GI - Nutrition & Toxic Ingestion

obesity

name this condition

- MC nutritional d/o in the US

- uses BMI and waist circumference (>35 F, >40 M)

- population: F>M, black & hispanic > white & asian

- can lead to insulin resistance/DM II, acanthosis nigricans, dyslipidemia, sleep apnea, GERD, cancer, liver dz, OA, and cholelithiasis

- blood glucose

- triglycerides

- HDL

- BP

- waist circumference

name the 5 factors to determine metabolic health

- normal: 18.5-24.9

- overweight: 25-29.9

- obese I: 30-34.9

- obese II: 35-39.9

- severely obese (III): 40+

name the ranges of BMI from normal to Severely obese (obese III)

- leptin

- melanocortin signaling

name 2 genetic causes for obesity

- maternal DM

- fetal malnutrition

name 2 constitutional causes of obesity

- psych meds

- steroids

- OCPs

- insulin

- BBs/alpha blockers

- HIV antivirals

name 6 medications that can be a secondary cause of obesity

- cushing's disease

- insulinoma

- hypothyroidism

name 3 conditions that can be a secondary cause of obesity

PCOS (polycystic ovarian syndrome)

name this condition related to obesity

- excess androgen production in females that causes hirsutism, irregular menstruation/amenorrhea, and infertility

- at risk waist circumference

- elevated triglycerides/on meds

- low HDL/on meds

- HTN/on meds

- elevated fasting glucose/ on meds

name the 5 factors of metabolic syndrome

- must have 3/5

Glucose-dependent insulinotropic peptide (GIP)

what hormone increases energy storage?

- leptin

- peptide YY

- cholecystokinin

- amylin

name 4 hormones that inhibit food intake

Phentermine(Adipex-P)

name this obesity medication

- reduces appetite for 3 months

- avoid in those w/ CVD and/or HTN

Saxenda (liraglutide)

name this obesity medication

- GLP1 agonist that inhibits glucagon release and delays gastric emptying

- given through weekly injection

Wegovy (semaglutide)

name this obesity medication

- mimics GLP1

- titrated to 2.4mg weekly SQ

- avoid in endocrine neoplasia and medullary thyroid cancer

phentermine/topiramate

name this obesity medication

- reduces appetite, increases satiety, and distorts taste

- avoid in CVD and pregnancy

Bupriopion/Naltrexone

name this obesity medication

- used commonly in smokers

- has risk of suicidal ideation

- avoid w/ drug/alc use

orlistat

name this obesity medication

- causes fat metabolism which leads to steatorrhea

- BMI >30 or BMI >27 w/ 1+ complications

- must be compliant w/ diet/exercise and behavior mods

describe the indication for obesity medication

Gastric Bypass (Roux-en-Y)

name this obesity procedure

- gastric pouch is reduced to the size of an egg

- makes ERCP difficult

lap band

name this obesity procedure

- an inflatable silicone device placed around the top portion of the stomach

- intended to slow consumption of food and thus reduce the amount of food consumed

obesity endoscopy

name this obesity procedure

- occupies gastric lumen to provide satiety

- removed after 6 mo to allow pt to adjust to lifestyle

- has different types: obalon, orbera, and reshape

- safety concerns: pancreatitis and death

NG tubes

name this enteral feeding

- a tube placed in the proximal bowel

- standard feeding tubes

- two types: keofeed tube and dobhoff tube (weighted)

PEG Tubes (Percutaneous Endoscopic Gastrostomy)

name this enteral feeding

- more prolonged enteral feeding systems (usually placed if greater than 2-6 wks)

- bowel obstruction

- perforation

- ischemia

- peritonitis

name 4 contraindications for enteral feeding

- sinusitis

- aspiration

- diarrhea

- bowel ischemia

- fluid overload

- refeeding syndrome

name some compilations of enteral feeding

parenteral nutrition

name this type of feeding

- aka TPN

- used for pts who cannot have PO or EN

- contains dextrose, AA, lipids, electrolytes, vitamins, minerals, and meds

- requires PICC or central venous cath

- short bowel syndrome/intestinal failure

- severe IBD

- obstruction

- EN feeding unlikely for 7-10 days

- severe catabolic stress

name some indications for TPN

- functional GI tract

- fluid intolerance

- glucose/electrolyte disruption

- severe bacteremia

- hemodynamic instability

name some contraindications for TPN

- electrolyte abnormalities

- line issues (pneumothorax, sepsis, thrombosis)

- refeeding syndrome

- hepatic steatosis

- cholestasis

- gallstones

name some complications of TNP

Rickets (osteomalacia)

name this condition

- pediatric condition defined as changes at the growth plate d/t deficient mineralization of bone

- occurs before the closure of the growth plate

- presentation: delayed fontanelle closure, parietal/frontal bossing, enlarged costochondral junction, widened wrists, and bow legs

- tx: vit D/sunlight and calcium

vitamin E

name this vitamin

- a fat soluble antioxidant found in seeds, nuts, spinach, beets, mango, and avocado

- deficiency: very rare, but can be seen in premature infants; causes hemolysis and neuropathy

- toxicity: leads to impaired wbc function, hemorrhagic CVA, and coag disruption

vitamin B1 (thiamine)

name this vitamin

- water soluble vitamin involved in the metabolism of AA and sugars

- found in yeast and pork

- deficiency: Beriberi, wernicke's encephalopathy, jorsakoff's psychosis, and alcoholism

dry beriberi

name this thiamine/B1 deficiency

- presents w/ peripheral neuropathy, paralysis, sensory loss, guillian barre, and sensory ataxia

Wernicke's encephalopathy

name this thiamine/B1 deficiency

- presents w/ nystagmus, opthalmoplegia, and ataxia

Korsacoff's psychosis

name this thiamine/B1 deficiency

- presents w/ hallucinations, impaired short term memory, and confabulation

Vitamin B2 (Riboflavin)

name this vitamin

- a water soluble vitamin that is a coenzyme in oxidation reduction pathways

- found in beef, lamb, milk, yogurt, eggs, and salmon

- deficiency: usually isolated to the mouth, skin, or hematologic issues; presents w/ hyperemia, edema, cheilosis, glossitis, seborrheic dermatitis, and normo/normo anemia

Vitamin B6 (pyridoxine)

name this vitamin

- a water soluble vitamin that aids in neurotransmitter production

- found in beef, fish, cereal , and starchy vegetables

- isoniazid can cause deficiency

Vitamin B9 (Folate)

name this vitamin

- a water soluble vitamin that aids in RNA/DNA production and controls homocysteine levels

- found in grains, leafy greens, and asparagus

- deficiency: seen MC in women of childbearing age and alcoholics; causes megaloblastic anemia, diarrhea, and glossitis

- needed supplemented when pregnant

Vitamin B12 (Cobalamin)

name this vitamin

- a water soluble vitamin that aids in the brain, NS, RBC formation, DNA synthesis, and fatty acid and AA metabolism

- found in fish, meat, poultry, eggs, and milk

- deficiency: seen MC in vegans, but overall rare; causes pernicious anemia, AMS, depression, psychosis, megaloblastic anemia, and pancreatic insufficiency

PKU (phenylketonuria)

name this condition

- an autosomal recessive dz of protein metabolism d/t the deficiency of an enzyme that causes toxic levels of phenylalanine

- presents w/ musty breath, urine, and/or skin, seizures, light skin color, and microcephaly

- can lead to intellectual development issues

- tx: low protein diet, no aspartame, special formula, fish oil, Kuvan (med)

G6PD deficiency

name this condition

- an x-lined recessive disorder of RBCs that leads to oxidative stress and hemolysis

- MC presents in black males

- sx: neonatal jaundice, HA, nausea, back pain, chills, and hemoglobinuria (only present during hemolysis)

- usually asymptomatic in females

- tx: folate and transfusions

- antimalarials (dapsoone, glyburide, primaquine, glipizide)

- henna

- mothballs

- fava beans

name some triggers of G6PD deficiency

Esophageal foreign body

name this type of foreign body

- managed w/ glucagon to relax smooth mm anf endoscopy to remove

- f/u to tx underlying cause and assess healing

gastric foreign body

name this type of foreign body

- endoscopy not always necessary; pts w/o sx can be observed w/ radiographs to see passage

- emesis not recommended

- case by case basis for endoscopy or surgical removal

anorectal foreign body

name this type of foreign body

- spontaneous passage is likely, btut can use laxatives and/or enimas

- evaluate/observe for perforation risk (extraction needed)

Toxic ingestion

name this type of foreign body

- MC alkaline materials such as lye or bleach

- can cause severe esophageal injury, necrosis, strictures, cancer risk

- avoid NG, emesis, and neutralizing agents

- tx: endoscopy within 24 hrsl, NPO, surgery consult, abx

Activated Charcoal

name this GI decontamination agent

- used within 1 hour of toxin ingestion in alert pts w/ no bowel obstruction

- not useful for mineral acids, alkalis, highly dissociated salts

ipecac

name this medication

- used to induce emesis, but not recommended d/t risk of aspiration

EGD (esophagogastroduodenoscopy)

name this procedure

- a flexible, fiberoptic endoscope under conscious sedation

- pt must be NPO after midnight

- pts in LLD for 10 mins

- used for dilation, biopsy, and tissue removal

- risk of aspiration, perf, bleeding, and infection

enteroscopy

name this procedure

- a longer, more complex procedure to visualize the mid-small bowel

- balloons used to anchor the endoscope

- can be done antegrade or retrograde

Manometry

name this procedure

- used to measure contractions and pressure gradients in the GI tract

- no sedation is given

- MC is esophageal and anorectal

ultrasound

name this diagnostic imaging

- a transabdominal study that is first line for liver and gallbladder

- useful for doppler exams, but is limited by bowel gas

CT

name this diagnostic imaging

- uses radiation and oral contrast (barium) to visualize structures

- MC used for obstruction, perforation, cancer staging, angiography, and enterography

- caution in those w/ renal issues, shellfish/iodine allergies, insulin pumps, or implanted glucometers

MRI

name this diagnostic imaging

- useful for visualization of viscera and soft tissues

- no radiation needed and image is enhanced w/ gadolinium

- MC used for MRCP, liver, enterography, and angiography

- caution in those w/ renal failure and metallic hardware

nuclear imaging

name this diagnostic imaging

- uses radioactive metal (technetium-99)

- MC used for bleeds (identifies location), gastric emptying tests, and gallbladder scans

- KUB

- CXR

name these two noncontrast images

- evals retained stool, FB, dilated bowels, and pneumoperitoneum

endoscopic ultrasonography (EUS)

name this advanced imaging

- combines endoscopy w/ US transducer

- internal is great for staging tumors and for interventional procedures

ERCP (endoscopic retrograde cholangiopancreatography)

name this advanced imaging

- pt is prone and intubated

- uses fluoroscopy

- good for visualization and intervention of the biliary tree

Elastography

name this advanced imaging

- uses vibration to enhance MRI and/or US of the liver

- measures liver stiffness

- elevated values suggest fibrotic liver disease or cirrhosis

wireless capsule endoscopy (pillcam)

name this advanced imaging

- uses to visualize the mid small bowel for bleeding and tumors for dx purposes

- in pts w/ strictures, may need patency capsule

- caution in pts w/ pacemakers, strictures, and those getting an MRI

luminal biopsy

name this type of biopsy

- uses snare or forceps to obtain tissue

- used to eval inflammation, dysplasia, malignancy, infection

- may be used w/ electocautery

visceral biopsy

name this type of biopsy

- tissue obtained through fine needle aspiration or core

- 45-65%

- 10-35%

- 20-35%

carbs should make up ____ - ____% of the diet

protein should make up ____ - ____% of the diet

fats should make up ____ - ____% of the diet

albumin

name this protein

- standard serum lab test to assess nutritional assessment

- has half life of 18-20 days

stunting

name this energy malnutrition

- pt is short statured and underweight during the first 2-3 yrs of life

Kwashiorkor

name this protein energy malnutrition

- aka edematous malnutrition

- pt has sufficient calories but inadequate protein

- occurs after cessation of breast feeding

Marasmus

name this protein energy malnutrition

- insufficient caloric intake and protein intake

protein energy malnutrition

name this type of malnutrition

- presents w/ ketosis, bradycardia, cachexia, hair loss, skin breakdown, immune suppression, hepatomegaly, ascites, and cerebral atrophy (late)

- has different types (Kwashiorkor, marasmus)

Refeeding syndrome

name this condition

- aggressive re-initiation of feeding

- leads to low potassium, magnesium, and phosphate

- causes elevated glucose, fluid overload, mm weakness, arrhythmias, diarrhea, and confusion

- opiates

- cannabis

name two drugs that decrease gut motility and appetite

>5% loss in 6-12 mo (w/o intent)

when is weight loss a concern?

Ghrelin

what hormone stimulates appetite?

gastric sleeve

name this obesity procedure

- portion of stomach is removed, leaving a banana-shaped stomach pouch

enteral feeding

name this type of feeding

- given is 5-7 days NPO

- reduces infection rates and complications such as organ failure and mortality

- maintains nutrition and gut integrity

- increases contractility and intestinal blood flow

vitamin A

name this vitamin

- fat soluble vitamin that plays a role in immunity and contains light sensitive proteins

- found in sweet potatoes, carrots, leafy greens, bell peppers, and fish

- precursor is beta carotene

- deficiency: night blindness

- toxicity: hepatotoxicity, intracrtanial HTN, teratogenic, atacia, pseudotumor cerebri, retinopathy

vitamin D

name this vitamin

- fat soluble vitamin found in various foods (dairy, fish, eggs) and is formed in the skin when exposed to UVB

- deficiency: demineralized bones, growth plate expansion, replacement of normal bone, osteomalacia

- toxicity: metastatic calcifications, renal failure, altered mentation

paget disease of bone

name this condition

- aka osteitis deformans

- focal d/o of bone metabolism that occurs in the aging skeleton (pts usually over 55)

- mostly asymptomatic, but can have bone pain/arthritic complaints and/or deformity

- tx: nitrogen containing bisphosphonates, calcitonin, hearing aids, PT/OT, and NSAIDs

vitamin K

name this vitamin

- a fat soluble vitamin dependent on clotting factors II, VII, IX, and X (have procoag and anticoag roles)

- type 1 found in plants and type 2 found in animal products

- deficiency: hemorrhage

- toxicity: anticoag interference

wet beriberi

name this thiamine/B1 deficiency

- presents w/ confusion, muscular atrophy, edema, tachycardia, cardiomegaly, CHF, and peripheral neuropathy

Vitamin B3 (Niacin)

name this vitamin

- a water soluble vitamin that facilitates numerous metabolic processes and has a role in lowering LDL and TGs, and elevating HDL

- found in meat and peanuts

- deficiency: pellegra 3-Ds (diarrhea, dementia, dermatitis); glossitis, vertigo, and stomatitis

- toxicity: flushing, hyperglycemia, hepatotoxicity, and hyperuricemia

vitamin C

name this vitamin

- a water soluble vitamin that is a cofactor in collagen synthesis, an antioxidant, and aids in iron absorption

- found in citrus fruit and liver

- deficiency: very rare but can cause scurvy; presents w/ fatigue, depression, inflamed gingivae, petechiae, and impaired wound healing

lactose intolerance

name this condition

- MC cause of selective carbohydrate malabsorption

- highest prevalence in asian pts, black pts, and native pts

- presents w/ gas, bloating, and osmotic diarrhea w/o wt loss

- tx: lactase or dairy free diet

Nut allergies

name this condition

- an IgE mediated response to proteins that causes urticaria, angioedema, anaphylaxis, and severe GI sx

- 1-2% of the population has

- RF: FHx of atopy, egg allergy, late introduction

- tx: Epi-Pen, desensitization oral immunotherapy w/ Palforzia (ages 4-17)

Button battery ingestion

name this type of foreign body

- severe esophageal perforation occurs within 2 hours of ingesting; medical emergency (needs endoscopy ASAP)

- pts should take honey after ingestion and Carafate in the ER

- must call national battery ingestion hotline

whole bowel irrigation

name this type of GI decontamination

- flushing the ingested poison from the entire GI tract

- used for drug packets, heavy metals, and enteric coated drugs

colonoscopy

name this procedure

- visual examination of the colon done under conscious sedation

- done to biopsy, dilate, and remove polyps

- can visualize terminal ileum via ileocecal valve

- risks of perforation, bleeding, and infection

barium

name this conventional contrast

- can swallow for an esophagram or given in enema for colon

- can visualize obstructions, inflammation, strictures, and motility issues