous vegetables such as broccoli, Brussels sprouts, cabbage, cauliflower • legumes (beans, peas and lentils) • onions • sprouts • beer • carbonated beverages • coffee • dairy products. Try the following suggestions to reduce swallowing air and producing gas: • Eat slowly. • Chew your food well. • Don't skip meals. • Eat small meals throughout the day. • Avoid talking while eating. • Don't smoke. • Avoid chewing gum. • Avoid drinking with a straw. • Avoid carbonated beverages.
6
Q
what is considered high output ileostomy
A
> 1Litre
7
Q
what should u do when u have high output ileostomy?
A
Add 1-2 extra litres (4-8 cups) of fluid each day. Good choices are: water, milk or milk alternatives, diluted 100% fruit juices, herbal or weak tea
Add 5 mL (1 tsp) of salt throughout the day. You can do this by sprinkling salt on your food and choosing saltier items such as canned soups or crackers.
Include potassium rich foods such as bananas, diluted orange juice, potatoes, tomato juice, milk and milk alternatives.
Do not restrict your fluids to control a high ostomy output. This could lead to dehydration or worsen existing dehydration.
Speak to your doctor or dietitian if you continue to have a high stool output. They may recommend an oral rehydration drink or have other dietary suggestions.
8
Q
what is POSTOPERATIVE ILEUS
A
temporary problems with bowel movement after surgical intervention, which prevents effective transit of intestinal contents or tolerance of oral intake
9
Q
Primary versus secondary POI
A
“primary” POI occurs without being caused by postoperative complications. A “secondary” POI occurs due to a postoperative complication such as infection, anastomotic leak, obstruction, etc
10
Q
what is considered as prolonged POI?
A
A POI is considered prolonged if it lasts >5 days
11
Q
ESPEN has recently defined diagnostic criteria for malnutrition according to two options
A
option 1: BMI <18.5 kg/m2
option 2: combined: weight loss >10% or >5% over 3 months and
reduced BMI or a low fat free mass index (FFMI).
12
Q
How is surgical stress response clinically manifested
A
- as salt and water retention to maintain plasma volume;
- increased cardiac output and oxygen consumption to maintain systemic delivery of nutrient and oxygen-rich blood;
- and mobilisation of energy reserves (glycogen, adipose, lean body mass) to maintain energy processes, repair tissues and synthesise proteins involved in the immune response
13
Q
what Causes hyperglycaemia in surgical response
A
peripheral and central insulin resistance
Peripheral insulin resistance refers to impaired insulin-mediated glucose uptake, whereas central insulin resistance refers to the inability of insulin to suppress glucose production from the liver
14
Q
What can be done to meet protein needs and support protein anabolism before surgery?
A
Dietary protein consumption and resistance exercise- training
15
Q
what is prehabilitation?
A
A process in the continuum of care that occurs between the time of diagnosis and the beginning of acute treatment (surgery, chemotherapy, radiotherapy) and includes physical, nutritional and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments
16
Q
Preoperative nutrition recommendations
A
Preoperative routine nutritional assessment offers the opportunity to correct malnutrition and should be offered. Preoperatively, patients at risk of malnutrition should receive nutritional treatment preferably using the oral route for a period of at least 7–10 days.
17
Q
anemia recommendations in colorectal surgery
A
Anaemia is common in patients presenting for colorectal surgery and increases all cause morbidity. Attempts to correct it should be made prior to surgery.
18
Q
Preoperative fasting and carbohydrate loading recommendation
A
Patients undergoing elective colorectal surgery should be allowed to eat up until 6h and take clear fluids including CHO drinks, up until 2 h before initiation of anaesthesia. Patients with delayed gastric emptying and emergency patients should remain fasted overnight or 6 h before surgery. No recommendation can be given for the use of CHO in patients with diabetes.
19
Q
what does IBD result from?
A
IBD is caused by inappropriate inflammatory response that results in a chronic intestinal damage
20
Q
what are the 2 types of IBD?
A
Crohn’s Disease
Ulcerative Colitis.
21
Q
is there a good single test to diagnose IBD?
A
no
22
Q
localization of Crohn’s vs UC
A
Crohn’s Disease the lesions are discontinuous and they can occur anywhere from the mouth to the anus. However, the most common locations are the terminal ileum, the large intestine which is also known as the colon, as well as then other areas in the small intestine.
- BOTH SI ad LI are affected
UC:
Lesions are continuous
Typically begin in the rectum and then move backwards through the large intestine. - ONLY large intestine is affected
23
Q
Presentations of Crohn’s
A
Terminal illium
The last section of SI before it enters into the colon-> Right lower quadrant is affected
Right lower quadrant abdominal pain
Also may result in diarrhea that may or may not be bloody
If a large part of small intestine is involved
Risk of malabsorption-> poor nutrition-> weight loss and fatigue
Large intestine/colon
Colon is mainly responsible for absorbing water from the stool->
Inflammation of the colon will result in water being poorly absorbed-> diarrhoea (may or may not be bloody)
24
Q
Presentations of UC
A
Most common presentation is diarrhoea with some diffuse cramps abdominal pain
Diarrhea is more commonly bloody in UC than in Crohn’s disease
25
Extra intestinal symptoms and how can they be "helpful"
Symptoms of Crohn's disease and UC that are not associated with the location of inflammation
Skin disease - Eythema Nodosum - red tender nodules
Joint pain that often seems to migrate between different joints such as the shoulders, elbows, hips, and knees
Redness of the eyes
Liver disease.
There are not many diseases that will cause these abdominal symptom that can be associated with IBD in association with some of these extra-intestinal symptoms.
So, if they're happening together that's actually a fairly specific sign that someone might have Inflammatory Bowel Disease
26
are lab studies for IBD specific/sensitive?
Laboratory findings of Crohn's disease and ulcerative colitis are fairly non-specific, but they're very sensitive for IBD if this findings are not present-> no IBD
27
Name lab studies in IBD
Markers of inflammation
Anemia
Malabsorption
28
Describe markers of inflammation lab test for IBD
Increased white blood cell count
Non-specific markers of inflammation that include an increased sedimentation rate and an increased C-reactive protein.
Very non-specific, as many inflammatory condition in the body can cause these findings.
However, they're very sensitive for Inflammatory Bowel Disease, as if someone doesn't have
an increased sedimentation rate or an increased C-reactive protein the process that's going on is likely not Crohn's Disease or Ulcerative Colitis.
29
Describe anemia as a lab test for IBD
May occur due to terminal illeum being affected in the case of Crohn’s Disease. Thus the body is not able to properly absorb vitamin B12 which is necessary to produce red blood cells
Both Crohn's Disease and Ulcerative Colitis can have bloody diarrhea. If this bloody diarrhea is occurring frequently and over long periods-> can result in anemia.
30
Describe malnutrition as a lab test for IBD
If small intestine and even parts of the large intestine are inflamed and not working properly this can lead to malabsorption b
Blood test can be marker of malabsorption
Low albumin level is the main marker of malabsorption
31
what are the steps of IDB diagnosis?
lab studies
diagnostic work up
biopsy
32
describe diagnostic workup for IBD
If lab findings, especially the markers of inflammation are present the next step would be diagnostic work up which is obtaining imaging studies
CT and MRI can be done
Barium Enema is a contrast dye that is inserted through the rectum into the intestine as it fills up and intestinal lumen x-ray is taken to look at the abdominal cavity
In Chron’s disease the results will display inflammation happening in both small intestine and large intestine which will be intermixed was normal looking intestines. This discontinuity it is characteristic of Crohn’s
In Ulcerative Colitis you'll see a continuous lesion that only involves the large intestine with no gaps of inflammation. Small intestine will look OK
33
biopsy for IBD
Type of procedure is largely based on the location of biopsy
The procedure is always two-fold: there is visualization of the lesion and the biopsy of microscopic pathology
For example Crohn's disease is suspected and the lesion is in the first part of the small intestine-> use an endoscope down the oesophagus through the stomach to see the first part of small intestine
-Visualization: Cobblestone appearance
- Biopsy of microscopic pathology: transmural inflammation where the inflammation caused by the disease goes through all three layers of the intestinal wall: the mucosa, the submucosa, and the muscularis externa as well as these noncaseating granulomas
These granulomas are a sign of chronic infection.
Ulcerative colitis where the inflammation is only in the colon-> sigmoidoscopy or colonoscopy where a camera is inserted through the anus and rectum to obtain a biopsy
- Visualization: frable appearance (looks like it would easily bleed or parts of it would just slough off)
- Biopsy of microscopic pathology: inflammation contained only in the mucosal and submucosal layers
34
primary functions of LI
reabsorption of water, electrolytes, some vitamins
• ~1500 species of bacteria live within
colon
• Fibre fermented = short-chain fatty acids
• Formation and storage of feces (entire process can take 12-72hrs)
• Vitamin K, biotin, and folate produced endogenously
35
Normal anatomy and physiology of the small intestine
* GALT- gut associated lymphoid tissue
* Enzymatic digestion
* Carbs, protein, fat
* Secretions
* Hormones
* Digestive enzymes, bicarb and bile from ancillary digestive organs: liver, gallbladder and pancreas
* 1.5L of digestive juices
* 3-day turnover of enterocytes
36
IBD is __, __ inflammatory condition of the GI tract.
Autoimmune, chronic inflammatory condition of the GI tract.
37
which part of the world experiences IBD more commonly? what does that suggest?
More common in Western world, which suggests a strong environmental/lifestyle influence
38
which layers of gut are affected: Crohn's vs UC
Crohn's: all 3
| UC: only inflames the innermost lining of bowel tissue.
39
• Ulcerations can lead to __ colon and toxic __
• Ulcerations can lead to thin ulcerated colon and toxic megacolon
40
What is toxic megacolon?
toxic meagacolon happens when inflammation causes it to distend and when that happens, the gas with feces is trapped
if not fixed, it can rupture -> risk of death
there is a lot of bacteria in the gut-> if this rupture becomes systemic it is very dangerous
41
What does inflammation with Crohn's lead to ?
Inflammation can cause fistulas that when healed are replaced with fibrotic tissue that can lead to recurrent strictures and obstructions.
42
what is a fistula and what can leak thorugh it? What are further complicaitons?
fistula is an abnormal openning
feces will be coming out of that fistula
when fistula heals, tissue becomes fibrotic -> patient can get a stricture (narrowing)-> can lead to bowel obstruction
43
Link between EN and fistulas
when fistula heals, tissue becomes fibrotic -> patient can get a stricture (narrowing)-> can lead to bowel obstruction- > no EN will be administered
if obstruction is in small intestine and we can by-pass it and obstruction is distal to the tube-> EN can be given
44
is there a specfic casue of IBD
no
45
Diet and IBD link
```
From large observational studies
1. High intakes of fat and meat:
increased risk
2. High fibre and fruits: decreased risk
3. High vegetables: decreased risk in UC
```
46
location: crohn"s vs UC
* UC involves the rectum and colon and extends in a continuous retrograde mode.
* During progression of CD, the inflammatory process can involve any part of the digestive tract, from the mouth to the anus, but mainly affects the distal ileum and the colon.
47
Concerns" CD vs UC
UC:
diarrhea (often bloody), dehydration, electrolyte imbalances
small intestine is not affected -> much less concerned with nutrition deficiencies
CD:
SI, especially illeum is affected -> concern of nutrition deficiencies
often weight loss occurs
diarrhea, electrolyte imbalances, dehydration as bowel is also inflamed
48
MIld-moderate stage of CD
* ambulatory,
* able to tolerate oral intake without dehydration, toxicity (fevers), abdominal tenderness, painful mass, obstruction, or >10% wt loss.
mild moderate stage-> feed is allowed
they can eat orally and can usually manage hydration relatively well
49
moderate- severe stage of CD
usually do not respond to treatment ( no response to meds)
Failure to respond to treatment for mild-moderate disease or those with more major symptoms of fevers, significant wt loss,
abdominal pain or tenderness, intermittent nausea or vomiting (without obstructive findings), significant anemia.
likely feed will be administered with ONS or enteral
children diagnosed with IBD get a PEG
50
severe-fuminant stage of CD
Persisting symptoms in spite of steroid Rx, or those presenting with:
• highfever,
• persistent vomiting,
• evidence intestinal obstruction, -> no feed, unless we can bypass the obstruction or it resolves
• rebound tenderness,
• cachexia, or
• evidence of abscess
likely NPO as usually they dont stop vomiting
51
remission stage of CD
asymptomatic, without inflammatory sequelae and includes those who have responded to acute medical intervention or surgical resection without gross evidence or residual disease.
• Does not include those who are taking steroids to be asymptomatic.
52
Crohn's Activity Index cut-offs
* Index values ≤150 and below are associated with quiescent disease; remission.
* Values >220 moderate to severe disease.
* Values >300 are seen with severe disease.
* Lowering 70 points is indicative of positive change.
53
IBD treatments
* Antibiotics
* Immune system suppressant E.g.Methotrexate
* Anti-inflammatory medications E.g.,corticosteroids(Prednisone); E.g.,Sulfasalazine(Azulfidine)
* Immunomodulators E.g., azathioprine (AZA)
* Biologic therapies E.g.,infliximab
* Surgical intervention: >60% of patients!
* UC = Colectomy (total, partial)
* Crohn’s= total colectomy and ileostomy
54
Components of IBD nutr assessment
```
Food intake/Nutrition-related history
Anthropometric
Nutrition-focused physical findings
Client history (PMHx, Social Hx)
Biochemical tests
```
55
Food intake/Nutrition-related history components
```
Usual food intake- bad dietary patterns, nutrient deficiency?
24 hr recall, food record
Supplements and herbal products
Knowledge, attitudes, beliefs
Previous diets and RD visits
Physical activity and function
Medications
```
56
Anthropometric assessment components
Current weight and weight history - time frame is very important
Body composition
57
Nutrition-focused physical findings components
loss of subcutaneous fat
muscle wasting, edema, skin rash
Nutrition-impact symptoms (NIS), including appetite, diarrhea
Bowel habits and description of BMs
Steatorrhea?
Signs of micronutrient deficiencies E.g., glossitis
58
Client history (PMHx, Social Hx) compoentns
```
Disease severity calculator
Duration of IBD, relapse frequency
Severity and extent of current symptoms
Previous surgeries
Support from family and friends
```
59
IBD biochemical test
* CBC
* Assess for anemia: B12, folate, Iron
* Electrolytes
* Serum zinc
* 25-Hydroxy Vitamin D
* Infection: Elevated WBC
* Inflammation: Elevated CRP or total lymphocyte count
Other medical tests:
• xylose absorption -to measure efficiency of carb absorption
• 72 hr fecal fat
• lactose breath test - to test lactose intolerance
• Schilling's test- to test B12 status
this is more common than the other tests
60
which nutrition aspect is important with inflammatin?
elevated WB cells = infection -> ensure that patient consumes enough protein as inflammation is basically a lot of inflammatory proteins
thus patients needs extra protein to support the synthesis of inflammatory proteins + meet protein intake goal
high CRP-> inflammatory state
61
Common nutrient deficiencies
Kcal due to Insufficient intake, increased rqmts,
Protein due to Insufficient intake, increased rqmts
Fluid and electrolytes due to High volume diarrhea, high output ostomy, short gut
Fe due to Blood loss, malabsorption
Mg, Zn due to High volume diarrhea, short gut, fistula
Ca, Vit D due to Long-term steroid use, lactose or dairy-restricted diets
B12 due to Surgical resection of stomach or ileum
Folate due to Medications
Water-soluble vitamins due to Surgical resection
Fat-soluble vitamins due to Steatorrhea
62
Red flag meds for nutr deficiencies
Methotrexate, Sulfasalazine-> folate
| Corticosteroids> Vit D and calcium
63
Folate deficiency, related meds and mechanism
| What to do?
• Deficient: 20-60% IBD pts
• Sulfasalazine competes with folate in intestinal lumen, causes reduced availability of folate.
• Methotrexate is an antagonist to folic acid
• Contributes to anemia
• What to do? Reduce medications or
add supplemental folate or both
64
Calcium and Vit D deficiency, related meds and mechanism
| What to do?
* Corticosteroids impair absorption and retention of calcium
* Alter activation of 1-alpha hydroxylase and thus conversion of 25(OH)D to 1,25(OH)2D is altered – implications for mobilization of bone mineral.
* What to do? Supplement Ca and Vit D
65
Possible side effects of corticosteroids (Prednisone)
- Hyperglycemia due to insulin resistance
- Fluid and salt retention
- Loss of potassium
- Osteoporosis
- Loss of lean mass
- Increased cholesterol and triglycerides Increased hunger and weight gain
- Increased metabolic stress (consider for SGA) and - increased risk of poor surgical outcomes: <10mg prednisone = low stress, >=10 & <30mg prednisone =moderate stress, and >=30 high stress.
66
prednisone reccs for surgery
Prednisone dose usually has to be decreased before surgery
67
Dose for Vit D and Calcium supplements with prednisone
ASPEN pg 515: with steroid 1500 mg/d elemental Calcium, 800 to 1000 IU Vit D
68
IBD: Common Nutrition Diagnoses
• “malnutrition” “inadequate oral intake” “increased nutrient needs” “food-medication interaction” “impaired nutrient utilization” “altered GI function” “unintended weight loss” “underweight”
• As estimated 65-75% of inpatients and more than 50% outpatients with Crohn’s disease experience significant weight loss (ASPEN)
- sitophobia = fear of eating
69
can diet cause or cure IBD
• No direct evidence that diet can cause or cure IBD
70
Nutrition goals in IBD patients
reduce symptoms, replace lost nutrients, maintain adequate intake and promote healing
71
Provider vs Patient centric
Provider centric: Focus on disease treatment
| Patient Centric: Focus on evaluation and treatment of patients
72
Your IBD patient decides to go diary-free to treat her disease. What do you do?
a. Educate her.
b. Help her meet nutrient needs (e.g., Ca, Vit D) while following a dairy-free diet.
c. Encourage her to keep a food, mood, activity, symptom diary.
d. Encourage her to see her gastroenterologist to optimize meds.
e. All of the above.
e. All of the above.
73
```
Nutrition Therapy During Exacerbation of Disease (flare up)
- energy
- protein
- ONS
etc
```
• Energy needs aim for 25-30kcal/kg: Higher end with higher disease severity or inflammation
• Protein needs 1-1.5 g/kg (ASPEN): Higher end with disease severity or inflammation or healing
• ONS: Semi-elemental, elemental may be better tolerated
- these are more expensive, so they might not be your first choice
try polymeric first’ if doesn’t work (intolerance symptoms) -> use SE/elemental
• Low-residue, lactose-free diet may be required: Increase fiber and lactose as tolerated (as pt responds to therapy)
• Small, frequent meals
• May use MCT oil if steatorrhea present
• Restrict gas producing foods or foods pt find problematic
• Multivitamin/mineral
74
why would we use MCT during a flare up
MCT doesn’t require bile to be digested and absorbed
75
Indications for low residue diet
* Acute flare up
* Stricture
* Short period of time
76
General guidelines for low residue diet
Chew well
Small frequent meals
Limit irritants
Avoid high fibre (insoluble) and high fat foods
77
What can be eaten during low-residue diet
• Vegetables: Cooked, juice
• Fruits:
- Cooked, juice, canned
- Fresh: peeled without seeds
• Grain products: Refined <2g of fibre/portion
• Milk and alt: Avoid if contain fruits or nuts
• Meat and alt
- Avoid fried, smoked, spicy, processed meat - No nuts/seeds or crunchy nut butter
• Fat: in moderation
78
Nutrition Therapy For Rehabilitation During Periods of Remission of IBD
* Maximize energy & protein when pt feels good (flare up will cause patients to use their body reserve)
* Weight gain and physical activity
* Normalize dietary patterns
* Food sources of antioxidants and Omega-3s
* Foods high in oxalates may increase risk for kidney stones E.g., dark chocolate, spinach, beets, peanuts, black tea
* Pro- and prebiotics might be helpful but limited evidence
* High fibre diet may prevent relapse but limited evidence: note patients often fear fibre
79
should fibre be restricted with IBD
there is no evidence that this would be beneficial
80
What is an elimination diet
```
remove food intolerance
Identify food triggers
Foods that cause the least irritation
Smaller, more frequent meals
introduce back one item every 3-4 days in small amounts
```
81
which foods seem to be improving/ worsening symptoms according to patients
Improved symptoms
• Yogurt
• Rice
• banana
```
Worsened symptoms
• Non leafy vegetables
• Leafy vegetables
• Spicy foods
• Fruits
• Nuts, seeds, beans
• Fried food
• Milk and dairy
• Red meat
• Soda, alcohol, coffee
• Popcorn, corn
• Fatty and high fibre food
```
82
IBD- EN or PN
- EN recommended when use of meds is not feasible and when additional nutrition is needed to improve or maintain nutritional status.
- Watch for refeeding syndrome!
- EN/ONS some evidence of inducing remission in patients with active Crohn’s disease. - PN and bowel rest provide no benefit to the routine treatment of IBD.
- May require PN if intestinal involvement of disease is extensive or short gut.
- PN is given only when EN or ONS is not tolerated
83
CASE STUDY: Harry
18 y male, ileal Crohn’s dx 6 mo ago
Wt:55kg,Ht:178cm,UBW:70kg6mosago.
Pain upon eating, Decreased intake (approx. 40% usual intake), fatigued
Increased WBC (15x109/L), increased CRP (10 mg/L), decreased hct (0.37), decreased hgb (120 g/L), decreased albumin (34 g/L)
- Sulfasalazine (6 g/d), prednisone (60 mg/d) ◦ CDAI=450
Is this patient a candidate for EN?
Micronutrient concerns?
Is this patient a candidate for EN?- yes (high weight loss, <50% of energy needs, very high disease score)
Micronutrient concerns?- Folate, B12, Calcium, vitamin D
84
Albumin and CRP- are they good indicators of malnutrition?
albumin is not telling you anything about nutrition status when CRP is high
when CRP is high, albumin drops as it is a negative acute phase protein
85
What is Ileostomy and Colostomy? Anastomosis?
* Creation of a stoma
* Ileostomy- colon and rectum are removed
* Colostomy- rectum removed
* Pouch appliance used to collect waste
if rectum stays in place, ileum can be reattached- anastomosis
done when ends of the removed colon look healthy
86
When can ileostomy be removed and when is it permanent?
reversal of ileostomy is considered after 6 month- bowel is reattached to the rectum
if rectum has been removed, the bag is usually permanent
87
More than __ of small intestine has to be removed before significant reduction in capability observed
Adaptation capabilites?
More than 50% of small intestine has to be removed before significant reduction in capability observed
as long as 50% of small bowel is still there, the small bowel can adapt-> less nutrient concern with time
88
__ and __ can perform each other’s role
Duodenum and jejunum can perform each other’s role
89
Ileum adaptation capabilities
Ileum can adapt to a point
90
Concerns of ileostomy in relation to normal physiology
• Ileocecal sphincter protects small intestine from bacteria translocation from lg intestine
- if colon is fully removed- this won’t be a concern
• Also ensures adequate transit time: no spinchter-> no control over transit time-> diarrhea
• B12 receptor site
• Primary site for reabsorption of bile: no bile reabsorption can also encourage diarrhea
91
```
what is Restorative surgery
for proctocolectomy (J-Pouch)
```
j-pouch is performed when all of the large intestine has been removed (colon + rectum)
small intestine will be used to form a rectum
92
Nutrition Therapy for Ileostomy and Colostomy
• Reduce risk for stoma obstruction for first 6-8 weeks postop
- Tough or stringy meats, raw vegetables, dried fruits, fruit skins, seeds, popcorn, fibrous f&v (pineapple, celery, membranes of citrus fruits) beans, mushrooms, snow peas
- Eat slowly, chew thoroughly
- Drink adequate fluids
93
Main recommendations for pre-op
- integration of nutrition into the overall management of the patient
- avoidance of long periods of preoperative fasting
- re-establishment of oral feeding as early as possible after surgery
- start of nutritional therapy early, as soon as a nutritional risk becomes apparent
- metabolic control e.g. of blood glucosereduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function
- minimized time on paralytic agents for ventilator management in the postopera
94
what are good fluid choices pos ilesotomy + hydration tips
```
Drink fluids throughout the day. Do not try to control your ileostomy output by limiting your fluid intake, especially during the first 6 to 8 weeks after the surgery while your body adapts to the ileostomy
Good fluid choices include:
•water
•milk or milk alternatives
•100% fruit juices, diluted
•herbal or weak tea
```
95
What are common causes of constipation?
* diet that is low in fibre-rich foods
* Not drinking enough fluids
* Limited daily physical activity
* Not going to the washroom when you feel the urge
* Change in your daily routine such as travelling
* Side effects from iron or calcium supplements and some medications
* Diseases and health conditions such as:
* underactive thyroid
* diabetes
* celiac disease
* irritable bowel syndrome
* hemorrhoids
96
Which supplements are recommended with ileostomy
Multivitamin and B12
multivitamin is given while bowel adapts
B12 is given all the time: injection or nasal sprays
97
How to minimize odor with ostomy
* Limit odour-causing foods such as asparagus, broccoli, onion, garlic
* Use of yogurt, parsley, buttermilk to decrease odour
98
How to minimize flatulence?
```
limiting these foods to reduce gas:
•cruciferous vegetables such as broccoli, Brussels sprouts, cabbage, cauliflower
- insoluble fibers often cause flatulence
•legumes (beans, peas and lentils)
•onions
•sprouts
•beer
•carbonated beverages
•coffee
•dairy products.
```
```
Try the following suggestions to reduce swallowing air and producing gas:
•Eat slowly.
•Chew your food well.
•Don't skip meals.
•Eat small meals throughout the day.
•Avoid talking while eating.
•Don't smoke.
•Avoid chewing gum.
•Avoid drinking with a straw.
•Avoid carbonated beverages.
```
99
Ostomy problem: watery fecal output
| Solution?
• Reduce insoluble fiber and increase soluble fiber
• Thicken stool with pectin, Metamucil- thickens and adds bulk
be careful as adding to much bulk may lead to obstruction
100
What is considered as high-output ostomY?
• >1200ml in 24 hrs (definitions vary)
101
Interventions with High Output ostomy
• Expert opinion suggests that individuals with an ileostomy increase daily fluid
intake by at least 250-500 mL over daily fluid requirements
• Increasing the intake of sodium-rich foods (canned vegetables, broth, tomatoes) or adding the equivalent of 5 mL (1 tsp) table salt to foods per day has been suggested for offsetting sodium losses.
• Electrolyte oral rehydration solutions may be warranted e.g. gastrolyte
• Foods that thicken the stool are encouraged.
• Should be monitored and have their electrolytes and fluids carefully managed to avoid dehydration and electrolyte imbalance.
