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D A A G A S T R O I G
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Hot Off The Press
Nutrition in Action
Practitioner Highlight
New to PEN
Research/QI in Progress
Diner Update
Medical Update
Nutrition in Action - Answers
NEWSLETTERSeptember 2016 I Issue 05
All comments & feedback welcome.Send to: Ruth Vo Gastro IG Convenor [email protected]
WELCOME TO THEDAA GASTRO IG NEWSLETTER
DAA GASTRO IG NEWSLETTER ISSUE 06
2
Welcome to our sixth and final edition for 2016.
My name is Felicity Ritorni and I am the new editor
of the Gastro IG newsletter. My background is acute
care dietetic however I am committed to continuing
to provide a quality newsletter aimed at
gastroenterology interest group members working
within all types of settings.
.I would love to hear any feedback from you about
the content or layout or any suggestions about what
else you might want to see in the newsletter.
This edition has been the result of the
volunteering efforts of a group of fantastic APD’s
who have come together to share this vision. They
are Lauren Reece,, Shamley Chand, Trang Soriano
and Hannah Ryrie.
Enjoy!
Felicity Ritorni
Gastro IG Committee member
Editor
HOT OFF THE PRESSBY FEL IC I TY R ITORN I AND HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 06
3
Dietitianled Gastroenterology clinic
Ryan, D., Pelly, F., & Purcell, E. (2016). The activities
of a dietitianled gastroenterology clinic using
extended scope of practice. BMC Health Services
Research, 16, 604. http://doi.org/10.1186/s12913016
18450
Enterovirus and Gastroparesis
Barkin JA, Czul F, Barkin JS, Klimas NG, Rey IR,
Moshiree B. (2016). Gastric Enterovirus Infection: A
Possible Causative Etiology of Gastroparesis.
Digestive Diseases and Sciences.
DOI:10.1007/s106200164227x. August 2016, 61(8) ,
PP 2344–2350
Infant Proctocolitis
Camargo LS, Silveira J, Taddei J, & Fagundes N.
(2016). Allergic Proctocolitis In Infants: Analysis Of
The Evolution Of The Nutritional Status. Arquivos de
Gastroenterologia, 53(4), PP 262266.
https://dx.doi.org/10.1590/S000428032016000400010
IBS and functional medicine – A case study
Plotnikoff G., & Barber M. (2016). Refractory
Depression, Fatigue, Irritable Bowel Syndrome, and
Chronic Pain: A Functional Medicine Case Report. The
Permanente Journal, 20(4), 104–107.
http://doi.org/10.7812/TPP/15242
H. Pylori and probiotics
Lue M, Yu S, Deng J, Yan Q, Yang C, Xia G, et al.
(2016) Efficacy of Probiotic Supplementation Therapy
for Helicobacter pylori Eradication: A MetaAnalysis of
Randomized Controlled Trials.11(10).
DOI:10.1371/journal.pone.0163743
H. Pylori and metabolic syndrome
Takeoka A, Tayama J, Yamasaki H, Kobayashi M, Ogawa
S, Saigo T, et al. (2016). Impact of Helicobacter pylori
Immunoglobulin G Levels and Atrophic Gastritis Status on
Risk of Metabolic Syndrome. PLoS ONE. 11(11). DOI:
10.1371/journal.pone.0166588
Paediatrics and effect after oral immunotherapy
EcheverríaZudaire L, FernándezFernández S, Rayo
Fernández A, MuñózArchidona C, ChecaRodriguez R..
(2016). Primary eosinophilic gastrointestinal disorders in
children who have received food oral immunotherapy.
Allergol Immunopathol (Madr). 44(6), PP 531536. doi:
10.1016/j.aller.2016.05.002.
Crohn's disease
Jauregui Amezaga A, Van Assche G, Practical Approaches
to "TopDown" Therapies for Crohn's Disease. Current
Gastroenterology Reports 2016, 18 (7): 35
Proton Pump Inhibitors
Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and
safe proton pump inhibitor therapy in acidrelated diseases
A position paper addressing benefits and potential harms
of acid suppression. BMC Medicine 2016 November 9, 14
(1): 179
Achalasia
FuruzawaCarballeda J, TorresLanda S, Ángel Valdovinos
M, CossAdame E, Martín Del Campo L, TorresVillalobos
G, New insights into the pathophysiology of achalasia and
implications for future treatment. World Journal of
Gastroenterology: WJG 2016 September 21, 22 (35):
7892907
NUTRITION IN ACTION CASE STUDY 6: CROHN'S DISEASE
BY FEL IC I TY R ITORN I
SR is a 17year old girl who presented to ED with acute diarrhoea and abdominal pain. After investigations she is
diagnosed with crohn's disease. She is referred to the dietitian for nutritional assessment and recommendations to
start exclusive enteral feeding orally in hospital and a plan for home.
1. List 4 nutritional issues associated with crohn's disease?
2. SR is 42kg and 165cm, BMI=15. She reports weight loss of approximately 5kg over 2 months. What
would SR’s nutritional requirements be?
3. What would be an appropriate feed type and why?
4. What pathology/examinations should be ordered upon diagnosis?
5. After 8 weeks SR is successfully weaned off exclusive enteral nutrition and she is symptom free. SR’s
parents however report they are restricting many foods from her diet with the fear she will have another
flare. Additionally they report searching the internet for crohn’s disease diets and ask you what diet is
most appropriate? How would you go about explaining this to SR and her parents?
DAA GASTRO IG NEWSLETTER ISSUE 06
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PRACTITIONER HIGHLIGHTBY TRANG SOR IANO
DAA GASTRO IG NEWSLETTER ISSUE 06
5
1. Could you please give me a background of your clinical experience and where you currentlywork?
I have worked at St John of God Subiaco Hospital since 2003 where I was the only clinical dietitian for
Perths largest private Hospital at the time. My role covered a wide variety of acute areas with a
particular focus in colorectal surgery, oncology and palliative care. Over this time I have developed a
dietetics department and have recently become the Manager of Allied Health where my position will
work to develop other AH services in the Hospital. In 2008 my way career had headed more into a
management role and I wanted to still keep the patient contact. I started to look at ways to specialise in
dietetics in private practice. There has been no looking back since this time. The balance between
management in a large private Hospital and being a specialist private practice has been an ideal
combination where both roles complement the other.
2. What does your role entail?
Specialised Nutrition Care is a dietetic practice where the APD’s have extensive experience in their area
of practice. I believe being able to have experience in a large acute care Hospital helps you establish
good clinical skills in a private practise setting. Working in Private Practice enables you to see the other
side of the story. The patients who are not hospitalised or who have been discharged requiring
significant dietetic support. My role at SNC is to ensure that the patients receive excellence in care and
that the dietitians practicing are continually maintaining a high level of knowledge in the area of
practise.
3. Could you describe your average day at work?
As my hours in private practise is limited each week my clinics are solely patient focused. After hours I
will spend the time communicating with the patients specialists and GP’s through letters and forms of
documentation.
4. What are the main gastroclinical patient group/s you see?
Functional Gastrointestinal Disorders (FGID), IBS/ Functional Dyspepsia, IBD, Coeliac Disease, all
Bariatric surgery LAGB, Sleeve gastrectomy and Bypass
SEN IOR CL IN IC IAN : CHARLENE GROSSEADVANCED ACCRED ITED PRACT IS ING DIET IT IAN
PRACTITIONER HIGHLIGHT - CONT...BY TRANG SOR IANO
DAA GASTRO IG NEWSLETTER ISSUE 06
SEN IOR CL IN IC IAN : CHARLENE GROSSEADVANCED ACCRED ITED PRACT IS ING DIET IT IAN
5. How do you keep current on the changing science of nutrition?
I cannot place enough emphasis on the importance of ongoing professional development in the areas we work in. I
hold pride in the level of knowledge I am able to provide to my clients in a way that makes sense to them. It is one
thing to read or learn about new areas of science but being able to apply to that as food on the plate is the skill
dietitians should strive for. The pile of books next to my bed is forever growing. Any new publication, resource or
conference with digestive health, gut microbiota, bariatric surgery gives my credit card a work out! Keeping up with
the changing science in nutrition is a job in itself. I listen to where my clients are sourcing information and have
been known to be up late at night to accidentally stumble across a link to a link to a link that then ends up with some
resourceful information.
6.What’s the best thing you like about your job?
Working with a client to improve their health is a humbling and rewarding experience. Some patients are debilitated
by their GI disease and have learnt to put up with it. By being able to think practically about the MNT that is
appropriate to their health and situation at the time and seeing that make a difference makes it all the worth while.
Sometime I find we get caught up in our profession by the celebrities working against us. I approach my work at the
level of the patient I see and the influence I can have on them with my knowledge and skill set.
7.What are some gastro related challenges you find about your job?
My biggest limitation is not having enough hours in my week to see my patient referral base while working in my
other role. For this reason I have established Specialised Nutrition Care where I can mentor my colleagues and use
their skill set to provide the Evidence Based Practise that is practical to the individuals situation. The area of
research related to the our guts is exploding yet not at a level we can translate into practical advise. I am thirsty for
more information and ways I can use food as medicine to heal the gut and the complex system that operates within
it. Over the years I have learnt to listen to peoples experience of what has worked for them and be more open to
alternative therapies. As dietitians we do not have all the answers and we need to accept that. By going on a
journey with my clients I learn so much from their story, their journey, their experience.
8. What are your most complex gastrointestinal patients you see?
I would suggest most patients suffering with GI problems are complex as there is no one size fits all. Everyone has
different lifestyles, profession, social situation, stress levels and medical history. Most patients attending want a
natural solution through dietary intervention and the complexity comes from establishing what is the right medical
nutrition therapy for them in the most simplified and least restrictive way. Aside from that I would say the most
complex over all are those that have rare conditions that are presenting with FGID. For example a current patient
has Ehlers Danlos understanding these disorders and how they may be linked to FGID can be at times
challenging and time intensive 6
BY TRANG SOR IANO
DAA GASTRO IG NEWSLETTER ISSUE 06
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NEW TO PEN
Updated Knowledge Pathways
Gastrointestinal System Gallbladder Disease
Updated practice Questions
What dietary factors reduce the risk of gallbladder disease?What level of fat restriction is required before surgery forpeople with gallbladder disease?Is a fatrestricted diet needed for individuals with gallbladderdisease after surgery?
Professional Tools
Gastrointestinal Disease Gallbladder Disease Background
RESEARCH/QI IN PROGRESSBY SHAMLEY CHAND & HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 06
DIETARY MANAGEMENT OF ACUTE , UNCOMPL ICATED DIVERT ICUL IT IS INA HOSP ITAL SETT ING – AN OBSERVAT IONAL PROSPECT IVE COHORT
STUDY
8
Robina Hospital Dietitians: Romina Nucera, Julie JenkinsChapman, Yvonne Chen and Kayla Russell.
Bond University Dietitians: Skye Marshall. Bond University Student Dietitians: Megan Crichton and
Camilla Dahl.
Robina Hospital, Robina, Gold Coast, QLD
Email: [email protected]
Background: It is known that modern Australian society is trending towards an ageing populationcombined with a poor intake of foods rich in dietary fibre such as wholegrains, fruits and vegetables.1
Therefore, as diverticulitis is highly prevalent in older adults, and becoming more common in younger
ages also, it is predicted to become even more prevalent in the future.2,3,4 Furthermore, the evidence
that is in existence to support current dietary management is inconsistent, of poor quality and lacking in
Australia.
At Robina Hospital in Queensland, approximately five to seven patients are admitted with acute
uncomplicated diverticulitis per week. The current dietary management of acute uncomplicated
diverticulitis is prescribed by the surgical team based on expert opinion rather than evidence based
guidelines and is not related to disease severity. Recommendations for discharge can be to follow a low
fibre diet (<15g fibre/d) for the initial twoweeks post discharge before gradual increase over 1 week to a
high fibre diet (>30g/d). Alternatively, patients are discharged on standard/full diets (1530g fibre/d), with
recommendations to gradually increase dietary fibre intake to high fibre diet (>30g /d) over the first week
post discharge.
Objectives: This study will identify potential associations between dietary prescription and patientoutcomes and health care use. Specifically, in patients with acute uncomplicated diverticulitis:
1. What is the effect of inpatient prescription of liberalised diets (solid diet within 48 hours) compared with
restrictive diets (fasting or fluidonly) on healthcare use (hospital length of stay) and gastrointestinal
symptoms?
2. What is the effect of discharge prescription of standard diets (full diet) compared with low fibre diets on
healthcare use (readmission rates and visits to general practitioner) and gastrointestinal symptoms?
Methods: Patients eligible for participation include adult inpatients (≥18 years old) admitted with adiagnosis of acute uncomplicated diverticulitis (Hinchey Classification 0Ib) diagnosed via CT scan and
managed with conservative treatment (no surgery performed or drainage placed). All eligible participants
will be invited to participate and will be asked to provide informed consent prior to participation. Usual
practice will be observed, therefore no interventions will be implemented and patient medical records will
be accessed to obtain information along with interviewing the participants.
RESEARCH/QI IN PROGRESSBY SHAMLEY CHAND & HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 06
DEVELOPMENT OF A TRA IN ING PACKAGE AND COMPETENC IESFOR DIET IT IANS ORDER ING PARENTERAL NUTR IT ION
9
Outcome objectives: The findings of this study can guide future interventional research that maylook at whether certain dietary management methods have the potential to improve health outcomes
and quality of life of individuals with acute uncomplicated diverticulitis. This may help to formulate best
practice guidelines for the dietary management to also achieve cohesion across treating physicians
and dietitians.
NB: The study is currently awaiting finalisation of ethical approval prior to commencing but aims for
data collection to begin from late December 2016.
References:1 Australian Bureau of Statistics (ABS). (201113). Australian Health Survey 2011 – 2013.
http://www.abs.gov.au/australianhealthsurvey
2 Elisei, W., & Tursi, A. (2016). Recent advances in the treatment of colonic diverticular disease
and prevention of acute diverticulitis. Ann Gastroenterol, 29(1), 2432.
3 Song, J. H., Kim, Y. S., Lee, J. H., Ok, K. S., Ryu, S. H., Lee, J. H., & Moon, J. S. (2010). Clinical
Characteristics of Colonic Diverticulosis in Korea: A Prospective Study. Korean J Intern Med, 25(2),
140146. doi:10.3904/kjim.2010.25.2.140
4 Everhart, J. E., & Ruhl, C. E. (2009). Burden of digestive diseases in the United States part I:
overall and upper gastrointestinal diseases. Gastroenterology, 136(2), 376386. doi:
10.1053/j.gastro.2008.12.015
Julia Fox; Dr Melinda White and Dr Robyn Littlewood (dietitians), Dr Looi Ee and Dr Tony CattoSmith
(Gastroenterologist) and Bruce Chio (Pharmacist) and Katie Howard (Nurse Navigaotor)
LADY CILENTO CHILDREN’S HOSPITAL, BRISBANE, QLD
Please contact Dietitian Julia Fox, Dietitian clinical leader surgical services (LCCH):
Background: In Australia Parenteral Nutrition (PN) is not listed as a scheduled medication, however, the
role of ordering/prescribing tends to be that of the medical officers. Dietitians are the experts in the
provision of nutrition support and often integral in devising the nutrition support regimes for patients on
PN.
The Lady Cilento Children’s Hospital (LCCH) in Brisbane currently manages approx. 20 patients on
PN/day. Each patient requires an order to be written daily and current practice is that the order must be
written by a medical officer. As per hospital procedures, a dietitian is always contacted to determine a
patients’ PN regime; the Doctor then transcribes the dietitians’ recommendations onto a fluid order
sheet. This process is open to transcription error and unnecessarily increases the work load of the
dietitian and the doctor. The time taken for PN ordering each day is estimated to be approximately 300
minutes and initial data collection has shown errors on over 50% of all orders.
RESEARCH/QI IN PROGRESSBY SHAMLEY CHAND & HANNAH RYR IE
DAA GASTRO IG NEWSLETTER ISSUE 06
10
Dietitian PN ordering is becoming common practice in ICUs across Australia with 20% of dietitians
prescribing PN. At present, there are no paediatric hospitals in Australia where dietitians order PN on the
general wards. At the LCCH there is strong support from medical teams, nurses and pharmacists for
dietitians to commence ordering of PN. Therefore, the development of a procedure, training package, and
competencies for dietitians on safe ordering of PN at the LCCH was developed, and will be implemented
and reviewed over the coming months.
Aims: To reduce the number of errors, the time taken and therefore the overall cost of PN provision at theLCCH.
Processes: A request for consideration of the proposal to allow for PN ordering by dietitians at LCCH wassent to the hospitals Medicines Advisory Committee. Approval was granted and the following process was
then undertaken by the clinical lead dietitian:
• Developed a training package, assessment and competencies tool for ordering of PN (based on ASPEN
guidelines)
• Developed chart audit tool for pre and post implementation analysis
• Developed implementation procedure site based
• Sought feedback from key stakeholders
• Sought endorsement from Children’s Health Queensland (CHQ) Allied Health Credentialing Committee •
Commenced preimplementation data collection
• Commenced roll out processes
Procedure: Initial Endorsement of Competence• The current lead PN prescriber (Gastroenterologist) will initially endorse the competence of 3 dietitians at
CHQ. (These dietitians have 10 + years’ experience working in paediatrics and parenteral nutrition)
• Learning activities (knowledge based questions and working cases), work shadowing, supervised cases
and competencies must be completed, signed off and endorsed.
• These 3 dietitians will become the lead dietitians with competence in PN ordering at the LCCH
• These dietitians will be responsible for ensuring competence of a small number of selected dietitians
across LCCH.
• Reassessment of Competence
• The competency of all dietitians must be reassessed annually utilising the PN Ordering Competency Tool
Implementation: The Procedure has been approved and endorsement by the CHQ Allied HealthCredentialing Committee and the Medicines Advisory Committee. Currently the 3 lead dietitians are
completing their education and assessments with an aim to be signed off as competent by January 2017.
Preimplementation evaluation has commenced as a snap shot (1 day per week for 6 weeks) of all
patients on PN in hospital using the developed chart audit tool.
Conclusions: PN is a complex therapeutic treatment process that is prone to errors and risks, therefore; itshould be ordered by clinicians with demonstrated competence in PN orderwriting to help optimise the
delivery of safe and effective treatment. A training package, assessment and competencies have been
developed at LCCH to allow a select number of dietitians to order PN. Dietitian order writing in adult
centres has resulted in increased efficiency and decreased number of errors whilst maintaining patient
safety and the LCCH aim to replicate these results. We would love to collaborate with other sites to
set National Standards on paediatric PN ordering for dietitians.
DINER UPDATE BY LAUREN REECE
DAA GASTRO IG NEWSLETTER ISSUE 06
11
Keeping Up to DateThere have been a great range of resources uploaded to Diner since the last newsletter covering topics
such as eating disorders, gut microbiota and communication skills.
If you are currently using freely available apps/ resources/ podcasts/ websites to keep up to date and you
think others may also benefit, please get in touch to have it included in the newsletter
Webinars and Webpresents
Communication skills for health professionalsWebpresent by Elaine Doyle, Communications Specialist
Last reviewed September 2016
This presentation covers:
The 3 mindsets if an outstanding communicator
Connecting and engaging your clients
Providing a clear message
Dealing with public speaking nerves
$38 through www.educationinnutrition.com.au
Social Media in Clinical DieteticsWebinar presented by Teri Lichtenstein, APD
Last reviewed November 2016
This webinar covers:
When and how to use LinkedIn and Twitter professionally
How LinkedIn and Twitter can help you in your clinical practice
Ethical issues in using social media professionally
$38 through https://educationinnutrition.com.au/presentations/view/socialmediainclinicaldietetics
Introduction to the Gut MicrobiotaWebpresent by Dr Paul Bertrand
Last reviewed November 2016
This presentation covers:
What the gut microbiota is
What the gut microbiota does
How bacteria communicate with the brain
Free link available through Diner
DINER UPDATE - CONT...BY LAUREN REECE
DAA GASTRO IG NEWSLETTER ISSUE 05
12
Dietary Factors and Gut Microbiota
Webinar presented by Matthew Snelson
Last reviewed November 2016
This webinar covers:
How gut microbiota is measured
Nutrients, food and diet types that can affect gut microbiota
Interpreting microbiota data
Free link available through Diner
Gut Microbiota: Link between diet during pregnancy and mental health of children
Webinar presented by Samantha Dawson Last reviewed November 2016 This webinar covers
Prenatal diet and mental health
Mechanisms: diet, gutbrain axis
Relevance of early life microbiota
Targeting the prenatal diet to influence microbiota
Free link available through Diner
Gut microbiota: Link to obesity and diabetes
Webpresent by Nicole Kellow, APD CDE
Last reviewed November 2016
This presentation covers
The role of gut microbiota
Research on the association between gut microbiota, obesity and diabetes.
Gut microbiota mechanisms involved in protection from obesity and diabetes.
Practical recommendations
Free link available through Diner
Self Compassion
Webpresent by Dr Kiera Buchanan, BPsych (Clin & Health)
Last reviewed November 2016
This presentation covers:
What is self compassion? How does it differ to selfesteem and/or self indulgence?
How is self criticism involved in eating/weight concerns?
Why is self compassion the missing ingredient in the treatment of eating/weight concerns
Using compassion focused therapy in people with eating disorders
$38 through https://educationinnutrition.com.au/presentations/view/selfcompassion
Websites
Feed you Instinct Produced by Rachel King, The Victorian Centre of Excellence in Eating Disorders
Last reviewed June 2016
The website is an interactive early intervention tool designed to support parents or carers of young people
experiencing eating and body image problems, or an emerging eating disorder.
The website aims to promote early identification of an eating disorder and rapid access to treatment, increasing
the likelihood of recovery.
Available free though http://www.feedyourinstinct.com.au
DINER UPDATE - CONT...BY LAUREN REECE
ISSUE 05
13
Books
FoodSensitive Babies: Dietary investigation for breastfed babies
Written by Joy Anderson
Last review October 2016
A book aimed at dietitians, other health professionals and parents. Covering causes of symptoms other than
food, lactose intolerance, food allergy, foodchemical intolerance, introducing solids, research evidence relevant
to these topics.
$44.95 (plus postage) through www.dieteticsandlactation.com.au
Other Resources
Nutrition Support FAQ Produced by the DAA Nutrition Support IG, IG Convener Suzie Ferrie
Last updated November 2016
A resource providing a list of FAQ questions from the listserv with answers and references
Downloadable freely on Diner
Snap8App
Produced by Andrew Howie, Howie Consulting
Last reviewed November 2016
Snap8App is an Android Smartphone App giving access to data from AusNut.
Users can view the 5400 foods and 50+ data fields. Once the App is loaded it is not dependent on internet.
Analyse diets and recipes.
$4.99 through the Google App Store
Further information available at https://snap8app.wordpress.com
SMACC (Social Media in Critical Care)
Podcast videos from the Social media and Critical Care Conference (SMACC), a medical community focused on
spreading education freely online. These talks are high quality presentations about innovative topics. The
content is largely medical, however topics such as leadership, feedback and research maybe useful in you
practice.
‘Leadership Not (just) for Men’ Presented by Dr Resa Lewiss
Available free at http://www.smacc.net.au/2016/11/leadershipisatraitofanindividual/
‘So, you think you’re a resuscitationist?’ presented by Dr Victoria Brazil Available free at
http://www.smacc.net.au/2016/09/thinkyoureresuscitationist/
‘Why most published research is wrong’ presented by Louise Cullen Available free at
http://www.smacc.net.au/2014/08/cullenwhymostpublishedresearchiswrong/
es and Resources
MEDICAL UPDATEBY LAUREN REECE & FEL IC I TY R ITORN I
DAA GASTRO IG NEWSLETTER ISSUE 06
Drugs
Hepatitis B
Entecavir APOTEXAn antiviral medication used to treat HepatitisB but reducing the amount of virus andimproving the condition of the liver and mayprevent progression to cirrhosis, liver failureand liver cancer.For further information and product informationsee www.medicines.org.au/listingnew.cfm
Literature
Clinical Guidelines on Nutrition Support inadults with Enterocutaneous Fistula (ECF)
A systematic review of available literature toanswer questions regarding the managementof patients with ECF.The questions included: What factors bets describe nutrition status What is the preferred route of nutrition support What protein and energy intake provide bestclinical outcomes Is fistuloclysis associated with betteroutcomes Are immuneenhancing formulas associatedwith better outcomes Does somatostatin provide better outcomes When is home PN indicated
Kumpf VJ, de AguilarNascimento JE, DiazPizarro Graf JI, Hall AM, McKeever L, SteigerE, Winkler MF, Compher CW ASPENFELANPE Clinical Guidelines: Nutrition Supportof Adult pateints with Enterocutaneous FistulaJPEN 2016 cont...
14
Percutaneous Endoscopic Gastrostomy withJejunal Extension (PEGJ)
A cohort study of patients who under went PEGJplacement. Outcomes measurements were shortand long term complications. A secondaryanalysis was done to assess weight changes andhospitalisations in the patients with chronicpancreatitis.
Ridtitid W, Lehmnan GA, Watkins JL, McHenry L,Fogel EL, Sherman S, Cote GA Short and longterm outcomes from percutaneous endoscopicgastrostomy with jejunal extension SurgicalEndoscopy 2016,
Herbal and dietary supplements and liverinjuryAn overview of potential hepatotoxic herbal anddietary supplements including epidemiology,clinical presentation and diagnosis andmechanism of toxicity.
De Boer YS, Sherker AH Herbal and dietarySupplement Induced Liver Injury Clinics in LiverDisease 2017; 21 (1);135149
Dietary supplements and IBD
A systematic review of the evidence for dietarysupplements: Curcumin, green tea, vitamins andminerals, probiotics, androgrpahis paniculata andboswellia serrate; in the management of IBD
Elliott JA, Docherty NG, Eckardt HG, Doyle SL,Guinan EM, Ravi N, Reynolds JV, le Roux CW.The role of dietary sypplements in inflammatorybowel disease: A Systematic Review. Eur JGastrolenterol Hepatol 2016;28(12);13571364
MEDICAL UPDATE - CONT... BY LAUREN REECE & FEL IC I TY R ITORN I
DAA GASTRO IG NEWSLETTER ISSUE 06
15
Crohn’s Disease
This paper provides the official
recommendations of the American
Gastroenterological Association (AGA) on the
management of Crohn’s disease (CD) after
surgical resection. The guideline was
developed by the AGA’s Clinical Guidelines
Committee and approved by the AGA
Governing Board.
Nguyen G, Loftus E, Hirano I, FalckYtter Y,
Singh S, Sultan S. American
Gastroenterological Institute Guideline on the
Management of Crohn's Disease After
Surgical Resection. Gastroenterology 2016
November
Treatment of Patients with Cirrhosis
This paper reviews the practical treatment of
patients with cirrhosis, with a focus on recent
developments. The recommendations
provided are based on results from clinical
trials, when available, and on current clinical
practice when controlled trials have not been
conduced.
Ge P, Runyon B. Treatment of Patients with
Cirrhosis. New England Journal of Medicine
2016 August 25, 375 (8): 76777
Portal Hypertension Bleeding
GarciaTsao G, Abraldes J, Berzigotti A,
Bosch J, Portal Hypertensive Bleeding in
Cirrhosis: Risk Stratification, Diagnosis and
Management 2016 Practice Guidance by the
American Association for the Study of Liver
Diseases. Hepatology: Official Journal of the
American Association for the Study of Liver
Diseases 2016 October
Diagnosis and management of Crohn'sdisease 2016
This paper relates to the European Crohn's
and Colitis Organisation (ECCO) evidence
based consensus on the diagnosis and
management of Crohn's disease and concerns
the methodology of the consensus process,
classification, diagnosis and medical
management of active and quiescent Crohn's
disease.
Fernando Gomollón, Axel Dignass, Vito
Annese, Herbert Tilg, Gert Van Assche,
James O Lindsay, Laurent PeyrinBiroulet,
Garret J Cullen, Marco Daperno, Torsten
Kucharzik, Florian Rieder, Sven Almer,
Alessandro Armuzzi, Marcus Harbord, Jost
Langhorst, Miquel Sans, Yehuda Chowers,
Gionata Fiorino, Pascal Juillerat, Gerassimos
J Mantzaris, Fernando Rizzello, Stephan
Vavricka, Paolo Gionchetti, EUROPEAN
Evidencebased consensus on the diagnosis
and management of Crohn's disease 2016:
Part 1: Diagnosis and medical management.
Journal of Crohn's & Colitis 2016
NUTRITION IN ACTION CASE STUDY: ANSWERS
DAA GASTRO IG NEWSLETTER ISSUE 06
16
ANSWERS DISCLAIMER: Please note it is beyond the scope of this newsletter to provide a thorough
and comprehensive response to the questions posted. Please refer to the references provided and
selfdirected research.
SR is a 17year old girl who presented to ED with acute diarrhoea and abdominal pain. After
investigations she is diagnosed with Crohns disease. She is referred to the dietitian for nutritional
assessment and recommendations to start exclusive enteral feeding orally in hospital and a plan for
home.
1. List 4 nutritional issues associated with crohns disease? • Malnutrition: Due to reduced intake/ restrictive diets/fear of eating, weight loss, increased
requirements during acute inflammation • Nutrient losses: blood loss and diarrhoea
• Malabsorption: acute inflammation, bacterial overgrowth, bile acid losses
• Impaired growth in children
References:
Amt C Brown et al; Existing dietary guidelines for Crohns diease and ulcerative colitis.Expert Rev.
Gastroenterol. Hepatology 5(3), 411425 (2011)
Amar S. Naik. Nutritional Care in Adults inflammatory bowel disease Practical Gastroenterolgy, June
2012; 1826
Lomer M. Nutrition in inflammatory bowel disease. Dietary and nutritional considerations for
inflammatory bowel disease. Proceedings of the nutrition society 2011; 70: 329335
2. SR is 42kg and 165cm, BMI=15. She reports weight loss of approximately 5kg over 2months. What would SR’s nutritional requirements be?Estimated requirements using Schofields EER= approx 8200kj (AF=1.25 and IF 1.2) and EPR= 4669
(11.5g/kg/d). This is a starting point for therapy however SR’s weight and hydration will need to be
monitored closely and requirements will need to be adjusted according to weight changes to avoid
under/over feeding as well as monitoring urine and fluid status to determine if over
hydrated/dehydrated.
3. What would be an appropriate feed type and why?
Fortisip 1.5kcal/ml feed. Polymeric feeds are as effective as elemental/semi elemental or CD specific
and more palatable.
References: Grogan JL, Casson DH, Terry A et al. Enteral Feeding Therapy for Newly Diagnosed
Pediatric Crohn’s Disease: A DoubleBlind Randomized Controlled Trial with Two Years FollowUp.
Inflam Bowel Dis, 2012. 18 24653
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4. What pathology/examinations should be ordered upon diagnosis?
I would recommend checking SR’s iron studies (including Hb, Iron, transferrin saturation and ferritin
level. Additionally I would ask the treating team to check micronutrients including Zinc, Selenium,
vitamin B12, folate, magnesium and fatsoluble vitamins. Furthermore a DEXA scan could provide a
measure of SR’s bone health.
References: Mullin E. Micronutrients in Inflammatory Bowel Disease. Nutr Clin Pract 2012 27:136
5. After 8 weeks SR is successfully weaned off exclusive enteral nutrition and she is symptomfree. SR’s parents however report they are restricting many foods from her diet with the fearshe will have another flare. Additionally they report searching the internet for crohn’s diseasediets and ask you what diet is most appropriate? How would you go about explaining this to SRand her parents and where would you refer them for further information?
I would try to explain to SR and her parent’s that longterm dietary restrictions may assist with
symptom relief however are not affective in treating IBD. Similarly avoiding specific foods and/or food
groups can lead to nutritional deficiencies. Websites which may be useful to SR and her family
include http://www.gesa.org.au and http://www.crohnsandcolitis.com.au