D A A G A S T R O I G  

3-4

5

6-8

9

10

11-13

14-15

16-18

Hot Off The Press

Nutrition in Action

Practitioner Highlight

New to PEN

Research/QI in Progress

Diner Update

Medical Update

Nutrition in Action - Answers

NEWSLETTERMarch 2017 Issue 7

All comments & feedback welcome. Send to: Felicity Ritorni Gastro IG Committee member felicity.ritorni@sswahs.nsw.gov.au

WELCOME TO THE DAA GASTRO IG NEWSLETTER

DAA GASTRO IG NEWSLETTER 

ISSUE 07

2

Welcome to our seventh edition. I hope you enjoyed

the December edition. Now that the new DAA

website is up and running you can access all previous

editions online. They can be found under the

Member’s community tab/Gastroenterology Interest

Group/Newsletters. 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 future newsletters.

 

This edition has been the result of the volunteering

efforts of a group of fantastic APD’s who have come

together. They are Lauren Reece, Shamley Chand,

Trang Soriano, Hannah Ryrie and Emma Armstrong.

 

My role is overseer and editor. My background is

clinical dietetics working in the acute care setting,

however I am committed to continuing to provide a

quality newsletter to benefit all Gastro IG members

from all different settings.

Happy reading!

Felicity Ritorni

Gastro IG Committee member

Editor

felicity.ritorni@sswahs.nsw.gov.au

HOT OFF THE PRESS BY EMMA ARMSTRONG AND SHAMLEY CHAND

DAA GASTRO IG NEWSLETTER 

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Oesophagectomy

Konosu M, Iwaya T, Kimura Y, et al. Peripheral vein

infusions of amino acids facilitate recovery after

esophagectomy for esophageal cancer: Retrospec-tive

cohort analysis. Annals of Medicine and Sur-gery.

2017;14:29-35. doi:10.1016/j.amsu.2017.01.016.

Jejunostomy Feeding Tubes

Bazzi, K, Lahoud, J, Sandroussi, C, Laurence, J.M,

Carey, S. and Yeo, D. (2017) Jejunostomy Feeding

Tube Placement in Gastrectomy Procedures: A Sys-

tematic Review. Open Journal of Gastroenterology, 7,

52-64.

https://doi.org/10.4236/ojgas.2017.72007

Long Term Parenteral Nutrition in Children

Namjoshi SS, Muradian S, Bechtold H, Reyen L,

Venick RS, Marcus EA, Vargas JH, Wozniak LJ.

(2017) Nutrition Deficiencies in Children With In-

testinal Failure Receiving Chronic Parenteral Nutri-tion.

Journal of Parenteral and Enteral Nutrition. 2017 Feb;

10.1177/0148607117690528

Medium Chain Triglycerides

Shah, N. D., & Limketkai, B. N. (2017). The Use of

Medium-Chain Triglycerides in Gastrointestinal Disorders.

PRACTICAL GASTROENTEROLOGY, 21.

Nutrition Supplementation in Colorectal Cancer

Burden, S. T., Gibson, D. J., Lal, S., Hill, J., Pilling, M.,

Soop, M., Ramesh, A., Todd, C. (2017) Pre-operative oral

nutritional supplementation with dietary advice versus

dietary advice alone in weight-losing patients with

colorectal cancer: single-blind randomized controlled trial.

Journal of Cachexia, Sarcopenia and Muscle, doi:

10.1002/jcsm.12170.

Fecal Microbiota

Malikowski, Thomas; Khanna, Sahil; Pardi, Darrell S.;

Fecal Microbiota transplantation for gastro in-testinal

disorders. Current Opinion in Gastroenterology, Jan2017;

33(1): 8-13.

Rika J. Goldberg, Sumit Bhalodia, Sherin Jacob, Hatil

Patel, Ken V. Trinh, Blessy Varghese, Jungmo Yang, Sean

R. Young, and Robert B. Raffa, Clostrid-ium difficile

infection: A brief update on emerging therapies. American

Journal of Health System Pharmacy. 2015, 1007-1012

(6p)

Dumping Syndrome

Van Beek, A. P., Emous, M., Laville, M., and Tack, J.

(2017) Dumping syndrome after esophageal, gas-tric or

bariatric surgery: pathophysiology, diagno-sis, and

management. Obesity Reviews, 18: 68–85. doi:

10.1111/obr.12467.

HOT OFF THE PRESS BY EMMA ARMSTRONG AND SHAMLEY CHAND

DAA GASTRO IG NEWSLETTER 

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ERAS

Bernard, Helena; Foss, Mark. The impact of the

enhanced recovery after surgery (ERAS) programme

on community nursing. British Journal of Community

Nursing. Apr2014; 19(4): 184-188

Dai Shida, Kyoko Tagawa, Kentaro Inada, Keiichi

Nasu, Yasuji Seyama, Tsuyoshi Maeshiro, Sachio

Miyamoto, Satoru Inoue, and Nobutaka Umekita.

Modified enhanced recovery after surgery (ERAS)

protocols for patients with obstructive colorectal cancer,

BMG Surgery 2017 Feb 16;17(1):

Forsmo HM, Pfeffer F, Rasdal A, Sintonen H, Körner

H, Erichsen C.Effects of an enhanced recov-ery after

surgery programme on emergency surgi-cal patients.

Int J Surg. 2016 Dec;36(Pt A):121-126

Wisely JC & Barclay KL. Pre- and postoperative

stoma education and guidance within an enhanced

recovery after surgery (ERAS) programme reduces

length of hospital stay in colorectal surgery. ANZ J

Surg. 2016 Nov;86(11):883-888

FODMAPS

Abigail Marsh, Enid M. Eslick, Guy D. Eslick. Does a

diet low in FODMAPs reduce symptoms associated

with functional gastrointestinal disorders? A

com-prehensive systematic review and meta-analysis.

European Journal of Nutrition. April 2016, Volume 55,

Issue 3, pp 897–906

Superior Mesenteric Artery Syndrome

Thompson, Kyle L. MS, RD, LDN, CNSC; Ziegler, Jane

DCN, RD, LDN; Trate, T. Cate MD; Trate, Douglas M. MD.

Superior Mesenteric Artery Syn-drome: A Nutrition-Focused

Clinical Update. Topics in Clinical Nutrition: January/March

2017 - Volume 32 - Issue 1 - p 2–14 doi:

10.1097/TIN.0000000000000090 Nutrition and Disease

Pancreatitis

Krishnan, Kumar, Nutritional management of acute

pancreatitis. Current Opinion in Gastroenterology. March

2017, Issue: Volume 33(2), p 102–106

Liang Hongyin, Huang Zhu, Wang Tao, Lin Ning, Liu

Weihui, Cui Jianfeng, Yan Hongtao & Tang Lijun (2017)

Abdominal paracentesis drainage improves tolerance of

enteral nutrition in acute pancreatitis: a randomized

controlled trial, Scandinavian Journal of Gastroenterology,

52:4, 389-395, DOI: 10.1080/00365521.2016.1276617

Social Media

Graham, Y.N.H., Hayes, C., Mahawar, K.K. et al.

Ascertaining the Place of Social Media and Tech-nology for

Bariatric Patient Support: What Do Al-lied Health

Practitioners Think? OBES SURG (2017).

doi:10.1007/s11695-016-2527-z

Access to articles To assist you in finding some of these articles we used data bases such as pubmed, medline, pogo frog, cinahl and ovid. If you are unable to gain access to full-texts please contact either Emma Armstrong (Emma.Armstrong@easternhealth.org.au) or Shamley Chand (Shamley.Chand@sswahs.nsw.gov.au)

NUTRITION IN ACTION  CASE STUDY 7: 

BY  LAUREN REECE

Ryan is a 29 year old male admitted to the ward with vomiting post oral intake, nausea, diarrhoea, weight loss,

depression and social isolation. His father had contacted the surgical team as he was concerned Ryan had not left

his home and had failed to attend multiple medical appointments.

Weight 52kg- 25kg weight loss in one year, height 1.86m, BMI 15kg/m2 Severe signs of muscle and adipose

depletion.

Ryan is well known to the dietetics department and the surgical team from a previous admission 1 year ago.

Ryan was diagnosed with appendix cancer and peritoneal metastases, he underwent extensive surgery including

gastrectomy, small bowel and colon resection with 3 anastomoses. The post-operative period was complicated by

respiratory failure and abdominal wound closure complications requiring a tracheostomy and 6 weeks in ICU.

Prior to surgery he was 91kg, and at time of discharge was 77kg.

1. What further information about Ryan’s anatomy do you need to assist with your nutrition

assessment and where can this be found?

On further investigation, Ryan has had a Billroth II partial gastrectomy and has 2.5m of proximal small bowel

anastomosed to the distal transverse colon.

2. What are some nutritional concerns post gastric resection?

3. What is the difference between a Billroth I and Billroth II gastrectomy?

4. What nutrients are you concerned about given Ryan’s anatomy?

After further investigation, Ryan is found to have delayed gastric emptying- 80% of meal remaining in stomach

after 4 hours.

5. What strategies can be used to improve symptoms associated with gastroparesis ?

DAA GASTRO IG NEWSLETTER 

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PRACTITIONER HIGHLIGHTBY FEL IC I TY R ITORN I

DAA GASTRO IG NEWSLETTER 

ISSUE 07

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1. Could you please give me a background of your clinical experience and where you currently work?

Initially my career was forged in community health primarily with a paediatric caseload both in Australia

and in London. I worked with many children and families with food allergies and intolerances in this

setting. I’ve also held a clinical position at the Royal Melbourne Hospital within the areas of

endocrinology and enteral nutrition. Four years ago, I left community health behind for private practice

work with Diet Solutions who are a group of dietitians specialising in GI disorders many of whom work

within the Monash University gastroenterology research department.

2. What does your role entail as a gastrointestinal dietitian? Can you describe your average day at work?

I mostly consult alongside gastroenterologists in their consulting rooms or at endoscopy centres at a

number of different locations around Melbourne. I’m often consulting from a different site most days of

the week which keeps things interesting. My days are generally spent consulting with private patients

with some allocation for time to develop patient resources or involvement in other business projects .

3. What are the main gastro-clinical patient group/s you see?

In my current role I see both adults and children primarily with functional gut disorders, coeliac disease,

IBD, gastroparesis, food allergies and intolerances. For the past few years I have been supporting

patients undergoing gastroenterologist-led programs aiming to treat the underlying factors that lead to

IBS including faecal microbiota transplant for IBS and IBD.

4. What are the main gastro-clinical patient group/s you see?

Functional Gastrointestinal Disorders (FGID), IBS/ Functional Dyspepsia, IBD, Coeliac Disease, all

Bariatric surgery - LAGB, Sleeve gastrectomy and Bypass

NICK DUNN

 PR IVATE PRACT ICE DIET IT IAN SPEC IAL IS ING IN NUTR IT ION

THERAP IES FOR FUNCT IONAL GUT DISORDERS INCLUD ING SUPPORT

OF PAT IENTS UNDERGOING FAECAL MICROB IOTA TRANSPLANT      

PRACTITIONER HIGHLIGHTBY FEL IC I TY R ITORN I

DAA GASTRO IG NEWSLETTER 

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5. How do you keep current on the changing science of gastro nutrition?

I have found following key figures within the gastro world via social media to actually be a brilliant way of

alerting me and gaining access to newly released research. I have found Monash university clinical

gastro update sessions to be a fascinating update on the different facets of gastro health particularly

learning more about the work being done in disciplines outside of nutrition and dietetics.

6. What do you find most interesting about your job or the area you are working in?

The heterogeneous nature of functional gut patients always poses a challenge. I like the ‘detective’

work that is required to determine the impact that certain foods have on their GI issues. It is not a one-

size-fits-all approach and I often combine forces with other related allied health clinicians or gut-focused

psychologists to achieve the best results for our patients. With specific comment to FMT, I find this

treatment utterly fascinating and the success some patients with severe gut disorders experience is

highly satisfying.

7. What are some gastro related challenges you find about your job?

Whilst the science is progressing quickly in the gastro world it is not yet at a point where we always have

evidence-based guidelines for managing patients. Functional gut symptoms are often a complex

manifestation of a number of factors and as we don’t have any reliable tests to lead us in the right

direction as to which foods are problematic. This poses a constant challenge. The variability of foods

that people tolerate is so wide I often find different patients reporting sensitivities to every possible food.

Having very little scientific backing when working with FMT patients is also difficult as I find myself

working with theories. I’m also unsure of how much a patient’s success is due to diet changed during

FMT therapy which can lead to questioning the value of dietetic input.

8. What are your most complex gastrointestinal patients you see?

• Chronic constipation with dyssynergic constipation

• Patients with multiple food sensitivities particularly those with both FODMAP, protein and chemical

sensitivities

• Coordinating patients often requiring a range of simultaneous therapies

NICK DUNN

 PR IVATE PRACT ICE DIET IT IAN SPEC IAL IS ING IN NUTR IT ION

THERAP IES FOR FUNCT IONAL GUT DISORDERS INCLUD ING SUPPORT

OF PAT IENTS UNDERGOING FAECAL MICROB IOTA TRANSPLANT      

PRACTITIONER HIGHLIGHTBY FEL IC I TY R ITORN I

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9. Have you been involved in any research projects regarding faecal transplant/gut microbiome? If so, would you be willing to share any information on your research in this area?

Not at this stage. I’m aware of other dietitians looking into to diet therapy with FMT at the moment within

partnerships with gastroenterologists who have a particular interest in FMT. The evidence is clearer on

the role of the interplay of diet and the gut microbiome (e.g. prebiotics, fibre) however further elucidation

is required on a number of other dietary factors (e.g. gluten, dairy, sugar). We really need research in

this area so I’m so pleased there are dietitians out there exploring the role of nutrition with FMT - watch

this space!

10. Do you have any words of advice to other dietitians currently working within the area of faecal transplant/gut microbiome or those who wanting to work in this area?

• Be open to experimenting with diet modification that may not have a clear evidence base

• Stay current on the rapid pace of research being undertaken in this area of gastro health through non-

traditional means e.g. social media

• Whilst changing the diet to improve the microbiome may be the dietitian’s main focus it’s often

beneficial to work with other relevant clinicians simultaneously for the best results for this group of

patients

• The bottom line is to be encouraging patients to work towards a whole-food diet reducing their reliance

on processed foods, sugar and other foods associated with poor gut health

NICK DUNN

 PR IVATE PRACT ICE DIET IT IAN SPEC IAL IS ING IN NUTR IT ION

THERAP IES FOR FUNCT IONAL GUT DISORDERS INCLUD ING SUPPORT

OF PAT IENTS UNDERGOING FAECAL MICROB IOTA TRANSPLANT      

BY SHAMLEY CHAND

DAA GASTRO IG NEWSLETTER 

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NEW TO PEN

➢ The knowledge pathway- key practise questions

- Q: What are the nutrition and safety challenges and considerations for individuals

following the low FODMAP diet? (Updated 23/01/2017)

http://www.pennutrition.com/KnowledgePathway.aspx?

kpid=23914&pqcatid=146&pqid=23919

- Gastrointestinal systems Irritable bowel syndrome and FODPMAPS- Evidenced

based. (Updated 17/02/2017)

http://www.pennutrition.com/KnowledgePathway.aspx?kpid=23914

- What are the effects of altering the intake of fermentable carbohydrates to improve

irritable bowel syndrome (IBS) symptoms?

http://www.pennutrition.com/KnowledgePathway.aspx?kpid=23914

➢ Client tools

-Eating and drinking with a ilesotomy (updated 12/12/2016)

https://bowelcancerorguk.s3.amazonaws.com/Test%20images/Publications%20/15Ileos

tomy.pdf -Eating and drinking with a colostomy (updated 12/12/2016)

https://73f8c5a452b5820a22c4-

bd125fe96a2f6f84b6be3071341f5c32.ssl.cf3.rackcdn.com/Test%20images/Publications

%20/16Colostomy.pdf

-Core factsheet. Postoperative feeding. Dumping syndrome (updated 12/12/2016)

http://corecharity.org.uk/wp-content/uploads/2016/06/Dumping-syndrome-leaflet.pdf

-Core factsheet. Hepatic disorders. Ascites (updated 02/12/2016)

http://corecharity.org.uk/wp-content/uploads/2016/06/Ascites-leaflet.pdf

RESEARCH/QI IN PROGRESSBY  TRANG SOR IANO   & HANNAH RYR IE

DAA GASTRO IG NEWSLETTER 

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Have you recently undertaken a project or QI activity? Or are you currently working on a project or health

promotion activity? We are interested in hearing from anyone doing amazing work to improve dietetics

practice and patient outcomes. We are looking for a brief outline of projects (300 words), including; aims,

methods, challenges and learning outcomes.

If your project is new or upcoming, not all details may be available - which is fine also! We would still love

to share a brief outline on your project and include the details of the dietitian, team or workplace involved

so other dietitians can see what fabulous projects are expected in the future.

If you have shared a project with us before and would be willing to provide an update we would also love

to hear from you!

If you would like to share your projects in the next edition of the Gastroenterology Newsletter please

contact Trang Soriano (t.nguyen8983@gmail.com) or Hannah Ryrie (hannah.ryrie@gmail.com).

DINER UPDATE BY  HANNAH RYR IE

DAA GASTRO IG NEWSLETTER 

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Keeping Up to Date

The exciting new website has arrived! Below are some new uploads. We are always looking for new Gastroenterology

resources to share. If you are currently using, creating, or developing freely available

apps/resources/podcasts/websites and think others may benenfit, please get in touch to have it included in the

newsletter.

Books

The handbook of clinical nutrition and dietetics

Written by Rowan Stewart

Last reviewed 10 February 2017

Handbook aimed at student dietitians, dietitians, and educators; for the application to clinical dietetics.

Every chapter of the 5th edition has been revised and updated, with the latest dietetic processes and

procedures. $110, available from https://australiandietitian.com/store/bestseller/slkds.html

Food as medicine – cooking for your best health

Written by Sue Radd

Last reviewed 14 December 2016

Content: Cook book containing 150 plant-based recipes to assist clients in prevention and management of

chronic diseases, including recipes from different cultures, seasonal menus, tips for the pantry and more.

$55, available from book stores, online stores and http://foodasmedicine.cooking

Webinars and web presents

Mindful Eating

Webinar presented by Sallyanna Pisk, APD Last reviewed 9 February 2017

This Webinar Covers:

• An introduction to mindfulness and mindful eating

• A guided mindful eating practice

No Cost, available from https://educationinnutrition.com.au/presentations/view/mindful-eating

Nutritional management of stomas

Webinar presented by Dr Sharon Carey, PhD, APD

Last reviewed 21 December 2016

This webinar covers:

• Outline of surgical procedures resulting in stoma formation

• Types of stomas

• The role of the stomal therapist and the Ostomy Association

• Immediate post-operative nutritional management

• Preparing your patient for returning home and long-term post-operative nutrition care

• Troubleshooting nutritional complications, including management of the high-output stoma

$38 through https://educationinnutrition.com.au/presentations/view/nutritional-management-of-stomas

DINER UPDATE  - CONT...BY  HANNAH RYR IE

DAA GASTRO IG NEWSLETTER 

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Nutritional management after upper gastrointestinal surgery Webinar presented by Dr Sharon Carey, PhD, APD Last reviewed 14 December 2016This Webinar covers: • Upper gastrointestinal (GI) surgical procedures: Oesophagectomy, Gastrectomy and Whipple procedure • Pre-operative nutrition management • Immediate post-operative nutrition management • Managing long-term symptoms: Early satiety and anorexia, Vomiting and reflux, Dumping syndrome, Malabsorption, Vitamin and mineral deficiencies $38 from http://www.educationinnutrition.com.au

Type 1 Diabetes and Coeliac Disease Webinar presented by Sally Marchini, APD Last reviewed 21 December 2016 This webinar covers: • Prevalence of type 1 diabetes and coeliac disease • Specific issues for people with type 1 diabetes and coeliac disease • Everyday practical tips • Resources and continuing care $38 from http://www.educationinnutrition.com.au

The International Dysphagia Diet Standard Initiative Webinar presented by Peter Lam, Dietitian, Canada, Co-chair IDDSI Last reviewed 15 December 2016 This webinar covers: $38 from https://educationinnutrition.com.au/presentations/view/the-international-dysphagia-diet-standard- initiative

Professional Resources

Short bowel clinical update PowerPoint presentation by Sarah Leighton Last reviewed 8 November 2016 Contains: Short Bowel Clinical Update from 20 July, Fremantle Hospital WA Available on DINER, no cost

Gastrointestinal food allergy workshop PowerPoint presentation by Vicki McWilliam APD, A/Prof Katie Allen and Katherine Murray APD Last reviewed 7 November 2016 Contains: Was presented at the 2010 DAA national conference. Food protein-induced enterocolitis syndrome (FPIES), - Food allergy-diagnosis and management of IgE and non-IgE food allergy and - Eosinophilic oesophagitis. Available on DINER, no cost

DINER UPDATE  - CONT...BY  HANNAH RYR IE

ISSUE 05

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PIP resources The new Professional Interest Portal (PIP) has arrived! PIP resources are topical and interesting information which may not necessarily have the strength of evidence, in the same way as DINER resources do. PIP resources could include information on emerging practice areas, topics with evidence that is building, or areas of interest for dietitians.

Introduction to the Non-Diet Approach eLearning Program written by Fiona Willer (Health, Not Diets) Last Reviewed March 2016 Content: Self-paced online course is perfect for dietetics students and those new to HAES(R). The course is hosted by the Open Learning platform and includes videos, journal articles, activities, assessment and a certificate of completion. Available from http://www.healthnotdiets.com/online-training

Nutrigenomics Part 1 (An introduction to this emerging field of nutrition science) Webinar presented by Dr Flavia Fayet-Moore, PhD, APD Last reviewed 5 August 2016 The presentation covers: • What is nutritional genomics? • What nutrigenomics means for dietitians – opportunities and potential impact on your practice • Applying nutrigenomics in your practice: caffeine and sodium as examples $38, Available from http://www.educationinnutrition.com.au

Nutrigenomics Part 2 (Applying Nutrigenomics in your practice) Webinar presented by Dr Flavia Fayet-Moore, PhD, APD Last reviewed 5 August 2016 The presentation covers the practical application of the following nutrigenomics tests: • Iron status • Weight management • Food intolerances: gluten and lactose • Eating behaviour: sugar preference and fat taste $38, Available from http://www.educationinnutrition.com.au

MEDICAL UPDATEBY EMMA ARMSTRONG AND TRANG SOR IANO

DAA GASTRO IG NEWSLETTER 

ISSUE 07

Medications

Prucalopride A randomized controlled trial which included 110 patients undergoing elective gastrointestinal sur-gery has found that patients who received oral prucalopride within 24hours after surgery result-ed in a shorter time to defecation, flatus and also decreased length of stay. It was concluded that Prucalopride is a safe and effective treatment to reduce post- operative ileus. Gong, J., Xie, Z., Zhang, T., Gu, L., Yao, W., Guo, Z., Li, Y., Lu, N., Zhu, W., Li, N. and Li, J. (2016), Randomised clinical trial: prucalopride, a colonic pro-motility agent, reduces the duration of post-operative ileus after elective gastrointestinal surgery. Aliment Pharmacol Ther, 43: 778–789. doi:10.1111/apt.13557

Prokinetic agents in critically ill patients receiving enteral nutrition A systematic review has been carried out to as- sess the efficacy and safety of prokinetic agents in critically ill patients receiving enteral nutrition. The review concluded that there is moderate-quality evidence that prokinetic agents reduce feeding intolerance in critically ill patients com-pared to placebo or no intervention. The impact on other clinical outcomes such as moratlity, pneumonia and length of ICU stay is unknown. Lewis, K., Alqahtani, Z., Mcintyre, L., Almenawer, S., Alshamsi, F., Rhodes, A. Alhazzani, W. (2016). The efficacy and safety of prokinetic agents in critically ill patients receiving enteral nutrition: a systematic review and meta-analysis of random-ized trials. Critical Care, 20, 259. http://doi.org/10.1186/s13054- 016-1441-z

cont...14

Nausea and Vomiting

A recent article published looks at conventional therapies (antiemetics and prokinetics) for treat- ing nausea and vomiting, as well as neuromodu- lators of which some may be more effective at treating chronic nausea. A good summary of the physiological mechanism of nausea and vomiting and discussion around new ideas for treating chronic nausea. Singh, P. & Kuo, B. Curr Treat Options Gastro (2016) Central Aspects of Nausea and Vomiting in GI Disorders. 14: 444. doi:10.1007/s11938- 016-0107

Opioid Induced Constipation in cancer patient’s Opioid-induced constipation (OIC) is a major con- tributor to morbidity in cancer patients. This arti- cle reviews the mechanism of OIC and describes the therapeutic options for its prevention and management. Nelson, A. D., & Camilleri, M. (2016). Opioid- induced constipation: advances and clinical guid- ance. Therapeutic Advances in Chronic Disease, 7(2), 121–134. http://doi.org/10.1177/2040622315627801

Literature

Hepatitis C Australian Recommendations for the manage- ment of hepatitis C virus infection: a consensus statement. January 2017

MEDICAL UPDATE - CONT... BY EMMA ARMSTRONG AND TRANG SOR IANO

DAA GASTRO IG NEWSLETTER 

ISSUE 07

15

Liver

ACG Practice Guideline: Evaluation of

Abnormal Liver Chemistries The American

College of Gastroenterology devel-oped a

practice guideline regarding the evalua-tion of

abnormal liver chemistries. These recom-

mendations are intended for use by physicians

and health providers and suggestions of pre-

ferred approaches to the diagnosis and

evalua-tions of abnormal liver chemistries.

Kwo P. Y., Cohen S. M., Lim, J. K., (2016).

ACG Practice Guideline: Evaluation of

Abnormal Liver Chemistries. Am J

Gastrenterol. Doi:10.1038/ajg.2016.517

Ulcerative Colitis

A study examined the link between the levels

of serum Vitamin D with the risk of clinical

relapse in patients with ulcerative colitis.

J. M. Gubatan*, S. Mitsuhashi, T. Zenlea, L.

Rosenberg, S. Robson, A. Moss. (2017).

Vitamin D levels during remission are

associated with the risk of clinical relapse in

patients with ulcerative colitis. Beth Israel

Deaconess Medical Centre, Harvard Medical

School, Division of Gastroenter-ology,

Department of Medicine, Boston, Massa-

chusetts, United States

Inflammatory Bowel Disease

Guideline: Preventative Care in inflammatory

bowel disease Recent statistics suggests that

inflammatory bowel disease patients do not

receive preventa-tive treatments similar to

general medical pa-tients. To improve the care

delivery to IBD pa-tients, these patients should

be co-managed by both gastroenterologist

and general practitioner. The following

guidelines outlines recommenda-tions for

preventative care in IBD patients.

Farraye, F. A., Melmed, G. Y., Lichtenstein, G.

R., and Kane S. V., (2017). Preventative care

in in-flammatory Bowel Disease. Am J

Gastroenterol 2017;112:241-258

Intestinal Failure: Chyme Reinfusion

A 15-year prospective cohort study conducted

in patients with intestinal failure investigated

whether Chyme reinfusion (a technique

consist-ing of extracorporeal circulation of

chyme) could be effective in restoring

intestinal absorption, decreasing the need for

parenteral nutrition (PN), improve nutritional

status and liver tests, as well as the feasibility

of home Chyme reinfusion. Results indicated

that Chyme reinfusion correct-ed intestinal

failure by restoring intestinal ab-sorption and

allowing PN in 91% of patients. Re-sults from

the study also indicated that chime reinfusion

is feasible in the home environment. Picot, D.,

Layec, S., Dussaulx, L., Trivin, F., & Thi-bault,

R. (2016). Chyme reinfusion in patients with

intestinal failure due to temporary double

enterostomy: a 15-year prospective cohort in a

referral centre. Clinical Nutrition.

If you are unable to gain access to full-texts

please contact either Emma Armstrong

(Emma.Armstrong@easternhealth.org.au) or

Trang Soriano (t.nguyen8983@gmail.com)

NUTRITION IN ACTION  CASE STUDY: ANSWERS 

DAA GASTRO IG NEWSLETTER 

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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

self-directed research.

Answers

1. What further information about Ryan’s anatomy do you need to assist with your nutrition assessment and where can this be found?

Anatomy

• Type of gastrectomy: Partial, sub-total or total gastrectomy; proximal, distal, sleeve gastrectomy

• Type of distal gastric anastomosis: Billroth I, Billroth II, Roux-en-y

• How much small bowel and colon are remaining

• The functions of resected organs and their impact on motility, absorption and secretion

Information sources

• History from the patient

• Previous operation reports: both electronic and hand written notes/drawn diagrams

• Medical imaging reports

• History from the surgical team- get them to draw you a picture

• Medical text books and online diagrams

2. What are some nutritional concerns post gastric resection?

• Weight loss- the most significant weight loss is seen in the first 3 months post-surgery. Although a

few patients can show weight gain, very few ever attain their pre-operative weight • Post-prandial

fullness- worse in the first 3-6 months postoperatively

• Nausea, vomiting and anorexia

• Gastric stasis or delayed gastric emptying- incidence in up to 13% of patients, caused by vagus

nerve resection, hypomotility or slow transit though the jejunal limb

• Dumping syndrome- Clinically significant symptoms in 5-10% of patients, however experienced in 25-

50% of patients. Symptoms are worst in the first 3 months post-operatively and can improve over the

first year.

• Fat malabsorption: Many patients experience fat mal-absorption, PERT should be considered and

may contribute to some clinical improvement

• Food intolerances • Small bowel bacterial over growth

• Vitamins and mineral deficiencies

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3. What is the difference between a Billroth I and Billroth II gastrectomy?

Billroth I: The remaining stomach is anastomosed to the duodenum, usually without the pylorus. Billroth II:

the greater curvature of the stomach is connected to the proximal jejunum. The duodenal stump is over

sewn creating a blind loop. The biliary and pancreatic enzymes still flow into the jejunum. Note: There are

some useful diagrams in google images or online medical textbooks

4. What nutrients are you concerned about given Ryan’s anatomy?

Gastrectomy

Fat malabsorption, Iron, Folate, Vitamin B12, Calcium and Vitamin D

Small Bowel Resection

Magnesium, Fat Soluble vitamins (ADEK), Calcium, Vitamin B12

5. What strategies can be used to improve symptoms associated with gastroparesis

Medical strategies used for the management of gastroparesis

• Prokinetics: Erythromycin, Metaclopramide (also has antiemetic properties), Domperidone

• Antiemetics

Diet strategies for the management of gastroparesis

• Recommendations are based on the understanding of gastric physiology.

• Small frequent meals to minimise abdominal fullness, nausea and vomiting

• Texture modification to include more liquids and pureed foods as these empty more easily from the

stomach

• Low fat content

• Low fibre diet is easier for gastric emptying and decreases the risk of bezoar formation

• Enteral Nutrition: Post-pyloric nutrition is preferable as it is less likely to exacerbate symptoms and can

be useful in providing additional nutrition and/ or hydration

• Gastric aspiration or decompression: Either a venting gastrostomy to drain gastric contents if symptoms

are severe. A gastro-jejunal tube may also be considered as this allows medications to be given into the

stomach and/or decompression of the stomach, while post-pyloric feeds and fluid can be administered.

• Enteral nutrition in patients with gastro-paresis should be planned with the surgeon/ radiologist placing

the tube to ensure the correct device is used

• Parenteral nutrition: Useful during acute exacerbation or severe malnutrition, with attempts made to

recommence enteral feeding.

• Medical/ Surgical interventions:

o Gastric Electrical stimulation: has shown to be effective in gastroparesis related to T2DM

but no evidence in post-surgical gastroparesis

o Botulinum Toxin: Evidence suggest that this may not be beneficial

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Tests to assess gastric stasis

• Scintigraphy (Gold Standard)- evaluates the emptying of a standard meal. Gastric emptying is impaired

when >50% of the meal is retained 2 hours post ingestion, or when 10% remains after 4 hours • Isotope

breath test- breath samples are taken post 13C or 14C labelled meal to assess for C02 metabolism •

Ultrasonogrpahy- Unable to assess the emptying of solids

References

APC PERT Guidelines 2015– Chapter 9 PERT post gastric surgery

Bouras E, Vazquez Roque M, Aranda-Michel J. Gastroparesis: From concepts to management. Nutrition in

Clinical Practice 2013 28:4;437-447

Carey S, Ferrie S. Chapter 14: Intestinal Failure in Advances in Medicine and Biology 2011, volume 23,

Nova Science Publishers, Inc.

Nutrition in UGI Surgery 2015 by Emma Osland, available free on Diner

Rogers, C. Postgastrectomy Nutrition. Nutrition in Clinical Practice 2011 26:2;126-136.

https://www.uptodate.com/contents/treatment-of-gastroparesis

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