Nutrition and gastrointestinal disorders

Question 1

What is the role of the dietician?

Answer 1

Dieticians must be registered with HCPC
Translate nutrition science into understandable, practical information about food
Treat a range of medical conditions with dietary therapy, specially tailored to each individual

Question 2

Order the parts of the intestines from longest to shortest?

Answer 2

Ileum
Jejunum
Colon
Duodenum

Question 3

What is absorbed in the duodenum?

Answer 3

Iron, calcium, vit A and D and some carbohydrate

Question 4

What is absorbed in the jejunum?

Answer 4

Vitamin B and C, fatty acids, some carbohydrate and protein

Question 5

What is absorbed in the ileum?

Answer 5

Bile salts and vit B12

Question 6

What is absorbed in the colon?

Answer 6

Water and sodium

Question 7

What is ulcerative colitis like?

Answer 7

Diffuse mucosal inflammation limited to colon

Question 8

What is crohn’s disease like?

Answer 8

Patchy, transmural inflammation which may affect any part of the gastrointestinal tract

Question 9

What is crohn’s like on an endoscopy?

Answer 9

Cobblestone mucosa, inflammatory polyps and skip lesions

Question 10

Which is more common out of UC and CD?

Answer 10

UC 243/100000

CD 145/100000

Question 11

What are the signs and symptoms of IBD?

Answer 11

Weight loss
Abdo pain
Bloody diarrhoea
Fatigue
Frequent need to use toilet

Question 12

How do you diagnose Crohns?

Answer 12

Clinical evaluation
Haematological investigations
Imaging
Endoscopy
Histological on biopsy
Negative stool examinations for infectious agents

Question 13

What factors can affect nutritional status in IBD?

Answer 13

B12 deficiency
Bile aicd malabsorption
Primary sclerosing cholangitis
Osteoporosis and osteomalacia
Anaemia 
Mood disorders in IBD
Malignancy
Surgical- enterocutaneous fistula or short bowel syndrome
Malnutrition

Question 14

What is the treatment for IBD?

Answer 14

Aminosalicylates- 5-ASA, sulfasalazine etc
Corticosteroids
Thiopurines
Methotrexate with steroids
Calcineurin inhibitors
Anti-TNF therapies
Surgery- try to avoid

Question 15

What sort of diet can be used to manage Crohn’s?

Answer 15

Liquid diet
Low fibre/residue
Food reintroduction slowly
Prebiotics/probiotics

Question 16

What sort of diet can be used to manage UC?

Answer 16

Dietary manipulation to minimise exacerbation of diarrhoea

Question 17

When are liquid diets used?

Answer 17

If other medical therapies are contraindicated
Adjunctive treatment with corticosteroid and treatment
Nutrition support

Question 18

What considerations are involved with liquid diet?

Answer 18

Type of feed
Route (oral or tube)
Cmpliance
Refeeding syndrome
Monitoring/assessment- alcoholism or cancer treatment

Question 19

What is refeeding syndrome?

Answer 19

Metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished

Question 20

What are the dietary modifications for Crohn’s?

Answer 20

Avoid fibrous parts of fruit and veg, wholegrains, nuts and seeds, gristle on meat, skin on meat or fish and edible fish bones
Consistency may need to be different

Question 21

What are probiotics used to treat?

Answer 21

Treatment and prevention of pouchitis VSL3 (inflammation of ileal pouch- artificial rectum surgically created out of ileal gut tissue in colectomy patients)
Some evidence for use in UC but not CD

Question 22

Problem with prebiotics?

Answer 22

Abdo pain, abdo bloating, diarrhoea and flatulence

Question 23

How well used are food intolerance tests for CD and UC?

Answer 23

Inappropriate
Result in food exclusions and nutritionally inadequate diets
Food intolerance in Crohn’s is unclear and no evidence

Question 24

What dietary therapy is there for diarrhoea?

Answer 24

Fluid- 10 cups per day, nutritious drinks and replace salt
Soluble fibre- jelly like fibre which helps stool absorb more water from stool
Avoid gas producing foods, high fibre or wholegrain cereals, alcohol, caffeine and personal triggers

Question 25

What are the nutritional consequences of IBD?

Answer 25

Inadequate intake due to anorexia, nausea, vomiting, diarrhoea or starvation for investigations Increased loss due to malabsorption (micro and macronutrients) and blood loss Increased requirements due to catabolic state- increased metabolic rate, increased energy expenditure, stress response and increased protein turnover

Question 26

What common nutrient deficiencies are there?

Answer 26

``` Calcium Vitamin D- common Other fat soluble vitamins Zinc Iron- common Vit B12 Folate in ulcerative colitis ```

Question 27

When is nutrition support given?

Answer 27

During active disease- in catabolic state so needs to maintain current nutritional state and prevent further deterioration During remission- improve/maintain nutritional state and maintain healthy BMI

Question 28

What routes of nutritional support are there?

Answer 28

Oral where possible Enteral tube feed (nasogastric tube, gastrotomy, nasoduodenal tube, nasojejunal tube, jejunostomy tube) Parenteral nutrition (post surgery, enterocutaneous fistula, high output fistula, anastomotic breakdown after GI surgery and short bowel syndrome

Question 29

What is the lifetime risk of having surgery in CD and UC?

Answer 29

CD- 70-80% UC- 20-30% Depends on severity

Question 30

What are the problems associated with short bowel?

Answer 30

``` Water, sodium and magnesium depletion Nutrient malabsorption Lactic acidosis Renal stones Gall stones Adaptation Social problems- diarrhoea ```

Question 31

What is coeliac disease?

Answer 31

An inflammatory, auto-immune condition of small intestinal mucosa that is induced by the ingestion of gluten and which improves when gluten is removed from diet

Question 32

What are the signs and symptoms of coeliac disease?

Answer 32

``` Diarrhoea Abdo pain Bloating Nausea and vomiting Lethargy Low mood Poor appetite Anaemia ```

Question 33

What is the diagnosis for coeliac disease?

Answer 33

Blood test for endomysial antibodies (EMA) and tissue transglutaminase antibodies (TGA) Possible to have a negative blood test yet have coeliac diseaseEndoscopy with duodenal biopsy is taken to confirm diagnosis

Question 34

What is the treatment of coeliac disease?

Answer 34

Gluten free diet- avoid wheat, barley, rue Avoid wheat starch, flour, rusk, brain, barley, malt/flour, oat bran and rye flour and wheat coated medications Gluten free food can be prescribed

Question 35

What factors affect compliance with coeliac disease treatment?

Answer 35

Lifestyle Eating out Cross contamination at home Holidays

Question 36

What are the associated risks of coeliac disease?

Answer 36

Dermatitis herpretiformis- skin condition of coeliac disease - rare Autoimmune conditions- increased risk of developing diabetes and thyroid disease Lactose intolerance- caused by gut damage (temporary)

Question 37

What risks are associated with non-compliance and undiagnosed coeliac disease?

Answer 37

``` Osteoporosis Cancer (lymphoma) Depression Continued GI symptoms Micronutrient deficiencies- iron, B12 and folate Anaemia Infertility and negative outcomes ```

Question 38

What is refractory coeliac disease?

Answer 38

Rare but persistent malabsorptive symptoms and villous atrophy on strict gluten free diet with negative serology for anti-tTG or EMA Focus is on correcting nutritional status, strict gluten free diet, immune suppression via steroids and monitoring for early detection of lymphoma

Question 39

What is IBS?

Answer 39

Common functional disorder of gut with no structural abnormality Affects 1 in 5 in UK

Question 40

What is suspected to cause IBS?

Answer 40

``` Biological factors: Visceral hypersensitivity Altered brain-gut interaction Altered motility Infections Environment Genes ``` ``` Psychological factors: Childhood abuse Disordered sleep Stress Dysfunctional coping Psychiatric disorders ```

Question 41

What are the signs and symptoms of IBS?

Answer 41

``` Abdo pain which may ease after opening bowels Diarrhoea and/or constipation Bloating and wind Passing mucus Incomplete evacuation Urgency to open bowels ```

Question 42

How do you diagnose IBS?

Answer 42

12 weeks or more in past 12 months of abdominal discomfort or pain that has 2 out of 3 features: Relieved with defecation Associated with a change in frequency of stool Associated with a change in consistency of stool

Question 43

How is IBS treated?

Answer 43

Education Reassurance Diet- Healthy eating Low fibre/high fibre dependent on symptoms Probiotics FODMAPS- dietician supervised diet Medication- Antispamodics, antidiarrhoeals/laxatives Psychological treatment- counselling, cognitive based therapy

Question 44

How does FODMAPS work?

Answer 44

Dietitian supervised diet- strict 6-8 week exclusion of all foods and 2-3 month reintroduction one by one

Question 45

Give a summary of lecture

Answer 45

IBD and short bowel- severe malnutrition, should be monitored carefully and proactive nutrition support required Coeliac disease- gluten free diet- Non-compliance= severe health risk IBS- diet, lifestyle, psychosocial considerations FODMAPS Identify risks and refer