GI lecture 3 Stomach Disorders pt II

water soluble vitamins

B and C

depleted quickly

lipid soluble vitamins

A, D, E, K

most stored in the liver

vitamin A

retinol

functions in eye integrity, immune system, reproductive, embryological development

vitamin A deficiency risk factors

bariatric surgery

vitamin A deficiency s&s

loss of dim vision

xerophthalmia

poor bone growth

acquired immune deficiency

reproductive problems

abnormal fetal development of the eye

vitamin A acute toxicity

associated with a sinvle dose >660,000 IU

N/V, vertigo, blurry vision

vitamin A chronic toxicity

associated w chronic ingestion of approx 33,000 IU

ataxia, alopecia, hyperlipidemia, hepatotoxicity, bone and muscle pain, visual impairment

B1

thiamine

essential for nerologic function and carbohydrate metabolism

yeasts, legumes, brown rice, cereals

B2

riboflavin

essential for fatty acid synthesis

reproduction of glutathione

body needs constant supply

B3

niacin

works in the body as a coenzyme and has over 400 enzymes dependent on it for various reactions

yeasts, meats, grains, legumes, corn treated w alkali, seeds

B5

pantothenic acid

B6

pyridoxine

needed for gluconeogenesis

dietary deficiency is rare

B7

biotin

B9

folic acid

fortification of rice is common

B12

cobalamin

required for correct RBC formation, neurological function, and DNA synthesis

bound to proteins in food and released by HCl

free B12 combines with intrinsic factor

food that reduce thiamine

raw fish, shellfish, ferns, tea, coffee, betel nuts

risk of B1 deficiency

low intake in diet

alcoholism

increased consumption (AIDS, malaria)

increased losses (diuretics, dialysis)

4 diseases that result from thiamine deficiency

wet Beriberi, dry Beriberi, Wernicke encephalopathy, Korsakoff syndrome

Beriberi risk factors

diets consisting of white rice with husk removed

weight loss surgery

patients receiving TPN

Wet Beriberi

high output heart failure with peripheral artery dialtion

weakening of capillary walls leading to advanced edema

neuropathy

exam comparable to thyrotoxicosis

dry Beriberi

muscle wasting (predominately lower extremities)

paralysis

nutritional polyneuropathy- symmetrical and consisting of both sensory and motor impairments

T/F: patients can present with both forms of Beriberi

true

Beriberi treatment

if critically ill- parenteral admin of B1 for 2-3 days followed by oral B1

Wernicke encephalopathy

acute delirium related to thiamine deficiency- requires emergency treatment to prevent death and neurologic morbidity

chronic alcohol use disorder and bariatric surgery

confusion, truncal ataxia, eye muscle weakness or paralysis

Korsakoff syndrome

chronic condition due to longstanding deficiency with dementia

confabulation, impaired short-term memory

treated w high-dose thiamine replacement

riboflavin deficiency risk factors

pregnancy/lactation

light therapy fir hyperbilirubinemia

elderly

malabsorption

eating disorders, chronic alcoholism, HIV

gluten-free diet

riboflavin deficiency symptoms

cheilosis and angular stomatitis

red, beefy tongue

oily, scaly skin rashes, generally just on scrotum or vulva

normochromic, normocytic anemia

Niacin deficiency risk factors

diet rich in corn

alcoholism

malabsorption syndromes

anorexia nervosa

Pellagra

vitamin B3 deficiency

dermatitis, depression, diarrhea, dementia, death

common in poor parts of Africa and India

vitamin B3 toxicity

reddened skin flush with itchiness or tingling on the face, arms, and chest

dizziness, low BP, fatigue, HA, upset stomach, nausea, blurred vision, impaired glucose tolerance and inflammation of liver in severe cases

vitamin b6 deficiency risk factors

malabsorption, alcoholism

pyridoxine-inactivating drugs

Isoniazid

Penicillamine

b6 deficiency symptoms

peripheral neuropathy and pallagra-like syndrome- seborrheic dermatitis, glossitis, cheilosis)

in adults- depression, confusion, seizures

synthetic B12 [does/does not] need acid environment to be in free form

does not

B12 deficiency causes

pernicious anemia

inadequate intake-alcoholic, vegan

malabsorption

ileum- enteritis, resection

biologic competition - tapeworm, microbiome problems

defective transport- tanscobalamin II def

prolonged use of PPI or H2 blockers can cause

food-bound B12 malabsorption

lack of IF or parietal cells causes

atrophic gastritis, gastrectomy, IF deficiency

vitamin B12 deficiency symptoms

onset is gradual

cognitive changes

anemia

patchy loss of myelin in the dorsal and lateral columns

weakness of legs, arms, trunks, tingling and numbness that progressively worsens

vision changes and change of mental status

bilateral spastic paresis

pressure, vibration, and touch sense diminish

+ babinski sign

prolonged B12 deficiency causes

irreversible nervous system damage

vitamin b12 deficiency treatment

oral:

inital dose 1000-2000 mcg per day for 1-2 weeks

maintenance 1000 mcg per day for life

intramuscular:

initial 100-1000 mcg every day/every other day for 1-2 weeks

maintenance 100-1000 mcg monthly

folate deficiency symptoms

loss of apetite, weight loss, weakness, sore tongue, headaches, heart palpitations, irritability, and behavioral disorders

macrocytic, megaloblastic anemia in adults

folate deficiency treatment

5-15 mg/day depending on cause

Vitamin C

important for collagen synthesis

antioxidant

deficiency- scurvy

scurvy risk factors

elderly, alcoholic, restrictive diets, anorexia nervosa

Scurvy

bleeding and bruising of skin, gums, nails, internally

tooth loss

joint swelling

fatigue

subungal hemorrhage

skin manifestations

scurvy treatment

ascorbic acid 250 mg QID x7-10 days then maintenance dose

Vitamin K

needed for making certain blood coagulation proteins and for binding calcium in bones and other tissues

made by bacteria in gut

dark green vegetables

vitamin K deficiency

depleted by diseases that disrupt bacterial flora - sx, malabsorption, sprue, IBD, disorders of bile or pancreatic secretion

common in newborns

check ________ in patients with bleeding symptoms

PT/INR

vitamin k deficiency treatment

vit K 10mg PO QD once, may repeat in 48-72 hours if coagulopathy persists

no known toxicity

vitamin D3

formed in skin by sun exposure

converted by liver, then kidney, to make active form (Calcitriol)

Calcitriol binds to vitamin D receptors

subclinical vit D deficiency

common

stores decline with age, especially in winter

associated with osteoporosis and possible fractures

vitamin D sufficiency

25(OH)D concentration >/= 20ng/mL (50 nmol/L)

vitamin D insufficiency

25(OH)D concentration 12-

vitamin D deficiency

25(OH)D concentration < 12ng/mL (30nmol/L)

risk of vitamin D toxicity

25(OH)D concentration > 100ng/mL (>250 nmol/L) in adults ingesting substantial amounts of calcium

significance of vit D

increased PTH, decreased bone mineral density

progression of osteoarthritis and falls

sarcopenia

may have immune effects

osteomalacia

cognitive dysfunction

key nutrients in osteoporosis

calcium and vitamin D

calcium recommended daily allowance

women- 1,000 mg/day (

men- 1,000 mg/day (

___ is essential for absorbing calcium

vitamin D

food sources of calcium

milk, fruits, vegetables, and fortified foods

food sources of vitamin D

oily fish, eggs, liver, fortified foods

patients at risk of vitamin D deficiency

older than 60yo

infrequently out in the sun or wear high spf sunscreen

have darker skin

obese

vitamin D recommendations

adults

rickets

deficient mineralization at the growth plate along with architectural disruption due to inadequate amounts/deficiency in calcium or phosphate

calcipenic rickets

due to calcium deficiency, generally caused by insufficient intake of vit D or failure to metabolize vit D into active form

phosphopenic rickets

caused by lowe phosphorus, usually due to renal phosphate wasting

rickets findings

delayed closure of fontanells

parietal and frontal bossing

craniotabes (soft skull bones)

progressive lateral bowing of the femur and tibia

rickets testing

calcium levels may be decreased or normal (calcipenic)

PTH elevated (calcipenic)

vitamin D low

phosphorus generally low in both calcipenic and phosphopenic

Alk phos generally elevated, sometimes markedly

calcipenic rickets treatment

1,000 mg calcium and vit D intake at recommended daily amount

phosphopenic rickets treatment

depends on cause

occasionally due to nutritional phosphate deficiency, but more often assoc w renal disorder w specific etiologies and treatments

osteomalacia

imparied mineralization at the bone matrix- usually occurs with rickets if bone plate is open

when bone plate is fused, osteomalacia occurs alone

can occur in adults or children

osteomalacia risk factors

homebound older adults, patients with malabsorption, limited sun exposure

osteomalacia causes

vit D deficiency, calcium deficiency, hypophosphatemia, CKD

osteomalacia clinical features

bone pain (#1 complaint)

muscle weakness

fractures

bone deformity

osteomalacia lab findings

elevated alk phos

reduced serum calcium and phosphate

vit D

osteoporosis treatment

use vitamin D and calcium, dosage depends on age and gender

vitamin D toxicity

N/V, weakness, frequent urination, bone pain, kidney problems (calcium stones)

seen in doses >60,000 IU daily for several months

vitamin D toxicity treatment

stop supplementation, possible cortiocosteroids

vitamin E

important in neuro and cardiac function

antioxidant

recommended daily intake 15 mg

vitamin E deficiency

extremely rare- typically from fat malabsorption or IBD

hyporeflexia, ataxia, opthalmoplegia, dementia

vitamin E toxicity

also extremely rare

bleeding, muscle weakness, fatigue, nausea, diarrhea

diagnosis based on pt's history and symptoms

vitamin E toxicity treatment

stop supplementation and possibly add vitamin K to help induce clotting

multivitamin contents

Vitamin D 8000 IU

folate 400 mcg

vitamin C 60 mg

zinc 15 mg

vitamin E 30-400 IU