GI Potpourri Washington State Academy of Nutrition and Dietetics

Objectives GI Potpourri Washington State Academy of Nutrition and Dietetics By the end of this presentation, participants will be able to: Differentiate between the types of inflammatory bowel disease and describe the nutritional implications and management Describe the diagnosis process for celiac disease, evidencedbased nutritional implications and management in pediatric patients Describe the absorptive capacity of each portion of the small bowel and the implications of resection Differentiate between short bowel syndrome and intestinal failure and describe the indications for intestinal transplant Presented by: Cheryl Davis, RD, CD, CNSC 4/16/13 Inflammatory Bowel Disease Complex immune disorder Etiology/pathogenesis unknown Genetic, environmental and lifestyle factors Basic definition: Inappropriate response to gut microflora by mucosal immune system in genetically predisposed individual Inflammatory Bowel Disease 1

Inflammatory Bowel Disease: Types Diet and Development of IBD Crohn s Disease Mouth to anus Transmural Segmental Ulcerative Colitis Isolated to colon Mucosal lining Continuous Incidence of IBD increasing in countries exposed to Western diet Associated with industrialization and wealth Possible mechanism: Increased intestinal permeability, leading to mucosal inflammation Which comes first? Role of bacterial translocation? Diet and Crohn s Disease Risk Diet and Crohn s Disease Risk Goal: Examine associations between dietary elements and risk for Crohn s disease (CD) among Canadian children Case-control study CD patients: diagnosed 2003-2006 (n=130) Controls: orthopedic clinic patients (n=202) Food Frequency Questionnaire Dietary habits within the 12 months prior to diagnosis Results: Higher fruit and vegetable intake associated with a decreased risk of CD Higher intake of nuts and fish associated with a protective effect No association with dairy products and CD Higher total fat intake associated with increased risk of CD, but not statistically significant Higher intake of omega-3 fatty acids associated with a lower risk for CD Amre et al. Imbalances in Dietary Consumption of Fatty Acids, Vegetables, and Fruits Are Associated With Risk for Crohn s Disease in Children. Am J Gastroenterol 2007; 102:2016-2025. 2

Effects of IBD on Nutritional Status in Children Protein-energy malnutrition Growth failure NASPGHAN IBD Committee, 2012 85% of pediatric patients have lost weight 46% have linear growth impairment Delayed sexual development Bone disease Malnutrition in IBD: Why? Poor intake Altered metabolism Decreased absorption with small bowel disease and/or surgical resections Increased nutrient losses Bowel rest Self or medically-imposed diet restrictions Mechanisms of Malnutrition Mechanisms of Malnutrition, continued Decreased intake Children with CD consume 40-80% estimated needs (Wiskin et al, 2007) Patients feel too sick to eat Gastrocolic reflex: increase in muscle movement in the GI tract when food enters the empty stomach May cause urge to have bowel movement immediately after eating Reinforces idea that food causes pain/symptoms May lead to food aversion Inflammatory state Significant metabolic disturbances Shift from anabolism to catabolism Stool losses Depends on frequency & quantity of stool Limited data to quantify extent of malabsorption Protein loss may be more significant than fat malabsorption 3

Nutrition Goals in IBD Diet Therapy in IBD Provide adequate calories for growth Supply adequate protein Prevent & treat metabolic bone disease Prevent & treat micronutrient deficiencies Minimize GI symptoms Exclusive Enteral Nutrition (EEN) Exact mechanism of action unclear Theories include (NASPGHAN, 2012): Decreased dietary antigens Overall improvement in nutritional status Provision of micronutrients to diseased bowel Decreased inflammation due to decreased dietary fat intake Exclusive Enteral Nutrition Use of EEN in the US 2005 study: steroids vs. formula in pediatric CD 55% chose nutrition intervention (n=44) 27% took formula orally 73% used NG tube Formula only until remission achieved 90% responded to formula intervention Median time to remission = 6 weeks 62% relapsed Median time to relapse: 54.5 weeks 2011 survey of 326 GI physicians Only 4% of US GI physicians reported frequent use of EEN Compared to 62% of physicians in western Europe & 36% in Canada 40% of US GI physicians responded that EEN is an appropriate or extremely appropriate therapy 31% reported never using EEN to treat CD 4

Use of EEN in the US Prevention of Crohn s Disease Relapse with a Semi-Vegetarian Diet 2011 survey of 326 GI physicians Lack of practice guidelines identified as primary barrier to use of EEN: No clear preference for type of formula with many physicans using more than 1 type: 47% polymeric 55% semielemental 37% elemental Variable duration 30% use EEN <6 weeks 46% use EEN 6-8 weeks 25% use EEN >8 weeks World Journal of Gastroenterology, 2010 Prospective study to establish whether a SVD has a preventative effect against relapse for patients in remission 2003-2008 22 adult patients enrolled Age range: 19-77 years Median age: 26.5 years Remission defined as disappearance of active symptoms of Crohn s disease Prevention of Crohn s Disease Relapse with a Semi-Vegetarian Diet Diet details: Offered daily: Miso soup, brown rice, vegetables, fruits, legumes, potatoes, pickled vegetables and plain yogurt Fish: Once a week (1/2 typical portion) Red meat: Once every 2 weeks (1/2 typical portion) Nutrient breakdown: 66% carbohydrate, 16% protein, 18% fat Prevention of Crohn s Disease Relapse with a Semi-Vegetarian Diet Diet/lifestyle advice: Discouraged: sweets, bread, cheese, margarine, fast foods, carbonated beverages and juice Encouraged: No smoking, regular physical activity, moderate or no use of alcohol, regular meals and not eating between meals 2 year follow up Food frequency questionnaire at 3 months, 1 year and 2 years 5

Prevention of Crohn s Disease Relapse with a Semi-Vegetarian Diet Results 15 of 16 patients who followed SVD maintained remission, 1 relapsed Remission rate: 100% at 1 year, 92% at 2 years Of 6 patients not following SVD, 2 maintained remission and 4 relapsed Remission rate: 67% at 1 year and 25% at 2 years Conclusion: Reasonable to conclude that SVD protected patients from relapse but an omnivorous diet did not. Other Popular Diets for IBD Specific Carbohydrate Diet Based on the book Breaking the Vicious Cycle by Elaine Gottschall Carbohydrates as monosaccharides only No grains, corn or potatoes No milk except for homemade yogurt fermented for 24 hours Anti-Inflammatory Diet Many interpretations May avoid gluten, top allergens, yeast, processed foods Encourage omega 3s, herbs, probiotics Practical Dietary Considerations for IBD Maximize calories and variety as much as possible Ensure adequate protein intake Temporarily limit fiber during a flare Chew thoroughly Formula can be used as treatment as well as method to supplement diet Ensure adequate calcium intake Consider a multivitamin with minerals Work with a dietitian to optimize nutritional status. Celiac Disease 6

What is Celiac Disease Pathogenesis of Celiac Disease Immune response to ingested gluten in genetically predisposed individuals that promotes an inflammatory reaction Classical features first described in 1887 What is gluten? Protein derived from wheat, barley, and rye Gluten is incompletely digested accumulation of large peptide fragments in the small intestine Peptides cross epithelial barrier and reach antigenpresenting cells Triggers inflammatory T-cells Produce proinflammatory cytokines Destroy surface epithelium Result = flattened mucosa Activates intraepithelial lymphocytes Pathogenesis of Celiac Disease Pathogenesis of Celiac Disease Genetic Factors HLA-DQ2 or HLA-DQ8 gene Presence necessary for the development of celiac Up to 40% of population also carries these genes but do not have celiac Absence of these alleles virtually excludes the diagnosis Environmental Factors: Protective effect associated with breastfeeding Increased risk associated with the introduction of glutencontaining solids before 4 months of age and after 7 months of age Gradual introduction of gluten-containing solids while breastfeeding may have protective effect Gastrointestinal infections, such as rotavirus, may increase risk in infancy. 7

Clinical Presentation of Celiac Disease Clinical Presentation of Celiac Disease Varies greatly based on age, duration and extent of disease, and presence of extraintestinal manifestations Classic symptoms: Children: Diarrhea, abdominal distention, failure to thrive Adolescents/Adults: Diarrhea, constipation, weight loss, weakness, short stature, abdominal pain, vomiting Extraintestinal Manifestations: Short stature Anemia Reduced bone-mineral density Chronic fatigue Pubertal delay Dental enamel hypoplasia Neurological symptoms Elevated liver enzymes Subclinical Celiac Disease Diagnosis of Celiac Disease Have no outward symptoms, but have positive serologic markers and villous damage Identified by screening at-risk groups First-degree relative with celiac Type 1 diabetes Down syndrome Turner syndrome Rheumatoid arthritis Systemic lupus erythromatous Part One: Screening IgA anti-ttg antibodies Children under 2 years of age lack ttg antibodies Part Two: Biopsy Biopsy of the small intestine is the standard for diagnosis Must not be avoiding gluten at the time of biopsy Pathologic changes: Villous blunting Intraepithelial lymphocytosis Increasing evidence that biopsy may not be necessary with ttg >100 U/mL Part Three: Improvement on a gluten-free diet 8

Treatment of Celiac Disease Treatment of Celiac Disease Nutritional therapy is the only accepted treatment for celiac disease. Lifelong removal of wheat, rye, and barley from the diet Complete removal of gluten will result in symptomatic, histologic, and serologic remission in most patients 70% reported an improvement within 2 weeks Antibody levels may normalize in 6-12 months Complete histologic improvement may take up to 2 years C: Consultation with skilled dietitian E: Education about celiac disease L: Lifelong adherence to GF diet I: Identification/treatment of nutritional deficiencies A: Access to advocacy group C: Continuous long-term follow up NIH Consensus Development Panel on celiac disease Niewinski M. Advances in Celiac Disease and Gluten-Free Diet. Journal of the American Dietetic Association. 2008:108:661-672. Potential Nutrient Deficiencies in Celiac Disease Gluten-Free Grains Iron Folate Calcium Fat-soluble vitamins B-vitamins Amaranth Arrowroot Bean flours Buckwheat Corn Flax Millet Potato Quinoa Rice Soy Tapioca Tef/Teff Clinical Enter department Nutrition Department name here 9

Gluten-Free Diet Reading Labels What about oats? Oats are not uniformly recommended as most commercially available oats are contaminated with gluten. Pure, uncontaminated oats in moderation are well-tolerated by most patients with celiac disease. Food Allergen Labeling and Consumer Protection Act of 2004 Clear labeling of products containing top 8 allergens, including wheat Products labeled as wheat-free could still contain barley or rye No federal regulation of term gluten-free yet Proposed definition is <20 ppm Gluten-Free Diet Complications of Celiac Disease Hidden Sources of Gluten Breading/coatings Communion wafers Croutons Luncheon meats Broths/soup base Soy sauce Potential Sources of Cross-Contamination Toaster Colander Cutting boards Butter, jam, peanut butter Patients with uncontrolled celiac disease have a higher risk of cancer than the general population Non-Hodgkin s lymphoma Oropharyngeal and esophageal adenocarcinoma Cancers of intestine, hepatobiliary system, and pancreas 10

Short Bowel Syndrome (SBS) Functional Definition: Malabsorption in the presence of a shortened small intestine. Decreased surface area Loss of digestive enzymes Loss of transport carrier proteins Short Bowel Syndrome Small Bowel Anatomy Duodenum Typical small bowel length: 300-800 cm in adults 200-250 cm in term infants at birth Duodenum Pyloric valve to ligament of Treitz Jejunum Proximal 2/5 of small bowel past ligament of Treitz Ileum Distal 3/5 of the small bowel to the ileocecal valve Contains bicarbonate-secreting glands to neutralize stomach acid Pancreatic & biliary secretions break down macronutrients Site of absorption for iron, calcium, magnesium, zinc 11

Jejunum Ileum Primary site of carbohydrate, protein, and water-soluble vitamin absorption Large junctions between cells Rapid flux of water and sodium to keep jejunal contents isoosmolar Carrier-mediated transport of monosaccharides, dipeptides, and amino acids Active absorption of fat via micelles Tight junctions between cells Decreased flux of fluid from vascular space to lumen More efficient absorption of fluid & electrolytes Shorter villi Carrier-mediated absorption of bile salts & B12 Hormone production Ileocecal Valve Colon Controls release of fluid into colon Prevents backflow of colonic bacteria into the small bowel Fluid and electrolyte reabsorption Storage & propulsion of stool Fermentation of malabsorbed carbohydrates into short chain fatty acids 12

Small Bowel Adaptation Stimulation for Adaptation Structural Changes Increase in size and absorptive surface Epithelial hyperplasia, villi lengthen Functional Changes Bowel transit time slows Hyperphagia Ileum can adapt in both structure and function Jejunum primarily adapts functionally Structural changes only occur with enteral nutrition Direct contact of nutrients with epithelial cells promotes regeneration Stimulates hormone production Stimulates pancreatic & biliary secretions Strategies to Manage SBS Strategies to Manage SBS Consider small bowel anatomy and function when making recommendations Formula osmolality, type and feeding schedule Watch closely for signs of intolerance they can be subtle at first Stool frequency Total volume of stool Diaper rash Hydration status Weight Managing SBS can be a long road If you hit a wall, don t give up re-evaluate Small bowel dilation? Consider bowel lengthening procedure such as STEP Bacterial overgrowth? Typically treated with enteral antibiotics and probiotics Stricture? Typically evaluated by contrast study May require surgical intervention 13

Strategies to Manage SBS TPN Management in SBS Manage PN carefully to avoid development of complications Total calories Macronutrient composition Micronutrient toxicity/deficiency Monitor routinely with PN duration 3 months Adequate fluid and electrolyte provision to account for increased GI losses Lipid restriction/minimization 1 g/kg/day SCH Data, published 2013 Historical cohort (2005-2008) compared to lipid restricted/experimental cohort (2009-2011) 132 infants in historical cohort 82 infants in experimental cohort TPN Management in SBS Average daily lipid dose: 2.1 g/kg compared to 1.25 g/kg Incidence of PN-associated liver disease (p=0.003): Lipid restricted: 22% Historical: 43% Relative risk of liver disease: 1.77X greater with higher lipid dosing after correcting for gestational age, diagnosis, PN duration and sepsis Similar weight gain in both groups Intestinal Failure and Transplant 14

Intestinal Failure (IF) Indications for Intestinal Transplant Irreversible gut failure Require maintenance parenteral nutrition Complications from parenteral nutrition Recurrent episodes of sepsis Loss of 2 central venous access sites Early cholestatic liver disease Portal hypertension Repeated episodes of dehydration Quality of life Controversial Fishbein TM. Intestinal Transplantation. N Engl J Med 2009;361:998-1008. Intestinal Transplant (IT) Types of Intestinal Transplants Number of new candidates for IT has decreased every year since 2006 Improved medical and surgical treatments for IF IT Transplant Rate Peak of 92.7 transplants per 100 wait-list years in 2005 49.2 transplants per 100 wait-list years in 2011 Pre-transplant mortality 51.5 per 100 wait-list years in 1998-1999 6.7 per 100 wait-list years in 2010-2011 Most common age group listed for transplant: 0-5 years 41.2% of candidates Isolated IT Jejunoileum Liver + small bowel Often includes pancreas and duodenum Multivisceral Stomach + liver + small bowel OPTN/SRTR 2011 Annual Report 15

Nutrition Support After IT Formula Selection After IT Immediate post-op period: Initiate TPN when fluid and electrolyte status stable Begin trophic enteral feeds as soon as bowel function established Typical initiation: 5 ml/hr Usually infused via J-tube directly into graft G-tube used for decompression Ileostomy created during transplant Allows for visualization of graft, endoscopy, and measurement of output Consider age of graft when selecting formula Use a low fat formula for first 4 weeks Takes time for lymphatic system to re-establish after IT At SCH, typically start with Vivonex Pediatric Keep formula osmolality <300 mosm/kg until tolerance established Advance rate as tolerated with ostomy output <40 ml/kg Nutrition After IT Long-term Outcomes After IT TPN typically weaned off by 6-12 weeks after IT May require IV replacement fluids as bridge to full enteral autonomy Gradually, J-tube feeds are converted to G-tube to allow more flexibility in feedings Most pediatric patients with IF have oral aversion, so the transition from G-tube to oral feedings can take months to years 5 year patient survival approximately 60% ~80% at 1 year ~70% at 3 years 5 year graft survival approximately 50% ~75% at 1 year ~60% at 2 years OPTN/SRTR 2011 Annual Data Report 16

THANK YOU I welcome your questions and comments 17