Acute and Chronic I: Malabsorption Syndromes

Biopsy of the Small Intestine

The slide on the left shows normal intestine and the finger-like villi, which absorb nutrients from food. The slide on the right, by contrast, shows the effects of celiac disease. The villi can no longer absorb nutrients because the intestine is inflamed and swollen.

Short Bowel Syndrome

. A condition in which nutrients are not properly absorbed (malabsorption) because a large part of the small intestine is missing or has been surgically removed. Most common causes: *Necrotizing enterocolitis *Volvulus *Jejunal atresia *Gastroschisis ***Problems with SBS: the small intestine is where most digestion of food and absorption of nutrients occur. People with short bowel syndrome have ↓ absorption of fluids, electrolytes, vitamins and other nutrients (due to ↓ in intestinal surface area).

Collaborative Care

. Administration and monitoring of nutritional therapy (may be long term). . Prevent complications from parenteral nutrition. Initially, PN is the primary source of nutrition. . Care of enteral feeding tubes and monitor feeding tolerance. Usually started ASAP. . Ostomy care. . Infants and children have chronic diarrhea—meticulous skin care to prevent skin breakdown. . Teaching for family and psychological support. . See that child's developmental and emotional needs are met.

Understanding UC and Crohn's

. As you can see, many of the symptoms of UC and Crohn's are the same, such as......they both have: anemia and numerous diarrhea stools. With UC, anemia comes from blood loss, whereas with Crohn's, it comes from nutritional deficits. Both have pain, although the characteristics are a little different.

Celiac Disease: Diagnostics

. Blood test—circulating IgA-gliadin, anti-reticulin, and anti-endomysial antibodies have a high degree of sensitivity and specificity for the diagnosis of celiac disease. . Biopsy of small intestines to detect intestinal changes— re-biopsied after treatment with gluten free diet to see if regeneration of intestinal villi occurs. . Stools for fecal fat. . CBC. . GI series—indicates intestinal malabsorption but will not specifically identify celiac disease. . The CeliaGENE test is a genetic test for HLA-DQ2 and HLA-DQ8.

Celiac Disease

. Called "gluten-sensitive enteropathy" . Disease of the small intestine characterized by abnormal mucosa with permanent intolerance to the protein gluten. This protein is found in the grain of wheat, barley, rye, and oats.

Management of Ulcerative Colitis

. Colectomy or pouch ileostomy . High protein, high calorie, low residue diet with bland foods in small frequent meals (vitamin and iron supplements) . Restrict intake of milk and gas forming foods . Patient may be NPO (maintain fluid and electrolyte balance) . Get plenty of rest—patient is often severely fatigued . TPN may be necessary to rest GI tract . Blood transfusions as indicated

Understanding UC and Crohn's IV

. Complications are different.....fistulas and abscesses are rare with UC, because it affects only the inner most layer of the bowel wall of the colon or rectum (most often in sigmoid colon and rectum); So with this disease, there is a greater chance of toxic megacolon. . With Cronh's, there is a chance of the patient developing abscesses and fistulas because it affects the entire thickness of bowel—most frequent site is terminal ileum (ileocolon); . Peritonitis is a complication for both because perforation can occur with UC and Crohn's. . Also, medications for both of these disease processes are the same.

Collaborative Care- 6 Elements in Management

. Consultation with a skilled dietitian. . Education about the disease. . Lifelong adherence to a gluten-free diet. . Identification and treatment of nutritional deficiencies. . Access to an advocacy group. . Continuous long-term follow-up by a multidisciplinary team.

Congenital defects that require bowel resection IV:

. Gastroschisis—a birth defect in which an infant's intestines (and sometimes stomach, liver and other organs) protrude out of the body through a small opening or "hole" in the abdominal wall which is usually located to the right of the umbilical cord. It occurs as a result of incomplete closure of the skin folds around the 6th week of development.

Diet Restrictions for Celiac Disease:

. Gluten free diet for life—CANNOT have the following: Any foods containing wheat, rye, barley oats....... . cereals . bread . cakes . cookies . candy . crackers . doughnuts . pies . spaghetti, macaroni . pizza . canned or instant soup . hotdogs . lunch meat . ice cream (unless made from soy) . most prepared and ready to eat meals

Celiac Disease: Pathophysiology II

. It is an autoimmune disease that occurs in genetically predisposed individuals. This immune response occurs in both the mucous membranes that line the small intestines and the intestinal epithelium. . There is a close link to HLA (Human Leukocyte Antigen) DQ2 and DQ8, although these HLA genes account for only 40% of the genetic influence. . Environmental factors, such as the amount and timing of gluten administration in infancy influence the disease.

Celiac Disease: Complications

. Malignant lymphoma of the small intestines or other GI malignancies. . Growth retardation. . Anemia. . Osteoporosis due to poor absorption of calcium. . Celiac crisis is rare, but life threatening. Clinically, it is characterized by severe diarrhea, dehydration and metabolic disturbances like hypokalemia, hypomagnesemia, hypocalcemia, hypoproteinemia. . Most children who comply with diet are healthy and remain free of symptoms and complications. . Can end up with metabolic acidosis

Management of Crohn's Disease

. May require surgical resection of diseased ileum . Cobalamin orally or by injection (Vit B12) . Vitamin and iron supplements . Avoid fried food (high fat)—fried, fatty foods lead to an exacerbation . Avoid milk and milk products—lead to an exacerbation . High protein, high calorie, low residue diet or may need TPN . Maintain fluid and electrolyte balance . Get plenty of rest . Stop smoking

Understanding UC and Crohn's III

. Most of the treatment regimen is the same........ get plenty of rest, maintain fluid and electrolyte balance, avoid milk and milk products, etc. . Review the dietary management—same for both except, Crohn's may need Vitamin B12....this is because Crohn's can occur in any part of the digestive tract, from the mouth to the anus. . Review the pathophysiology—there are similarities and differences....Both are autoimmune diseases with a genetic predisposition.....However, UC is associated with a low fiber diet and Crohn's with smoking. They also affect different parts of the bowel......be sure to review this.

Congenital defects that require bowel resection:

. Necrotizing enterocolitis (NEC)—death of intestinal tissue (necrosis), affecting sick or premature infants. . Etiology not clear. It is thought that intestinal tissues are weakened during delivery by too little oxygen or blood flow. When feedings are started and food moves into the weakened area of the intestinal tract, bacteria from the food damages the intestinal tissues. Tissues may be severely damaged and die. Intestinal perforation may occur leading to severe infection in the abdomen and sepsis. ***What Causes NEC? The exact cause of NEC is unknown, but experts believe that different factors might play a role. These include: *an underdeveloped intestine *too little oxygen or blood flow to the intestine at birth (usually the result of a difficult delivery) *injury to the intestinal lining *heavy growth of bacteria in the intestine that erodes the intestinal wall *formula feeding (babies who are breastfed have a lower risk of developing NEC)

Celiac Disease: Collaborative Care II

. Teach about celiac crisis—considered an emergency and can lead to shock and death. . Steroids to manage inflammation and maintain fluid and electrolyte balance during celiac crisis. . During a crisis, avoid high fiber foods such as nuts, raisins, raw fruits with skins, raw vegetables; when inflammation has subsided, may resume these foods. . Consult a nutritionist. . Provide family with resources: Celiac Sprue Association.

Celiac Disease: Collaborative Care

. Teach ways to adhere to diet—Very difficult to eliminate gluten when child starts school or if family is on a fixed income. . May need lactose free diet if intestinal mucosa damage is severe. Lactose intolerance is frequently a side effect of celiac disease. Celiacs who eat gluten become lactose intolerant after the villi and microvilli in their small intestine become damaged, and are no longer capable of catching and breaking down the lactose molecule. The problem usually disappears when celiacs remove gluten from their diet, which allows the damaged villi and microvilli to grow back. ***Lactose Intolerance symptoms: Bloating. Pain or cramps in the lower belly. Gurgling or rumbling sounds in the lower belly. Gas.

Goals with Bowel Resection and SBS:

. To preserve as much bowel as possible during surgery. . Maintain optimal nutrition status in order to maintain optimal growth and development. . Stimulate intestinal adaption with enteral feedings (through NG or gastrostomy tube). . Minimize complications such as with long-term PN (CL infection, metabolic complications, hyperlipidemia, electrolyte disturbances); monitor liver function tests—liver dysfunction can occur because of parenteral nutrition (PN).

Congenital defects that require bowel resection II:

. Volvulus—a condition in which the bowel becomes twisted....may be the result of a congenital malrotation. . Twisted intestines may become obstructed or may become injured when the twisting cuts off the intestine's blood supply. If the blood supply is cut off for a prolonged period, gangrene can develop, cause a hole in the wall of the bowel (perforation), and become life-threatening. . Therefore, it is an emergency that requires immediate surgical treatment. ***Malrotation occurs when the intestines don't position themselves normally during fetal development and aren't attached inside properly as a result. The exact reason this occurs is unknown.

Celiac Disease: Pathophysiology

. When gluten products are consumed, an immune reaction occurs in the small intestine in which mucosal cells are damaged. . This results in atrophy of intestinal villi, hyperplasia of crypts, and infiltration of epithelial cells with lymphocytes....thus leading to an inability to absorb certain nutrients from food. ***Intestinal villi—thread-like projections in the intestines for absorbing nutrients and H2O; Crypts are located between villi.

Four Characteristics of Celiac Disease: Manifestations

1. Impaired fat absorption—steatorrhea (excessively large, fatty, pale, frothy, foul-smelling, stools). 2. Impaired nutrition—malnutrition, vomiting, anorexia, muscle wasting, abdominal pain and distention, vitamin deficiency, anemia. 3. Behavioral changes—irritability, lethargy. 4. Celiac crisis—severe episodes of watery diarrhea and vomiting. Often precipitated by GI infection, emotional disturbance, or ingesting products with gluten. Manifestations most often appear between the ages of 1 and 5 years old when foods with gluten (cereals, pasta, and breads) are introduced in the child's diet.

Ulcerative Colitis Versus Crohn's Disease: Manifestations IV

Crohn's: . Slowed growth and delayed sexual development in some childhood cases . Nutritional deficits due to: reduction in intestinal surface; impaired absorption of fat, vitamin B12, folic acid, iron, calcium, vitamins A, C, D, E, and K; malabsorption of protein and carbohydrates

Understanding UC and Crohn's II

Differences include: . UC has bloody diarrhea with mucus and pus in stools. . Crohn's has foul-smelling, fatty stools with no bloody diarrhea (occasionally: rectal bleeding). . UC is more likely to suffer from hypovolemia due to stool and blood loss. So, weight loss is usually not a chronic problem. . Crohn's suffers from weight loss and growth problems due to nutritional deficiencies. Hypovolemia is not a problem because the people usually don't have as many diarrhea stools and there is no or rarely, blood loss.

Congenital defects that require bowel resection III:

Jejunal atresia—believed to result from an intrauterine ischemic event....the mid-section of the small intestine (jejunum) is narrow, absent, or not attached to the large intestine.

Pharmacology Management of Inflammatory Bowel Disease

Look at table in the ppt. 4 slides

Collaborative Care II

Pharmacologic agents may be necessary: *H2 blockers and PPIs inhibit gastric acid production and secretion. *Octreotide (Sandostatin) slows gastric emptying and small bowel transit. Helps control chronic diarrhea. *Cholestyramine—helps control diarrhea. *Antibiotics are used to reduce bacterial overgrowth in the intestines.

Ulcerative Colitis Versus Crohn's Disease: Parts of Digestive System Affected

UC: . Affects only the inner most layer of the bowel wall of the colon or rectum—mucosa and submucosa (most often in sigmoid colon and rectum) . Rectum affected 95% of the time Crohn's: . Deep in the lining of the walls of the colon and/or small intestine—entire thickness of bowel . Occurs in any part of the digestive tract from the mouth to the anus; most frequent site: terminal ileum (ileocolon) . Rectum affected 50% of the time

Ulcerative Colitis Versus Crohn's Disease: Pathophysiology

UC: . Autoimmune disease caused by genetic and environmental factors (low fiber diet) Crohn's: . Genetic, autoimmune disease caused by the immune system attacking the GI tract and producing inflammation...... smokers 3X more likely

Ulcerative Colitis Versus Crohn's Disease: Manifestations II

UC: . Nausea/vomiting (sometimes) . Anorexia . Weight loss (rare) . Frequent fever . Low serum K+ . Intermittent periods of remission and exacerbation Crohn's: . Colicky pain (intermittent) and tenderness in the abdomen, especially the lower right side . Abdominal distention . Weight loss (may be severe) . Low-grade fever

Ulcerative Colitis Versus Crohn's Disease: Manifestations

UC: . Numerous stools (4-20 stools per day) . Bloody diarrhea . Pus or mucus in the stool . Anemia . Mild to severe abdominal cramps Crohn's: . Numerous stools (3-4 stools per day) . Foul-smelling, fatty stools . Sometimes constipation because of a blockage . Rectal bleeding (occasionally) . Anemia

Ulcerative Colitis Versus Crohn's Disease: Parts of Digestive System Affected II

UC: . The inflammation begins at the rectum and moves up the colon in a continuous manner. Continuous areas of inflammation. Crohn's: . Inflammation usually happens in patches along the digestive tract, will "skip areas" of healthy tissue in between. Histopathology

Ulcerative Colitis Versus Crohn's Disease: Complications

UC: . Toxic megacolon leading to perforation; colorectal cancer; fistulas and abscesses rare (does not extend through bowel wall) Crohn's: . Bowel obstruction, fistulas, strictures, abscesses, perforation (involves entire bowel wall); cancer of the small intestine, colorectal cancer (more common in UC)

Inflammatory Bowel Disease- UC and Crohn's Disease

Ulcerative Colitis . Most common site is rectum and sigmoid colon. Pseudopolyps or ulcerations of mucosa. Crohn's Disease . Most common site is the terminal ileum. Cobblestone pattern of mucosa.

Foods they CAN have

Vitamin supplements are also needed: folic acid, iron, fat-soluble vitamins Lactose intolerance is often presumed-therefore lactose (milk) is often excluded from diet