Hot Off The Press Pg 03
Nutrition in Action Pg 4-7
GASTRO IG NEWSLETTER
October 2015 I Issue 02
Diner Update Pg 10
Medical Update Pg 11
Research & QI Pg 8-9
New to PEN Pg 07
Practitioner Highlight Pg 12
Welcome to our second edition. I hope you enjoyed the first edition in July. Once the new DAA website is up and running there will be access to each edition online as well as the case study answers. We had fantastic feedback from many of you from the first edition. A new section for this edition is ‘What’s new in PEN’. Don’t hesitate to provide any feedback.
This edition has been the result of the volunteering efforts of six fantastic APD’s who have come together to share this vision. They are Lauren Reece, Felicity Ritorni, Lina Briek, Shamley Chand, Trang Soriano and Debby Andersson.
My role is overseer and editor. My background is acute care clinical dietetics specialising in gastrointestinal surgery. Regardless of my frame of reference, I intend to do my upmost at providing something of benefit to all the different settings and applications of nutrition members of the Gastro IG belong to.
Enjoy!
Ruth Vo
Gastro IG ConvenorEditor
Welcome to the Gastro IG Newsletter
HOT OFF THE PRESSBy Lauren Reece & Trang Soriano
We’ve searched through the academic databases to provide a list of recent and relevant literature in nutrition related gas-troenterology topics.
Intravenous Lipids and LFTs
Badia-Tahull MB, Llop-Talaveron J, Leiva-Ba-dosa E. Impact of intravenous lipid emulsions on liver function tests: Contribution of paren-teral fish oil. Nutrition. 2015;31(9):1109-16.
Pancreatic Insufficiency
Bartel MJ, Asbun H, Stauffer J, Raimondo M. Pancreatic exocrine insufficiency in pancreat-ic cancer: A review of the literature. Dig Liver Dis. 2015.
Dumping Syndrome
Berg P, McCallum R. Dumping Syndrome: A Review of the Current Concepts of Patho-physiology, Diagnosis, and Treatment. Dig Dis Sci. 2015.
Nutrition Consequences of esophagecto-my
Baker M, Halliday V, Williams RN, Bowrey DJ. A systematic review of the nutritional conse-quences of esophagectomy. Clin Nutr. 2015.
HOT OFF THE PRESS cont..
Chyle Leak
Steven BR, Carey S. Nutritional management in pa-tients with chyle leakage: a systematic review. Eur J Clin Nutr. 2015;69(7):776-80.
Enteral nutrition and Crohn’s
Nguyen DL, Palmer LB, Nguyen ET, McClave SA, Mar-tindale RG, Bechtold ML. Specialized enteral nutrition therapy in Crohn’s disease patients on maintenance infliximab therapy: a meta-analysis. Therap Adv Gas-troenterol. 2015;8(4):168-75.
FODMAPs in Children
Chumpitazi BP, Cope JL, Hollister EB, Tsai CM, Mc-Means AR, Luna RA, et al. Randomised clinical trial: gut microbiome biomarkers are associated with clin-ical response to a low FODMAP diet in children with the irritable bowel syndrome. Aliment Pharmacol Ther. 2015;42(4):418-27.
Inflammatory Bowel Disease
Shah ND, Parian AM, Mullin GE, Limketkai BN. Oral Diets and Nutrition Support for Inflammatory Bow-el Disease: What Is the Evidence? Nutr Clin Pract. 2015;30(4):462-73.
BCAA and Encephalopathy
Gluud LL, Dam G, Les I, Cordoba J, Marchesini G, Borre M, et al. Branched-chain amino acids for peo-ple with hepatic encephalopathy. Cochrane Data-base Syst Rev. 2015;9:CD001939.
Non-Alcoholic Fatty Liver Disease
Rusu E, Enache G, Jinga M, Dragut R, Nan R, Popescu H, et al. Medical nutrition therapy in non-alcoholic fatty liver disease - a review of literature. J Med Life. 2015;8(3):258-62.
We also came across an article we thought would be of interest, and useful to enhance our research skills:
McKeever L, Nguyen V, Peterson SJ, Gomez-Perez S, Braunschweig C. Demystifying the Search Button: A Comprehensive PubMed Search Strategy for Per-forming an Exhaustive Literature Review. JPEN J Par-enter Enteral Nutr. 2015;39(6):622-35.
Case Study 2: NEW
Arnold is a 48-year-old gentleman that was referred to you, as an inpatient dietitian, for poor oral intake. Upon scanning Arnold’s medical file, you discover Arnold is a frequent flyer in and out of hospital. His Child Pugh score has worsened since last admission and now sits at a B, with moderate ascites and hepatic encephalopathy, on the background of alcoholic liver disease.
1) What does it mean to have a worsening Child Pugh score, and list three criteria used in this scoring system?
2) List at least three factors contributing to Arnold’s poor oral intake?
The doctors have commenced Arnold on 300mg of oral thiamin three times a day, lactulose 20mls every 4 hours, a 1.5L fluid restriction and an oral nutrition supplement (ONS) drink at 0800.
3) List three reasons why Arnold’s gastrointestinal absorptive capacity will be impaired.
4) At what percentage is thiamin absorption impaired by alcohol vs. malnutrition?
a) 20% vs. 40%
b) 90% vs. 80%
c) 50% vs. 70%
You ask to cease the ONS prescribed at 0800 and instead commence Arnold on 100mls of a vanilla flavored ONS at 0800, 1200, 1400 and 2000, and deliver a sandwich at 2200.
5) Provide a brief explanation as to why you want to shorten Arnold’s “fasting time” at night. It is now day 5 of admission and even after Arnold’s ascitic tap, his oral intake remains at an average of 40% estimated protein requirements. His encephalopathy has improved and he is now at baseline cognition.
6) List three factors you would take into consideration before recommending enteral feeding.
NUTRITION NUTRITION
IN ACTION
By Lina Breik
Gastro IG Newsletter JULY 2015 Case Study ANSWERS
DISCLAIMER:
The answers given in this case study have been gathered from the recommended readings listed below each question, as well as from experience of a dietitian working in this clinical field. The answers are not exclusive to all answers possible.
Sally is a 23-year-old female referred to you day 1 post total colectomy and formation of an end ileostomy on the background of colon cancer.
1) List three nutritional issues you expect Sally to encounter in the first week post-op.
Answer: Some common nutritional issues include:
- Electrolyte imbalances, special consideration to Magnesium with high output ileostomies
- Maintaining hydration as ileostomy output can be up to 2000ml initially post-op. Keep in mind that it can take 1-3 weeks for stoma output to start to decrease and thicken.
- Meeting the increased energy and protein requirements while Sally may be on a fluid diet for first few days post-op (depending on your hospitals practices)
- Prolonged post-op ileus limiting diet progression in the post-op period. Please note that a post-op ileus is inevitable, the fear is when it prolongs for > 3 days.
- Nausea and loss of appetite in the immediate post-op period further limiting Sally’s ability to consume adequate oral nutrition supplement drinks
- Abdominal distension and pain causing pressure on the stomach further limiting appetite
Recommended readings:
- Carey S, Ferrie S. Intestinal Failure. Advances in Medicine and Biology. Volume 23, Chapter 14.
- Matarese L. Nutrition and Fluid Optimization for Patients with Short Bowel Syndrome. Journal of Parenteral and Enteral Nutrition; 2013 37:161
- Luckey A. Mechanisms and Treatment of Postoperative ileus, ARCH SURG 2003 Vol 138 (review article)
- Carey S. Nutritional Considerations in Stoma Management 2014. Education in Nutrition DVD.
2) List three non-nutritional issues you expect Sally to encounter in the first week post-op.
Answer: Some common non-nutritional issues include:
- Spiking temperatures due to an intra-abdominal collection, which may warrant further surgery
- Subsequent bowel obstruction/perforation characterised by (but not exclusive to); increasing abdominal distension, nasogastric output or vomiting, which may warrant further surgery
- Psychological distress associated with hospital stay and/or body image with the presence of a stoma bag
Cont...
Sally’s renal function kept dropping every time the doctors would reduce the intravenous fluid input. This issue kept delaying Sally’s discharge date.
3) Bullet point three dietary strategies you could implement to assist.
Answer: Some dietary strategies may include:
- Increase sodium intake at meals to maximise absorption higher up in the small bowel
- Restrict hypo/hyperosmolar fluids and start oral rehydration solutions with a concentration of sodium of 90mmol/L
- Restrict insoluble fibre and increase soluble fibre as this will help thicken the output and slow transit time
- Limit simple sugars as they are hyperosmolar and can cause an increase in stomal output if consumed in large amounts
- Foods to thicken output: potatoes, white rice, bananas, stewed apples, marshmallows, smooth peanut butter, etc.
Recommended readings:
- Carey S, Ferrie S. Intestinal Failure. Advances in Medicine and Biology. Volume 23, Chapter 14.
- Parrish C. The Clinician’s Guide to Short Bowel Syndrome. Practical Gastroenterology 2005 Series #31.
- Willcutts K, Scarano K, Eddins B. Ostomies and Fistulas. Practical Gastroenterology 2005 Series #35
- Carey S. Nutritional Considerations in Stoma Management 2014. Education in Nutrition DVD.
- Bloomfield-Stone S, Ferrie S. Nutritional considerations in stoma management. World Council of Enterostomal Therapists Journal, 2003; 23(2), 20-26
4) Bullet point three non-dietary strategies you would recommend to the team.
Answer: Some non-dietary strategies include:
- Liaise with surgical team regarding commencing proton pump inhibitors to control gastric acid hypersecretion that is a common response to gut resection/inflammation
- Liaise with surgical team regarding the commencement of gut slow medications such as loperamide and codeine phosphate
- If Sally is already on loperamide, suggest altering the timing of gut-slowing medications to 30 minutes pre-meals (if not already taken at those times) and consider dose increase to a maximum of 60mg daily
Recommended readings:
- Carey S, Ferrie S. Intestinal Failure. Advances in Medicine and Biology. Volume 23, Chapter 14.
- Nightindale J. Guidelines for management of patients with a short bowel. British Medical Journal. GUT 2006; 55
Sally attends an outpatient appointment about 3 weeks post operation. Upon questioning, you discover Sally has lost weight, complains of excessive bloating and flatulence, she looks pale and fatigued with obvious angular stomatitis. Her stomal output had remained constant in amount since discharge at 1-1.2L/day, however, her oral intake had significantly reduced due to the abdominal discomfort she has been experiencing.
5) Beside quantity, what else should you consider about her stomal output?
Answer: Besides quantity, the quality of the stomal output is important to note in the nutritional assessment, such as colour and consistency of the output. The colour and consistency of the stomal output can direct you to better understand how well Sally’s gut has adapted post-op to the resection and how well she is absorbing the food she is eating.
6) Name one condition that could be causing the 1) abdominal discomfort, and one conditions that could be causing 2) the paleness, fatigue and angular stomatitis?
Answer:
1) Abdominal discomfort can be caused by small bowel bacterial overgrowth
2) Paleness, fatigue and angular stomatitis can be indicative of iron-deficiency anaemia given majority of iron is usually absorbed in the terminal ileum which Sally maybe missing a large portion of. See Jeejeebhoy’s review article referenced below for a detailed diagram of nutrient absorption sites.
Recommended readings:
- DiBaise J. Nutritional Consequances of Small Intestinal Bacterial Overgrowth. Practical Gastroenterology 2008 Series #69.
- Jeejeebhoy K. Short bowel syndrome: a nutritional and medical approach. CMAJ. 2002 May 14; 166(10): 1297–1302.
NEW IN PENBy Trang Soriano
Gastrointestinal System- Irritable bowel syndrome: FODMAP Practice Questions
Q: Should individuals with irritable bowel syndrome (IBS) be tested for FODMAP malabsorption? How effective are tests for determining response to the low FODMAP diet?
Q: What is the effectiveness of a low FODMAP diet for managing symptoms in individuals with IBS?
Q: What are nutrition issues/considerations for individuals following the low FODMAP diet?
WEBSITE: https://www.pennutrition.com
RESEARCH & QI By Lauren Reece & Felicity Ritorni
In September and October, we sent out an email to find out what the Gastroenterology IG is doing in terms of current/completed research projects, QI projects, improvement initiatives and health promotion initiatives. Here are a few of the responses we received.
If you would like to feature and share your research/QI projects in the next Gastro IG newsletter please contact Lauren ([email protected]) or Felicity [email protected] .
Long-term nutritional status and impact on quality of life in patients following oesophagectomy: a meta-analysis.
Background: the survival rate in patients post oesophagectomy have increased in recent years with advances in treatment therapy and the 5 year survival rate after surgery has seen to be increasing.
This has prompted a greater need to assess the long-term outcomes and complications of patients following oesophagectomy.
Aim: Define the degree of malnutrition, identify macro and micro-nutrients deficiency, and assess the adequacy of dietary intake and ongoing nutrition-impact symptoms in patients beyond the 1 year post oesophagectomy.
Methods: carry out a meta-analysis of recent published studies looking at long term nutrition outcomes of patients following an oesophagectomy.
Outcome measures: health related quality of life, nutrition impact symptoms, dietary quality, and nutritional status.
Where to from here: the study has commenced as of October 2015
Contact: Trang Soriano, Nepean Hospital [email protected]; Guy Eslick, Nepean Clinical School and University of Sydney [email protected]
Group-based diet and lifestyle education for Non-alcoholic fatty liver disease (NAFLD)
Background: At the St George Hospital Multidisciplinary Liver Clinic, there have been an increasing number of referrals for diet and lifestyle education for the management of NAFLD. This resulted in an increased waiting time for patients requiring an appointment with the dietitian. Evidence has shown that group-based intervention can be an effective way to educate and achieve changes for other lifestyle conditions.
Aims:
- Improve patient participation, interaction and support to enable positive health changes
RESEARCH & QI cont...
Aims: Cont...
- Provide education to participants regarding diet and lifestyle management for NAFLD in a time-efficient manner
- Reduce waiting periods for dietitian appointments in Liver Clinic
Method: Medical and nursing staff were provided with inclusion and exclusion criteria, and encouraged to refer suitable participants to the group education sessions. Five sessions were conducted over a one year period, including discussions about healthy eating, exercise and practical activities such as label reading and recipe modification. Surveys were completed by participants at the completion of the session.
Outcome Measures:
- Survey results regarding whether participants valued the session
- Waiting periods and ‘do not attend’ from Liver Clinic
Where to from here? Early results show this group education format has been a more time-effective way of delivering dietary intervention. Results will be collated and group sessions modified to reflect participant feedback.
Acknowledgements: This project was designed and commenced by previous Gastroenterology Dietitian Rachel Pons.
Contact: Nicole Getreu, St George Hospital. [email protected]
Fasting Patients Project: An audit of patients fasting for surgery on the surgical ward at The Sutherland Hospital.
Background: Patients awaiting surgery can often experience prolonged periods of preoperative fasting, or days of consecutive fasting due to delay or cancellation of surgery which can place them at high risk of malnutrition.
Aim:
- To identify the unnecessary periods of fasting experienced by patients.
- To develop a snack pack which can be provided to patients if a procedure is cancelled outside of mealtimes and available post dinner until fasting time commences.
- To develop and implement fasting protocols.
Methods: A two week audit was conducted on patients undergoing surgery to identify the length of fasting time. A pre-questionnaire was completed and the snack pack implemented.
A post questionnaire will be conducted to identify patient satisfaction with snack pack contents.
Outcome measures: To determine whether the implementation of the snack pack reduces patient fasting time
Where to from here: A reaudit of fasting patients post snack pack implementation.
Contact: Lee Griffiths, The Sutherland Hospital, [email protected]
DINER UPDATEBy Debby Andersson
1. Nutrition and Hydration Policy Support Handbook For Acute Adult Inpatient Setting. The aim of this policy support handbook is to provide guidelines for Dietitians and other health professionals to develop local or state level nutrition and hydration policies and/or standards. This document is intended to summarise key research and current evidence for nutrition and hydration care relevant to the acute hospital setting. It is anticipated that this will improve the consistency of nutrition and hydration care for inpatients of acute adult hospitals.
Nutrition and Hydration Policy Support Handbook
2. Vitamin B12 and folate
The presentation covers: Metabolism and functions of B12 and folate: Deficiency of B12 and folate and Food sources and current intake. $38 for DVD or recording of webinar, suggested further reading and multiple choice questions.
www.educationinnutrition.com.au
3. Improving surgical outcome by ERAS (Enhanced Recovery After Surgery)
The presentation covers: •What is ERAS? •The ERAS team •Nutrition intervention in ERAS •Case study •Local data and outcomes
$38 for DVD or recording of webinar, suggested further reading.
www.educationinnutrition.com.au
4. Supplement - The Benefits of Breakfast Cereal Consumption: A Systematic Review of the Evidence
Published in a supplement in the international review journal, Advances in Nutrition, this review is the first time the evidence relating to breakfast cereal consumption and nutrition and health has been systematically assessed using the stringent NHMRC criteria. This review spans more than 230 papers published over 30 years (to October 2013) and includes 21 level of evidence statements ranked from A to D, using the methodology and format recommended by the NHMRC.
Supplement - The Benefits of Breakfast Cereal Consumption: A Systematic Review of the Evidence
Additional information:
For dietitians who have limited experience with seeing patients with TPN or enteral feeds. Resources below are good start off points:
-Parenteral nutrition manual (http://dmsweb.daa.asn.au/dmsweb/frmDINERDetails.aspx?id=503)
Parenteral Nutrition Manual
-Enteral nutrition manual (http://dmsweb.daa.asn.au/dmsweb/frmDINERDetails.aspx?id=115)
Enteral Nutrition Manual
-ACI guidelines for parenteral nutrition (http://www.aci.health.nsw.gov.au/)
PPIs
Pantoprazole sodium sesquihydrate
Pantoprazole is a proton pump inhibitor. It inhibits specifically and dose proportionately H+/K+-ATPase, the enzyme which is responsible for gastric acid secretion in the parietal cells of the stomach. The substance is a substituted benzimidazole which accumulates in the acidic environment of the parietal cells after absorption.
GORD
Esomeprazole Sandoz
Esomeprazole Sandoz is taken to treat reflux oesophagitis. This can be caused by reflux of food and acid from the stomach into the oesophagus. Reflux can cause a burning sensation in the chest rising up to the throat. Esomeprazole Sandoz is also taken to help stop reflux oesophagitis coming back or relapsing.
Ranitidine hydrochloride (Rani 2)
INDICATIONS Short-term treatment of proven duodenal ulcer and gastric ulcer Maintenance treatment to reduce the risk of relapse in duodenal ulcer documented healing of benign gastric ulcer Treatment of gastrinoma (Zollinger-Ellison syndrome) Short-term symptomatic treatment of reflux oesophagitis unresponsive to conservative anti-reflux.
Now accepted drugs used for Eosinophilic oesophagitis are:
- Budesonide: - used to treat Crohn’s disease, and is a corticosteroids. It works by decreasing inflammation in the digestive tract of people who have Crohn’s disease.
- Fluticasone:- is a man-made corticosteroid
ELELYSO® (taliglucerase alfa)
The injection is a plant cell-based enzyme replacement therapy (ERT) indicated for long-term treatment of Type 1 Gaucher disease in adults and children.
MEDICAL UPDATE
By Debby Andersson & Shamley Chand
Cancers
CYRAMZA (contains the active ingredient ramucirumab).
CYRAMZA is used to treat advanced gastric cancer (including cancer of the junction between the oesophagus and the stomach). It belongs to a group of medicines known as antineoplastic agents. It works by cutting off the blood supply that allows cancer cells to grow.
Hepatitis
Viekira Pak-RBV is used to treat chronic hepatitis C infection in adults including those with cirrhosis. This treatment is used for patients with hepatitis C and consists of 3 different types of tablets. Viekira Pak-RBV includes medicines called direct-acting antiviral agents and also includes ribavirin to treat your HCV infection. It works by lowering the amount of hepatitis C virus in the body.
Hepatitis C
Sofosbuvir
Sofosbuvir is another antiviral drug that can be added to combination treatment for chronic hepatitis C. It is a direct-acting nucleotide polymerase inhibitor. The prodrug is converted to a nucleotide analogue in hepatocytes. This active analogue then binds to RNA polymerase which terminates RNA synthesis and inhibits viral replication.
Simeprevir
HCV protease inhibitor. Treatment of chronic hepatitis C infection (HCV genotype 1, 4) in combination with peginterferon alfa + ribavirin in adults greater than or equal to 18 yrs.
PRACTITIONER HIGHLIGHTDAY IN THE LIFE OF
LIZ WILLIAMS - COMMUNITY DIETITIANBy Shamley Chand
1.Could you please give me a background of your clinical experience and where you currently work?
I work as a Complex, Aged and Chronic Care Dietitian, primarily funded by HACC/CHSP, in the communities of Blacktown and the Hills in Western Sydney. I graduated 4 years ago, initially working as a research assistant in food intolerance and in residential aged care facilities before beginning in this position in early 2014.
2. What does your role entail?
Our service provides a home visiting service for clients who are unable to access other dietetic services and require nutrition intervention and support. Most of my clients are over the age of 65, however any adult with a chronic or complex medical condition is also able to access the sup-port of the multidisciplinary team I work with. Because of this, my role is quite diverse!
3. On average how many gastrointestinal patients do you see?
I might see 3-4 clients a month with gastrointestinal issues as the primary reason for referral, although it is common for gut symptoms to underlie the referrals for weight loss or poor ap-petite. I then provide review and support for 2-6 months on average, depending on the client’s needs and progress.
4. What are the main gastro-clinical patient group/s you see?
The most common reasons for referral are weight loss/malnutrition, often paired with gut symp-toms related to cancer-therapy or palliation, and colostomy or ileostomy management. Nausea, constipation, diarrhoea, early satiety and taste changes are common. I also manage enterally fed clients in the community.
5. How do you keep current on the changing science of gastro- nutrition?
Mainly through webinars, evidenced-based guidelines and journal articles, clinical supervision and reflective practice, and following the Gastro IG. With such diversity in my case-load, there is limited time to specialize!
6. What’s the best thing you like about your job?
I love working with the client to find strategies which work for them, and having a chance to build rapport over several visits. It is very rewarding when clients have success in reaching their goals and experience improved QOL.
7. What are some gastro related challenges you find about your job?
There are many clinical challenges, but one of the most challenging areas of stoma management is developing confidence in the older clients to go back to normal, flexible, healthy eating pat-terns to support long-term nutritional QOL, health and their independence. Often they have had traumatic experiences and want to “stick to the rules” they were initially given.
8. What are your most complex gastrointestinal patients you see?
I do not see the most complex of gastro-intestinal cases. What complicates most of them is the home and social environments, rather than the gastro diagnosis, per se.
9. What are the main types of gastro related educations that you provide to your patients? HPHE, texture-modified diets, education addressing the management of nausea, taste changes, constipation, and diarrhoea, and healthy eating education for ileostomy and colostomy clients, with some symptom management included as needed.
Ruth VoGastro IG ConvenorEditor
GASTRO IG NEWSLETTER
October 2015 I Issue 02
