Malnutrition (GI)

Question 1

Define malnutrition. (3)

Answer 1

• BMI <18.5, or
• unintentional weight loss >10% within last 3-6 months, or
• BMI <20 and unintentional weight loss >5% within last 3-6 months

Question 2

How many patients over 65 are malnourished?

Answer 2

10% and most of them are living independently

Question 3

What are some risk factors for malnutrition? (4)

Answer 3

• GI problems e.g. Crohn’s, Coeliac, GORD
• dysphagia
• socially isolated
• low income

Question 4

How is malnutrition screened for?

Answer 4

Malnutrition Universal Screening Tool (MUST)

Question 5

When is MUST done for malnutrition?

Answer 5

On admission to care/nursing homes and hospital or if there is a concern e.g. elderly thin patient with pressure sores

Question 6

What does MUST take into account? (3)

Answer 6

• BMI
• recent weight change
• presence of acute illness

Question 7

What does MUST categorise patients into?

Answer 7

Low, medium and high risk (of malnutrition)

Question 8

How do we calculate MUST score?

Answer 8

• step 1: BMI score (>20=0, 18.5-20=1, <18.5=2)
• step 2: unplanned weight loss in past 3-6m (<5%=0, 5-10%=1, >10%=2)
• step 3: if patient is acutely ill AND there has been or is likely to be no nutritional intake for >5d = score 2
• step 4: add scores together to calculate overall risk of malnutrition (NICE definition above uses score of 2+):
  
  • 0 = low risk - routine clinical care
  • 1 = medium risk - observe
  • 2+ = high risk - treat (dietician, increase intake, monitor and review)

Question 9

What are the clinical features of malnutrition? (5)

Answer 9

• unintentional weight loss
• lack of interest in eating or drinking
• feeling tired all the time
• feeling weak all the time
• getting ill often and taking long to recover

Question 10

What tests can we order to check for problems due to malnutrition? (2)

Answer 10

• FBC to check for anaemia (low Hb)
• urinalysis to investigate high WBC –> UTI

Question 11

How do we manage malnutrition? (4)

Answer 11

• dietician support if patient is high risk
• a ‘food first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’) rather than just prescribing oral nutritional supplements (ONS)
• if ONS are used they should be taken between meals, rather than instead of meals
• if severe - can put in a feeding tube

Question 12

What are the two types of feeding tubes (malnutrition)?

Answer 12

• enteral nutrition - food passes through GI tract e.g. into stomach/small intestine e.g. NGT, NJT (side effect is diarrhoea)
• parenteral nutrition - IV infusion into central vein e.g. subclavian vein, bypassing the GI tract

Question 13

Which type of feeding is superior (malnutrition)?

Answer 13

Enteral nutrition > parenteral nutrition

Question 14

What complication can occur upon feeding (malnutrition)?

Answer 14

Refeeding syndrome

–> hypophosphatemia, hypokalaemia, hypomagnesaemia

Question 15

What issues can refeeding syndrome lead to? (3)

Answer 15

• hypophosphatemia
• hypokalaemia
• hypomagnesaemia (may predispose to Torsades de pointes)

Question 16

How can we prevent refeeding syndrome (malnutrition)?

Answer 16

If a patient has not eaten for >5 days, aim to refeed at no more than 50% of requirements for first 2 days

Question 17

What are some examples of nutritional disorders (malnutrition)? (2)

Answer 17

• marasmus - inadequate protein intake AND caloric intake –> emaciated appearance, severe muscle wasting, subcutaneous fat loss
• Kwashiorkor - inadequate protein intake BUT adequate caloric intake –> bilateral pitting oedema, distended abdomen, hair thinning, skin/hair hyperpigmentation, dermatitis

Question 18

What are the symptoms of vitamin K deficiency and how do we treat it? (6+3)

Answer 18

• bruising, petechiae, haematomas
• oozing of blood at surgical or puncture sites
• risk of massive uncontrolled bleeding
• stomach pains
• cartilage calcification
• severe malformation of developing bone, or deposition of insoluble calcium salts in walls of arteries
• Rx - phytonadione, liver, green leafy vegetables

Question 19

What are the symptoms of thiamine (vitamin B1) deficiency and how do we treat it? (4+2)

Answer 19

• alcohol abuse
• Wernicke’s encephalopathy - confusion, ophthalmoplegia and nystagmus, gait ataxia
• Korsakoff’s psychosis - anterograde amnesia, retrograde amnesia, confabulations, aphasia
• Beri-Beri - tachycardia, dyspnoea, oedema, peripheral neuropathy
• Rx - thiamine infusion with glucose (IV Pabrinex) - avoid straightaway in alcoholics

Question 20

What are the symptoms of niacin (vitamin B3) deficiency and how do we treat it? (4+1)

Answer 20

Sx: 4Ds

• dermatitis
• diarrhoea
• dementia
• death

Rx: niacin supplementation (nicotinamide)

Question 21

What are the symptoms of iodine deficiency and how do we treat it? (6+6)

Answer 21

• goitre
• hypothyroidism
• cretinism - permanent intellectual disability
• miscarriages
• premature delivery
• congenital abnormalities
• Rx - iodine supplementation, dairy, shellfish, saltwater, fish, eggs

Question 22

What are the symptoms of vitamin C deficiency (scurvy) and how do we treat it? (6+6)

Answer 22

• spongy gums
• capillary fragility - petechiae, ecchymoses, perifollicular haemorrhage
• corkscrew hairs
• arthralgia
• anaemia
• impaired wound healing
• Rx - citrus fruits, tomatoes, broccoli, bell peppers, potatoes, supplements

Question 23

What are the symptoms of zinc deficiency and how do we treat it? (9+6)

Answer 23

• skin lesions
• acne
• eczema
• alopecia
• immune dysfunction
• impaired vision
• impaired smell and taste
• delayed maturation
• appetite loss
• Rx - zinc supplementation, fortified cereals, wholegrains, nuts, meats, oyster/beef/lamb