Doctor's Reference Guide To Dietetics - Diseases/disorders of the stomach, intestines and liver

DISEASES/DISORDERS OF THE STOMACH, INTESTINES AND LIVER

Acute/Chronic Pancreatitis
Chronic Constipation
Celiac Disease and Dermatitis Herpetiformis (DH)
Ulcerative Colitis
Crohn Disease
Cystic Fibrosis
Colonic Diverticulosis and Diverticulitis
Dumping Syndrome
Gastroesofageal reflux
Lactose Intolerance
Cirrhosis of the Liver
Liver Disease
Diarrhea in Toddlers
Irritable Bowel Syndrome (IBS) / Spastic Colon
Short Bowel Syndroom

Acute/Chronic Pancreatitis

Adults

Best time to refer to the dietician:

following diagnosis.

Relevant information for the dietician:

Diagnosis: acute pancreatitis (mild/severe, predictive scores: APACHE-II, Imrie or CRP), chronic pancreatitis (if relevant: exocrine/endocrine dysfunction), cause, potential complications, any comorbid conditions
Symptoms: anorexia, nausea, vomiting, abdominal pain, diarrhea, steatorrhea, edema
Laboratory tests:

serum: amylase, lipase, blood glucose, CRP
urine: amylase, amylase-creatinine clearance ratio.

Medication/Therapy: antacids, pancreatic enzymes, pain relievers, antibiotics, insulin, oral hypoglycemic agents, vintamin/mineral supplements, any surgeries
Other: height, (changes in) weight, alcohol abstinence if relevant

Aims of the diet:

reduce the symptoms
maintain/improve nutritional status

Characteristics of the diet:

Mild acute pancreatitis

oral nutrition is often resumed within 5-7 days: if oral food is not tolerated (increase in upper abdominal pain), start enteral nutrition within 5 days, through a gastric tube, with a feeding tube past the pylorus if necessary due to gastroparesis
Nutritional support is not necessary unless the patient has poor nutritional status.

Severe acute pancreatitis

nothing orally; if enteral feeding is tolerated, administer as soon as possible (the first choice is polymeric feeds, and if these are not tolerated then oligomeric feeds). Administer enteral tube feeds into the jejunum (past the ligament of Treitz). If the gastrointestinal tract is inaccessible and/or intake is inadequate, then (supplement with) parenteral nutrition.
Energy (enriched): basal metabolism (Harris & Benedict) + extra allowances (depending on the severity of the pancreatitis)
Protein-enriched: 1.2-1.5 g/kg of actual body weight
If possible (when hematology results have normalized and pain has decreased) change to oral feeding. Begin with a carbohydrate-rich liquid diet. Then progress to solid foods, if necessary low-fat diet.
After recovery there are no dietary restrictions.
Abstaining from alcohol is necessary only if alcohol was the cause of the pancreatitis.

Chronic pancreatitis

Energy-enriched: basal metabolsim (Harris & Benedict) + extra allowances
Protein-enriched: 1.2-1.5 g/kg of actual body weight
Frequent small meals
No alcohol (regardless of the cause)
For diabetes mellitus: see “Diabetes Mellitus”

An acute exacerbation of chronic pancreatitis can be treated as acute pancreatitis.

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

The literature reflects the fact that there is debate over the best timing and composition of oral nutrition in the recovery phase following acute pancreatitis. Approximately 20% of patients have upper abdominal pain upon resuming oral feeding. The pathophysiology of this is not yet understood.
In the case of chronic pancreatitis with exocrine dysfunction, pancreatic enzymes should be supplemented with every meal that contains fats. The role of pancreatic enzymes as pain medication is controversial.
Eighty percent of patients with chronic pancreatitis can be treated adequately with a normal diet supplemented with pancreatic enzymes; 10-15% of patients need additional oral nutritional supplements, and tube feeding is indicated for 10% of the patients with chronic pancreatitis. PEGJ is indicated in the case of long-term administration of tube feeding. Total parenteral nutrition (TPN) is given only as preparation for surgery if oral nutrition is not possible, but it is never given long term.
In the case of chronic (primarily alcoholic) pancreatitis, supplementation of electrolytes, vitamins and micronutrients may be necessary.

References:

Gaag NA van der, Boermeester MA et al. Behandeling van chronische pancreatitis: stand van zaken, recente inzichten. Ned Tijdschr Geneeskd. 2009;153:232-238

Meier R, Ockenga J et al. ESPEN guidelines on Enteral Nutrition: Pancreas. Clin Nutr 2006; 25:275-284

Petrov MS, Santvoort HC van, et al. Oral Refeeding After Onset of Acute Pancreatitis: A Review of Literature. Am J of Gastroenterology 2007; 102:2079-2084

Acute/chronic pancreatitis was written by Elles Steenhagen, dietician at Universitair Medisch Centrum Utrecht (UMCU), also writing on behalf of the Chirurgisch Overleg Diëtisten Academische Ziekenhuizen (CHIODAZ) and Hermien Noordhoff, dietician at Universitair Medisch Centrum Groningen (UMCG).

Chronic Constipation

Best time to refer to the dietician:

Diagnosis chronic constipation when at least two of the following symptoms are present:

Children

less than three bowel movements per week
paradoxical diarrhea
cessation of bowel movements
painful, hard or pellet-like stools
palpable abdominal and/or rectal fecal mass

Adults

straining in at least ¼ of the attempts at defecation
the sensation of incomplete evacuation of the stool in at least one quarter of all attempts
pseudodiarrhea
hard or pellet-like stools in at least ¼ of all attempts to defecate
fewer than three bowel movements per week

Relevant information for the dietician:

Diagnosis: constipation (habitual, primary, secondary, as a result of motility disorders, possible underlying disorders such as MS, hypothyroidism, any comorbid conditions and/or genetic factors, possible complications (diverticulosis, diverticulitis, hemorrhoids, anal fissures), any comorbid conditions
Medication: laxatives (bulking agents, osmotics, emollient or contact laxatives), medications that have constipation as a side effect (such as psychopharmaceuticals, parasympathicolytics, iron supplements and powerful diuretics)
Other: contact laxative abuse (e.g. senna).

Aims of the diet:

improve the pattern of bowel movements and gastrointestinal symptoms

Characteristics of the diet:

Children

based on national Nutritional Guidelines (quality and quantity adjusted for age), with extra attention to adequate:

fats
dietary fibers: age + 5 g
fluids: infants approx. 150 ml per kg of body weight, children of up to 10 kg 1000-1500 ml per day.

Adults

fluids: 2-2.5 L of fluid, elderly at least 1.7 L
dietary fibers: at least 15 g fiber/1000 kcal and/or aim to increase dietary fiber 10-15 g more than in the current diet.

For all ages, pay special attention to the following:

regular meal pattern with 3 main meals per day, including a big breakfast to stimulate the gastrocolic reflex
variation in the type of dietary fibers consumed, both fermentable and nonfermentable
eat slowly and chew food thoroughly
use caution with products that cause gas, as well as hot spices, coffee, alcohol, tobacco, carbonated drinks, sorbitol and fructose.

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

The dietician pays special attention to:

the relationship between eating habits, lifestyle and constipation, especially in the case of chronic constipation
physical activity
regular bathroom visits and giving in to the urge to defecate
adequate rest and relaxation
dietary habits based on myths: the presumed constipating or purging effects of foods

An increase in dietary fiber without a corresponding increase in fluids has the opposite effect.
During the initial phase of dietary treatment, an increase in dietary fibre may lead to a worsening of symptoms.
Bulking agents should only be used when necessary to supplement the amount of fiber in the diet.
Some medications can promote constipation.

References:

Graham MG, Mokrynski G. Evidence based management of chronic constipation. Patient Care: 2007

Heitkemper M, Wolff J. Challenge in chronic constipation management. Nurse Practitioner, 2007

Liu BH, Yang XQ. Efficacy of cellulose on functional constipation. Zhonghua Wei Chang Wai Ke Za Zhi. 2009 Mar;12(2):182-4

Nederlandse Vereniging voor Kindergeneeskunde/Nederlands Huisartsen Genootschap. Richtlijn Obstipatie bij kinderen van 0 tot 18 jaar. Utrecht: 2009

Spinzi G, Amato A et al. Constipation in the elderly: management strategies. Drugs Aging. 2009;26(6):469-74. doi: 10.2165/00002512-200926060-00003

Chronic Constipation was updated by Marije van Dun en Zindia Nanver, students at Voeding & Diëtetiek, Haagse Hogeschool (HHS).

Celiac Disease and Dermatitis Herpetiformis (DH)

Best time to refer to the dietician:

immediately after finding atrophy of the villi / after establishing the diagnosis of celiac disease (synonym: gluten intolerance) and/or dermatitis herpetiformis (DH) (synonym: Duhring disease).

Relevant information for the dietician:

Diagnosis: celiac disease (Marsh classification IIIA-C) and/or DH, any comorbid conditions (specifically, diabetes mellitus type I, thyroid abnormalities)
Celiac symptoms: chronic diarrhea, constipation, abdominal pain, weight loss, failure to thrive, anemia (unexplained), osteoporosis, chronic fatigue, generalized or lactose malabsorption, delayed puberty, menstruation and fertility disorders, aphthous ulcers, hypoplasia of tooth enamel
Symptoms of DH: highly pruritic skin eruptions with eczematous vesicles, bumps and blisters.
Laboratory tests:

Serological testing: IgA antibodies for endomysium (EMA) and transglutaminase type 2 (tTGA): the IgA-tTGA are usable at the follow-up. If there is an IgA deficiency in children, the anti-gliadin IgG antibodies (IgG AGA) are measured. In familial diagnostic screening, AGA diagnostic testing in adults is now considered to be obsolete HLA typing.
Follow-up: hemoglobin (Hb), mean corpuscular volume (MCV), iron levels, vitamin B12, folic acid, tTGA
Histology: villous atrophy with crypt hyperplasia and an increase in intraepithelial lymphocytes (Marsh classification IIIA-C)
Bone density test (DEXA scan) for diagnosing celiac disease an adult.

Medication: corticosteroids, azathioprine, vitamin and mineral supplements, dapson (for DH).
Other: height, (changes in) weight .

Aims of the diet:

improve/restore the damaged villi of the small intestine
maintain/restore normal growth / nutritional status
improve/prevent symptoms
improve/prevent complications

Characteristics of the diet:

Gluten-free diet
If symptoms persist 6-12 months after starting the diet, possibly restrict the use of (food products made with) gluten-free wheat starch
For DH: combination of dapsone and a gluten-free diet
Ensure adequate intake of dietary fiber, iodine, iron, vitamin B1, folic acid
lactose-free in the case of lactose intolerance; see “Lactose intolerance.”

Treatment time:

Care level 3*, see “Dietician’s working methods.”

Specific remarks:

Lactose malabsorption usually recovers spontaneously (secondary to villous atrophy)
Recovery of damaged intestinal villi can take up to 5 years, depending on age and how long the disease has been present. Some cases will not fully recover.
Dietary noncompliance poses a greater risk for developing osteoporosis and the symptoms listed above. In the elderly, if the diagnosis was made at a more advanced age (> 50 years), extra attention should be given to monitoring malignancies (T-cell lymphoma).
In patients with diabetes mellitus type I whose diabetes remains difficult to regulate despite good compliance, celiac disease should be considered a comorbidity (prevalence 3-8%).
Medications and vitamin and mineral supplements sometimes contain wheat starch (traces of gluten); the package insert/ingredients should be read carefully.
Calcium supplementation at 1000 mg per day is necessary when oral intake is inadequate and the lab tests showed low serum levels.
A gluten challenge can be performed to diagnose celiac disease in patients who have started a gluten-free diet without first having had a biopsy, with serologic test results and a biopsy result of Marsh classificatie I or II.
For DH, both the skin and the intestinal disease respond well to a gluten-free diet, in which case the medication can sometimes be reduced or discontinued.

References:

Bastiani W. Coeliakie. In: Handboek Dieetbehandelingsrichtlijnen. Maarssen: Elsevier gezondheidszorg; 2009

Corazza, GR Stefano M et al. Bones in coeliac disease : diagnosis and treatment. Best Practice & Research Clinical Gastroenterology 2005; 19: 453-465

Mearin ML, Kneepkens CMF, Houwen RHJ. Diagnostiek van coeliakie bij kinderen; richtlijnen van kindergastro-enterologen. Nederlands Tijdschrift voor Geneeskunde 1999;143:451-455

Nederlandse Vereniging van Maag-Darm-Leverartsen. Richtlijn Coeliakie en Dermatitis Herpetiformis. Haarlem: 2008

Wolters VM, Nadort C et al. Is gluten challenge really necessary for diagnosis of coeliac disease in children younger than 2 years? J Pediatr Gastroenterol Nutr 2009 May; 566-70

Celiac Disease and Dermatitis Herpetiformis was written by the Diëtisten Info Netwerk Coeliakie (DINC), contact person Wieke Bastiani, dietician at Amphia Ziekenhuis.

Ulcerative Colitis

Best time to refer to the dietician:

When ulcerative colitis is diagnosed, combined with at least one of the following:

an exacerbation
suspected malnutrition
complications

Relevant information for the dietician:

Diagnosis: ulcerative colitis, possible complications, intestinal stoma (if present), ileostomy, IRA (ileorectal anastomosis), IPAA (ileal pouch-anal anastomosis, or “pouch”), ileorectal anastomosis, any comorbid conditions
Symptoms: abdominal pain, diarrhea, failure to thrive / weight loss, anemia, fever, fatigue
Laboratory tests: CRP, albumin
Medication: mesalazine preparations, corticosteroids, immunosuppressants, Remicade® (infliximab), antibiotics, VSL3® (probiotic), vitamin and mineral supplements (iron)
Other: height, (changes in) weight, elimination pattern

Aims of the diet:

reduce the symptoms
support the medicinal treatments
maintain/achieve good growth curve / nutritional status
maintain/improve the fluid, mineral and electrolyte balance.

Characteristics of the diet:

Ulcerative colitis in remission

normalization of nutrient deficiencies
in the case of malnutrition: see “Weight Loss / Malnutrition”, if necessary with additional dietary products

Inflammation of the entire colon (pancolitis)

energy-enriched: resting/basal metabolism (Schofield/Harris & Benedict) + extra allowances
protein-enriched: the requirement depends on the disease activity
high sodium and fluids: depending on diuresis and elimination in diarrhea

Toxic megacolon

nothing orally
parenteral nutrition

Inflammation of the last section of the colon and the rectum (proctitis)

recommended allowances based on national Nutritional Guidelines
extra fluids: amounts depending on the urine volume
for IRA, IPAA, INRA (ileoneorectal anastomosis), (sub)total colectomy with ileoanal anastomosis (with reservoir/pouch):

extra fluids: depending on urine volume
extra sodium: depending on urine volume, sodium in the urine and how much diarrhea. Salt capsules may need to be taken.
solid foods should be taken with liquids
be aware of food products that can cause gas

probiotics in the form of VSL#3® are effective in preventing recurrence of pouchitis and preventing pouchitis directly after placement of an ileoanal pouch
individual customization of product and meal choice, taking into account food interolerances and completeness of the nutrition
for ileoostomy: see “Ileostomy”
for colostomy: based on national Nutritional Guidelines

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

Dietary intervention is important to facilitate catch-up growth in children during long-term remission.
Despite indications that supplementing omega-3 fatty acids might contribute favorably to the induction and maintenance therapy of ulcerative colitis patients, there is not enough evidence for this to recommend it for general use.
In the case of IPAA, INRA, over the long term the may thicken and the frequency of stools may decrease.
During puberty and in long-term use of > 7.5 mg corticosteroids per day, pay extra attention to calcium and vitamin D.

References:

Beijer S. Dieetbehandelingsrichtlijn inflammatoire darmziekten, Elsevier. 2006

CBO. Richtlijn Diagnostiek en Behandeling van Inflammatoire Darmziekten bij Volwassenen. Utrecht: 2006

Lochs H, Dejong C, Hammarqvist F. Espen guidelines on enteral nutrition: Gastrenterologie. Clinical Nutrition 2006, 25, 260-274

Ulcerative Colitis was updated by Anneke Donker, dietician at Leids Universitair Medisch Centrum (LUMC), writing also on behalf of the dietician network Maag Darm Lever (MDL).

Crohn Disease

Best time to refer to the dietician:

Diagnosis of Crohn disease combined with at least one of the following:

an exacerbation
suspected malnutrition
complications

Relevant information for the dietician:

Diagnosis: Crohn disease, inflammation/stricture and location, fistulae, bowel resections that have been performed (including length, site, and whether they do or do not include intestinal stoma), any complications, comorbidity
Symptoms: abdominal pain, diarrhea, bloody stools, failure to thrive / weight loss, anemia, fatigue, fever, frequency of inflammations
Laboratory tests: CRP, albumin
Medication: mesalazine preparations, corticosteroids, immunosuppressants, Remicade® (infliximab), Humira®, vitamin and mineral supplements
Other: height, (changes in) weight, elimination patterns (amount, composition).

Aims of the diet:

reduce symptoms
promote remission
support the medicinal treatment
maintain/achieve good growth curve / nutritional status
maintain/improve fluid, mineral and electrolyte balance
normalize nutritional deficiencies, paying specific attention to absorption problems.

Characteristics of the diet:

Crohn disease in remission:

Recommended allowances based on national Nutritional Guidelines
Normalization of nutrient deficiencies
If malnutrition exists, see “Weight loss / Malnutrition,” if necessary with additional dietary supplements

Exacerbation of Crohn disease:

Energy-enriched: resting/basal metabolism (Schofield/Harris & Benedict) + extra allowances
Protein-enriched: requirement depends on disease activity
Tube feeding: for children, total tube feeding (for 6 weeks) is the primary therapy; for adults, tube feeding should be considered to support the medicamentous treatment.
High fistulae: tube feeding past the fistula, and/or parenteral nutrition
Hyperoxaluria:

Extra fluids: at least 1.5 L + losses (diuresis/stool)
Fats: based on national Nutritional Guidelines, if necessary with calcium supplementation
Oxalate restriction is only useful when there are recurring kidney stones.

Stricture in the small intestine: depending on the nature and site of the stricture:

avoid coarse dietary fibers
consistency: ground or puréed / liquid
enteral and/or parenteral nutrition.

Resection of terminal ileum and adequate intake

supplement the fat-soluble vitamins if tests show a deficiency and vitamin B12 (by injection)
tube feeding and/or parenteral nutrition.

Additional dietary supplements in the event of reduced food intake
For short bowel symdrome: see “Short Bowel Syndrome”
For ileostomy: see “ileostomy”
For lactose intolerance: see “lactose intolerance”
For colostomy: see national Nutritional Guidelines.

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

Nutrition and diet can play a primary therapeutic role in the treatment of adult Crohn disease patients.
Intestinal resections, chronic active disease, short bowel syndrome, intestinal failure, pancreatic insufficiency and ileostomy elevate the risk of clinically relevant deficiencies.
Certainly in children, remission is largely achievable if enteral tube feeding is used until the child has stopped growing.
During puberty and with long-term use of > 7.5 mg corticosteroids per day, pay extra attention to calcium and vitamin D intake.
In the case of low serum values in laboratory results, supplement vitamins and minerals, especially magnesium, zinc and iron. In the case of ileocecal resection, supplement vitamin B12 and folic acid.
There is insufficient evidence for the treatment and prevention of Crohn disease with probiotics. Neither has a meaningful role been demonstrated in maintaining remission.
Supplementing omega-3 fatty acids (as monotherapy) for Crohn disease patients has no consistently beneficial effect on keeping Crohn disease in remission.
Enteral nutrition aimed at maintaining remission may reduce the use of corticosteroids and immunosuppresants, and thus also their adverse effects. Long-term nutritional therapy and the avoidance of corticosteroids also leads to improved growth in children and adolescents.

References:

Akobeng AK, Thomas AG. Enteral nutrition for maintenance of remission in Crohn’s disease (Review), The Cochrane collaboration; the Cochrane library 2009, Issue 4

Beijer S. Dieetbehandelingsrichtlijn inflammatoire darmziekten, Elsevier, 2006

CBO. Richtlijn Diagnostiek en behandeling van inflammatoire darmziekten bij volwassenen. Utrecht: 2006

Lochs H, Dejong C, Hammarqvist F. Espen guidelines on enteral nutrition: Gastrenterologie. Clinical Nutrition 2006, 25, 260-274

Razack R, Seidner DL, Nutrition in inflammatory bowel disease Curr Opin Gastroenterol 23:400-405, 2007

Crohn disease was updated by Anneke Donker, dietician at Leids Universitair Medisch Centrum (LUMC), also writing for the network of dieticians Maag Darm Lever (MDL)

Cystic Fibrosis

Best time to refer to the dietician:

following diagnosis

Relevant information for the dietician:

Diagnosis: cystic fibrosis (CF), any comorbid conditions such as pancreatic insufficiency, CF-related diabetes (CFRD), distal intestinal obstruction syndrome (DIOS)
Symptoms: steatorrhea, acute or chronic malnutrition / unintended weight loss, recurrent respiratory infections
Laboratory tests: fecal fat excretion, glucose day curve with postprandial glucose testing, if necessary combined with continuous glucose monitoring (CGM)
Medication: antibiotics, pancreatic enzymes, antacids, insulin, corticosteroids, laxatives, fat-soluble vitamin supplements
Other: height, (changes in) weight, growth curve, bioelectrical impedance analysis (BIA) as needed (for adults), pulmonary function tests

Aims of the diet:

maintain/achieve good nutritional status

Characteristics of the diet:

Energy-enriched: 100-150% of the recommended dietary allowance, depending on the individual energy requirements. The total individual energy requirements can be assessed on the basis of clinical observation, (growth) and nutritional status. Determining energy requirements based on resting/basal metabolism (the Schofield/Harris & Benedict equation) + extra allowances (up to 50%) often turns out to underestimate the need, in practice, in the case of CF patients.
Protein-enriched: for catch up growth / weight gain, and for respiratory infections

children

9-15% of total caloric intake in the case of chronic malnutrition

adults

1.6-2.0 g/kg of body weight for adults

Fats: recommended daily allowance, with at least 2% of total caloric load in the form of polyunsaturated fatty acids
Supplementing vitamins A, D, and E is standard, vitamin K according to indication
extra sodium in the event of hot weather, fever, diarrhea or strenuous physical exercise
for CFRD: treatment with insulin and, as needed, continuation of energy-enriched diet; for more information see “Diabetes Mellitus”
for DIOS: adequate fluid intake, optimal enzyme supplementation and oral laxatives.

Treatment time:

Care level 3*, see “Dietician’s working methods.”

Specific remarks:

Multidisciplinary approach: Given the complexity of treatment, the patient with CF must be treated within a multidisciplinary team. The core disciplines involved are: (pediatric) pulmonologist, gastroenterologist, internist, physiotherapist, dietician, CF nurse specialist, psychologist and social worker.
In the case of exocrine pancreatic insufficiency, pancreatic enzymes should be supplemented with every meal, snack or liquid meal that contains fats, and with enteral nutrition.
when advising the specific amounts and the distribution of pancreatic enzymes, aim for the following fecal fat excretion percentage: < 20% for infants; < 15% for children up to 3 years old; < 7% for children over age 3 and for adults.
If oral food intake is insufficient, additional dietary supplements or enteral nutrition are often given, if necessary via a percutaneous endoscopic gastrostomy (PEG).
Additional enteral nutrition should be given at night, if possible.

References:

CBO. Richtlijn Diagnostiek en Behandeling Cystic Fibrosis. Utrecht: 2007

Sinaasappel M, Stern M et al. Nutrition in patients with cystic fibrosis: a European Consensus. J Cystic Fibrosis 2002;1(2):51-75

Taminiau JAJM, Meer K de et al, editors. Werkboek enterale voeding bij kinderen. Amsterdam: VU Boekhandel/Uitgeverij B.V.: 1997; 9-18. See also www.stuurgroepondervoeding.nl > ziekenhuis > toolkit kinderen

Winder-Bakker E, Vries JHM de, Hollander-Kraayeveld FM. Cystic Fibrosis. In: Handboek Dieetbehandelingsrichtlijnen, Maarssen: Elsevier gezondheidszorg; 2002

Cystic fibrosis was updated by Eefje Winder-Bakker, dietician at Medisch Centrum Alkmaar (MCA), Francis Hollander, dietician at Universitair Medisch Centrum Utrecht (UMCU) and Inge de Meer, dietician at Academisch Medisch Centrum (AMC), writing also on behalf of Werkgroep Diëtisten Volwassenen met Cystic Fibrosis (DVCF).

Colonic Diverticulosis and Diverticulitis

Adults

Best time to refer to the dietician:

following diagnosis.

Relevant information for the dietician:

Diagnosis: colonic diverticulosis, colonic diverticulitis (if relevant, complications such as fistulae, inflammation of the surrounding tissues/organs, perforations, abcess, peritonitis, diverticular bleeding, local edema with intestinal obstruction), any comorbid conditions.
Symptoms:

colonic diverticulosis: colic pain or constant abdominal pain, constipation and/or diarrhea, flatulence, mucus and/or blood in the stool, dyspeptic symptoms, bloating
diverticulitis coli: (colicky) abdominal pain, fever, in addition to flatulence, nausea, vomiting, severe diarrhea or severe constipation, bloody stools, anorexia, dyspeptic symptoms.

Medication: bulking agents, osmotic laxatives, contact laxatives, antispasmodics, antibiotics, pain relievers, opioid drugs, parasympatholytic drugs, calcium and aluminum salts, loop diuretics, iron supplements
Other: any misuse of (natural) laxatives.

Aims of the diet:

for colonic diverticulosis: relieve symptoms and prevent complications
for colonic diverticulitis: heal infection and inflammation and rest the bowels.

Characteristics of the diet:

Colonic diverticulosis

follow national Nutritional Guidelines with adequate dietary fiber: 3.4 g/MJ per day, balance between fermented and unfermented fibers, if necessary fiber-enriched diet (at least 15 g/1000 kcal and/or aim for at least 10-15 g more than the ordinary diet)
in the case of healthy and complete nutrition with adequate fiber: 2 L drinking fluids
in the case of fiber-enriched diet: 2-2.5 L drinking fluid
regular meals with a big breakfast in order to promote the gastrocolic reflex
eat slowly and chew food well

Colonic diverticulitis

nothing by mouth in the acute phase: for mild forms of uncomplicated diverticulitis (clear) liquid meals without pits, seeds or pulp, low-residue liquid meals or tube feeding; enteral or parenteral feeding for severe forms.

Treatment time:

Care level 2, see “Dietician’s working methods.”

Specific remarks:

Physical exercise stimulates passage in the colon.
Give in to the urge to defecate.
Avoid tension and stress.
Avoid foods that aggravate symptoms.
Use laxatives only on doctor’s prescription.
Wearing tight clothing is not advisable.
If overweight, losing weight can be beneficial.

References:

Lanschot JJB van, Gouma DJ et al. Gastro-intestinale chirurgie en gastroenterology in onderling verband. Houten: Bohn Stafleu Van Loghum 1999. p. 344–50

Maag Lever Darm Stichting. Divertikels en diverticulitis. Nieuwegein: 2002

Marel-Sluijter S van der. Diverticulziekte en IBS. In: Handboek Dieetbehandelingsrichtlijnen.

Maarssen: Elsevier gezondheidszorg; 2009

Colonic Diverticulosis and Diverticulitis was written by Saskia Tabak, dietician at Universitair Medisch Centrum Groningen (UMCG), also on behalf of the dietician network Maag Darm Lever (MDL) and Sigrid van der Marel-Sluijter, student of Nutrition and Dietetics at Haagse Hogeschool

Dumping Syndrome

Adults

General information:

Dumping syndrome is present when the release of food into the small intestines is too rapid. The etiology is not yet well understood. Symptoms develop only after consuming food and fluids; the person is symptom-free when fasting. Nutritional counseling is the first choice in treating dumping syndrome. In a small group of patients, dumping symptoms persist despite dietary guidelines. Early dumping (10-30 minutes postprandial) or a combination of early and late dumping (1-3 hours postprandial) are most common. Late dumping alone is less common. Severe dumping symptons can result in weight loss, fear of eating, and malnutrition.

Best time to refer to the dietician:

following diagnosis
when starting oral load, after surgery that involves the risk of dumping

Relevant information for the dietician:

Diagnosis: dumping syndrome can occur after any gastric surgery, including bariatric surgery when the vagus nerve is damaged (e.g. in esophageal surgery), pyloroplasty and pylorectomy, any comorbid conditions. Not all postprandial hypoglycemic conditions can be attributed to dumping syndrome.
Symptoms:

Early dumping is distinguished by symptoms caused by the osmotic reaction to food in the small intestine, including abdominal cramps, nausea, diarrhea, bloating, heart palpitations, sweating, dizziness, headache, fatigue and/or weakness
Late dumping is distinguished by symptoms caused by reactive hypoglycemia, including sweating, tremors, weakness, difficulty concentrating, diminution of consciousness, confusion and/or hunger (with yawning).

Medication: acarbose (Glucobay®) and octreotides (Sandostatin®)
Other: height, (changes in) weight

Aims of the diet:

reduce symptoms
maintain/improve nutritional status

Characteristics of the diet:

Frequent small meals
Chew well and eat slowly.
Mainly high osmolar liquid food and meals rich in carbohydrates are poorly tolerated:

limit consumption of drinks with meals
restrict mono- and disaccharides, as they increase relative intake of fats and protein.

Try milk (dairy products) in small amounts. These are not always well tolerated. Cultured dairy products are sometimes better tolerated.
For malnutrition: see “Weight Loss / Malnutrition”

Treatment time:

Care level 1, see “Dietician’s working methods.”

Specific remarks:

If the dietary recommendations have inadequate effect, it can be helpful to rest for half an hour after a meal or to ingest liquid foods in a half-reclining position.
Soluble, fermentable, viscous fibers such as pectin, (guar) gums (Resource®, Opti Fibre®), oligosaccharides and undigestible starches delay gastric emptying and passage through the small intestine in the normal stomach. Discuss with the doctor whether it is advisable to try these products if symptoms of (late) dumping persist.
Lactase deficiency and gluten intolerance sometimes manifest only after gastric surgery. Symptoms partially overlap with those of dumping syndrome.
There is a risk of steatorrhea (if octreotide is necessary, this risk increases) and with it, over the long term, anemia, osteomalacia and osteoporosis.
It may be necessary to supplement the fat-soluble vitamins A and D, vitamin B12, calcium, iron and folic acid (in particular when steatorrhea is present and following bariatric surgery).
After bariatric surgery, hyperplasia of islets of Langerhans or nesidioblastosis may be a complication. Isulinoma should be ruled out.
Sometimes it is necessary to keep a diary of foods being eaten.

References:

Hasler W. Dumping Syndrome. Current Treatment Options in Gastroenterology, 2002;5:139-45

Tack J, Arts J et al. Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nature Reviews Gastroenterology and Hepatology 2009; 6, 583-590

Toh SY, Zarshenas N, Jorgensen J. Prevalence of nutrient deficiencies in bariatric patients. Nutrition. 2009 Nov-Dec;25(11-12):1150-6

Ukleja A. Dumping syndrome: Pathophysiology and treatment. Nutr Clin Pract 2005 20(5): 517-525

Vecht J, Masclee A, Lamers C. The Dumping Syndrome. Current Insights into Pathophysiology, Diagnoses and Treatment. Scand. J. gastroenterol 1997;32(Suppl 223):21-7

Dumping Syndrome was updated by Anneke Droop, dietician at Leids Universitair Medisch Centrum (LUMC) and Monique van Kemenade, dietician at Erasmus Medisch Centrum, writing also on behalf of the Chirurgisch Overleg Diëtisten Academische Ziekenhuizen (CHIODAZ).

Gastroesofageal reflux

Best time to refer to the dietician:

following diagnosis

Relevant information for the dietician:

Diagnosis: gastroesophageal reflux disease, any comorbid conditions
Symptoms:

Infants (in the case of primary pathophysiological reflux)

nutrient deficiencies, esophagitis, stricture formation, laryngitis, pulmonary disorders, apnea

Adults

acid stomach, regurgitation, dysphagia, odynophagia, retrosternal pain, bloating, belching, hoarseness, laryngitis, chronic cough, hypersecretion of saliva, globus pharyngeus, benign stricture formation

Medication:

medications that aggravate reflux symptoms: antiepileptics, xanthine derivatives, parasympatholytic drugs, calcium antagonists in the nifedipine class of drugs, anticholinergic drugs, psychopharmacologic medications, cardiovascular drugs, antacids, metoclopramide
medications that reduce reflux symptoms: proton pump inhibitor, H2 receptor antagonists, prokinetic drugs.

Other: height, (changes in) weight

Aims of the diet:

Infants

maintain/optimize growth curve.

Adults

reduce symptoms by achieving healthy body weight (BMI 20-25 kg/m²)
aim for normoglycemia
optimize/improve elimination pattern

Characteristics of the diet:

Infants

symptoms of uncomplicated reflux in children can be limited by thickening food.

Adults

ample dietary fiber and fluid intake
limited consumption of alcohol
limited consumption of fats
reduced portion sizes and increased frequency of meals
spread food throughout the day
if necessary, eliminate foods that influence LES pressure, acid secretion and/or pH
if overweight, see “Overweight”

Treatment time:

Care level 1, see “Dietician’s working methods.”

Specific remarks:

Promote healthy habits:

smoking cessation
adjust position when lying down or sleeping (do not lie down immediately after a meal, and elevate the head at a 30-35° angle, lie on the left side)
adjust posture (do not bend over from the waist)
do not wear tight-fitting clothing
healthy exercise

References:

Flos R. Dieetbehandelingsrichtlijn peptische reflux. In: Dieetbehandelingsrichtlijnen.

Elsevier, Bunge: 2005

Nilsson M, Johnsen R et al. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004 Dec;53(12):1730-5

Penagini R, Mangano M, Bianchi PA. Effect of increasing the fat content but not the energy load of a meal on gastro-oesophageal reflux and lower oesophageal sphincter motor function. Gut. 1998 Mar;42(3):330-3

Terry P, Lagergren J et al. Reflux-inducing dietary factors and risk of adenocarcinoma of the esophagus and gastric cardia. Nutr Cancer. 2000;38(2):186-91

Zhang Q, Horowitz M et al. Effect of hyperglycemia on triggering of transient lower esophageal sphincter relaxations. Am J Physiol Gastrointest Liver Physiol. 2004 May;286(5):G797-803

Gastroesophageal reflux was updated by Liesbeth Haverkort, dietician at Academisch Medisch Centrum (AMC) and Marjan Mullers, dietician at Maastricht Universitair Medisch Centrum (MUMC+), also on behalf of Chirurgisch Overleg Diëtisten Academische

Ziekenhuizen (CHIODAZ).

Lactose Intolerance

Best time to refer to the dietician:

when lactose intolerance is suspected, to confirm or rule out the diagnosis
following diagnosis

Relevant information for the dietician:

Diagnosis: congenital, primary or secondary lactose intolerance, any comorbid conditions
Symptoms: nausea, vomiting, borborygmus (stomach growling), meteorism (bloating), (chronic) abdominal pain, abdominal cramps, diarrhea, flatulence
Laboratory tests: results of hydrogen breath test or other diagnostic testing
Medication: lactase enzymes, calcium and/or vitamin supplements.

Aims of the diet:

reduce symptoms
maintain/achieve complete nutrition.

Characteristics of the diet:

Lactose-restricted, depending on the degree of intolerance:

5-10 g lactose per day is generally well tolerated. Some people may tolerate more than this.
Cultured dairy products are better tolerated than non-cultured.
Milk is better tolerated if it is taken spread over the course of the day in combination with meals.
If lactose restriction still gives problems: restrict lactose further or go lactose-free.

Use of lactase enzyme, as needed
Follow national Nutritional Guidelines, with extra attention to calcium and vitamin B2.

Treatment time:

Care level 1, see “Dietician’s working methods.”

Specific remarks:

Secondary lactose intolerance is usually temporary. If the underlying disorder has been cured or is being treated, the lactose intolerance will improve or fully resolve.
The tolerance threshold of lactose may increase when intestinal flora adjust to the amount of lactose
In the event of acute gastroenteritis in infants, it is recommended to continue breastfeeding.
Primary lactose intolerance is more common in people originating from Africa, South America, Asia or the Mediterranean than in West European countries
Toothpaste and medications often contain lactose.

References:

Genuchten-Gessner S van. Lactose-intolerantie. In: Handboek Dieetbehandelingsrichtlijnen.

Maarssen: Elsevier gezondheidszorg; 2003

Kneepkens CMF. Lactosemalabsorptie: oorzaken en klinische consequenties. Huisarts Wet 2000;43:465-8,477

McBean LD, Miller GD. Allaying fears and fallacies about lactose intolerance. J Am Diet Assoc 1998;98:671-76

Stefano MG di, Veneto S et al. Lactose malabsorption and intolerance in the elderly. Scand J Gastroenterol 2001;36:1274-8

Vries S de, Schaafsma E. Lactose in farmaca geeft geen problemen. Pharmac Weekblad 1998;133(16):650

Lactose Intolerance was updated by Jacqueline Lancel, dietician at Careyn and Nicole van Houdt, dietician at Universitair Medisch Centrum Nijmegen (UMCN), also writing on behalf of Diëtist & Voedselovergevoeligheid (D&VO) and Voedselovergevoeligheid Overleg Diëtisten

Academische Ziekenhuizen (VOODAZ).

Cirrhosis of the Liver

Adults

Best time to refer to the dietician:

Diagnosis of cirrhosis of the liver with at least one of the following:

decompensated liver cirrhosis
suspected malnutrition

Relevant information for the dietician:

Diagnosis: etiology, complications, any comorbid conditions, Child-Pugh class
Symptoms: anorexia, nausea, vomiting, reduced consciousness, abdominal pain, fatigue, weight loss, itching, icterus
Laboratory tests: bilirubin, INR, albumin, vitamins A, D, E, K, B1 and B12, zinc, magnesium and folic acid, HbA1c, glucose, sodium, liver function tests
Medication: diuretics (furosemide, spironolacton), lactulose corticosteroids, vitamins / minerals / trace elements
Other: height, (changes in) weight, TIPS, on wait list for OLTX, degree of ascites (estimated)

Aims of the diet:

reduce symptoms/complications
maintain/improve nutritional status
support the medication

Characteristics of the diet:

Energy enriched: basal metabolism (Harris & Benedict) + extra allowances
Protein enriched: 1.2-1.5 g protein/kg ideal weight (the requirement depends on the severity of the liver cirrhosis)
Frequente meals (4-7 x per day)
Small meal before bedtime with carbohydrates and protein (related to nitrogen balance at night) and a good breakfast as soon as possible after rising
No alcohol

Ascites

Restricted sodium: not to exceed 2000 mg per day
Restricted fluids: for hyponatremia (< 125 mmol/L)

Encephalopathy

Protein-enriched: 1.2-1.5 g protein/kg ideal weight

Cirrhosis of the liver with complications

osteoporosis: see “Osteoporosis”
malnutrition: see “Weight Loss / Malnutrition”

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

Restricting dietary fat to less than recommended allowances is not advisable for liver disease.
It is not necessary to restrict protein intake in the case of encephalopathy.
Edema and ascites may mask weight loss. In this case it is recommended to make calculations based on upper arm (muscle) circumference and to use functional parameters such as grip strength to determine the nutritional status.
Supplementation of vitamins A, D, E, K, B complex, iron, calcium, zinc, selenium, potassium and magnesium or a multivitamin and mineral supplement may be necessary.
The diagnosis of encephalopathy is based on clinical signs and symptoms and, if relevant, the blood levels of ammonia. These levels do not correlate with the degree of encephalopathy.

References:

Merli M, Riggio,O. Dietary and nutritional indications in hepatic encephalopathy, Metab Brain Dis (2009)24:211-221

Moore KP, Aithal GP. Guidelines of the management of ascites in cirrhosis. Gut 2006;55(Suppl. V1):Vi1-Vi122. doi:10.1136/gut.2006.099580)

O’Brian A, Williams R. Nutrition in End-Stage Liver Desease: Principles and Practice. Gastrenterology 2008; 134:1729-1740

Plauth M, Cabre E et al. ESPEN Guidelines on Enteral Nutrition: Liver disease Clinical Nutrition (2006) 25, 285–294

Schulz, GJ, Campos ACL, Coelho JCU. The role of nutrition in hepatic encephalopathy; Current Opnion in Clinical Nutrition and Metabolic Care, 2008, 11;275-280

Cirrhosis of the Liver was updated by Anneke Donker, dietician at Leids Universitair Medisch Centrum (LUMC), writing also on behalf of the dieticians’ network Maag Darm Lever (MDL) Diëtisten

Liver Disease

Children

Best time to refer to the dietician:

Diagnosis of liver disease in combination with at least one of the following:

impaired digestion and absorption
underweight / failure to thrive
abnormal habits compared to what is normal for child’s age.

Relevant information for the dietician:

Diagnosis: liver disease and type (such as extrahepatic biliary atresia, acute or chronic hepatitis, Alpha-1-antitrypsine deficiency), any comorbid conditions, operations such as the KASAI procedure)
Laboratory tests: bilirubin, ammonia, amino acids, albumin, glucose
Medication: diuretics, fat-soluble vitamins, minerals, lactulose
Other: height and changes in weight (growth curve), cranial circumference (under age 2), upper arm circumference, biceps en triceps skin folds, ascites and/or edema.

Aims of the diet:

maintain/achieve good growth curve / nutritional status
prevent vitamin and mineral deficiencies
prevent hypoglycemia
limit a delay in motor development
teach good dietary habits based on normal eating habits for age.

Characteristics of the diet:

Energy-enriched: depends upon the extent of impaired digestion and of underweight / failure to thrive
Protein (enriched):

aim for 2 - 3.5 g/kg ideal body weight
foods of high biological value, distributed throughout the day
for encephalopathy: protein: 1-1.5 g/kg ideal body weight

Fats:

preference for emulsified fats
ensure adequate amounts of essential fatty acids
severe cholestasis: fats should be partially in the form of medium chain triglycerides (MCT) as an energy source
carbohydrates: for hypoglycemia, have frequent meals and meals during the night (if necessary, via continuous enteral tube feeding during the night) or continous enteral tube feeding during the day and during the night
if diuretics have an unsatisfactory effect and/or if there is fluid retention: restrict fluid and sodium

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

Fat restriction is undesirable due to the high energy requirements.
Ascites may mask weight loss.
Supplementation of the fat-soluble vitamins and minerals (especially calcium, magnesium, iron and zinc) may be necessary.

References:

Kneepkens CMF, Taminiau JAJM, Polma HA, editors. Werkboek Kindergastro-enterologie. Amsterdam: VU uitgeverij; 2002

Ramaccioni V, Soriano HE et al. Nutritional aspects of chronic liver disease and liver transplantation in children. Pediatr Gastroenterol Nutr 2000;30(4):361-67

Shaw V, Lawson M. Clinical Paediatric Dietetics. Oxford: Blackwell Science Ltd; 2001

Sutton MM. Pediatric liver transplantation. In: Hasse JM, Bleu LS (ed.). Comprehensive guide to transplant nutrition. Chicago: American Dietetic Association; 2002

Taminiau JAJM, Meer K de et al, editors. Werkboek enterale voeding bij kinderen. Amsterdam: VU Boekhandel/Uitgeverij BV; 1997 See ook www.stuurgroepondervoeding.nl > ziekenhuis > toolkit kinderen

Liver Diseases in Children was updated by Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ).

Diarrhea in Toddlers

Best time to refer to the dietician:

following diagnosis

Relevant information for the dietician:

Diagnosis: diarrhea in toddlers, any comorbid conditions
Medication: antibiotics, laxatives
Other: height, (changes in) weight

Aims of the diet:

normalize elimination pattern
maintain/achieve a good growth curve.

Characteristics of the diet:

based on national Nutritional Guidelines, with attention to adequate amounts of fat, fiber, fluid and fructose (the 4 Fs: fat, fiber, fluid and fruit sugar)
normalize intake of mono- and disaccharides and sweets.

Treatment time:

Care level 1, see “Dietician’s working methods.”

References:

Kneepkens CMF, Carmiggelt EC, Leeuw MBA de. Voedingsadvisering bij jonge kinderen. 2008. ISBN 9789023244387

Kneepkens CMF, Hoekstra JH. Peuterdiarree. Ned Tijdschr Geneeskd 1996 Oct;41:2026-8

Verberg J. Chronic Niet Specifieke Diarree (CNSD) op peuterleeftijd. In: Handboek Dieetbehandelingsrichtlijnen, Maarssen: Elsevier gezondheidszorg; 2002

Diarrhea in Toddlers (formerly “Chronic Non-specific Diarrhea (CNSD) at Toddler Age”) was updated byCarien Stapelbroek, dietician at Dietistenpraktijk Di-eetgezond and Nienke

Wierdsma, dietician at LIV voeding- en leefstijladvies, writing also on behalf of Jeugdgezondheidszorg Diëtisten (JGZ).

Irritable Bowel Syndrome (IBS) / Spastic Colon

Best time to refer to the dietician:

following diagnosis using the Rome III criteria (within the preceding 12 months, at least 12 weeks of symptoms of abdominal pain or abdominal discomfort, relieved after defecation, and/or change in frequency and/or change in consistency of defecation, and accompanied by at least 2 or more of the following symptoms):

abnormal defecation frequency (> 3 times a day or < 3 times a week)
abnormal stool form (hard and pellet-like, soft or watery) in more than ¼ of the bowel movements
abnormal passage of stools (abnormal straining, false urgency to move the bowels or a sensation of incomplete evacuation of the bowels) in more than ¼ of the bowel movements
mucus in the stools in more than ¼ of the bowel movements
bloating on more than ¼ of the days

Relevant information for the dietician:

Diagnosis: IBS / spastic colon, any comorbid conditions
Symptoms: nausea, abdominal pain, diarrhea, constipation, mucus in the stools, vomiting, globus pharyngeus, difficulties swallowing, abdominal bloating, flatulence
Laboratory tests: abnormal Hb and Fe
Medication: antispasmodics, antidiarrheal drugs, laxatives (bulking agents, if applicable osmotic laxatives), antibiotics
Other: previous history and symptoms, abuse of (contact) laxatives (such as senna).

Aims of the diet:

reduce symptoms

Characteristics of the diet:

Increased fluids: 1.5-2.5 L in drinking fluids
A regular dietary pattern, with extra attention to having 3 main meals per day, including a large breakfast to stimulate the gastrocolic reflex
No standard fiber enrichment, but adjust the quantity of fiber to the symptom pattern.
For constipation, increase dietary fiber:

at least 15 g per 1000 kcal and/or aim for 10-15 g more than in the normal diet
varied use of different types, both fermentable and non-fermentable fibers

ensure complete nutrition, due to the possible omission of foods due to symptoms
identify and restrict specific products that can cause symptoms
identify products that cause gas, hot spices, coffee, alcohol, tobacco, carbonated drinks, sorbitol, fructose
if lactose-intolerant: see “Lactose-intolerance”

Treatment time:

Care level 2, see “Dietician’s working methods.”

Specific remarks:

Pychosocial factors may play a role.
Ensure adequate physical exercise.
Ensure that patient eats slowly and chews food well.
Increasing dietary fiber without increasing fluids will have the opposite effect.
Use fiber preparations only if necessary, as an addition to the fiber content in food.
Fermentable fibers seem to have a more beneficial effect than non-fermentable fibers.
During the initial phase of treatment, an increase in dietary fiber may lead to a worsening of symptoms
Research is currently in progress on the effect of probiotics (dosages, strains and forms of administration).

References:

Bijkerk CJ, Muris JW et al. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2004 Feb 1;19(3):245-51

Bijkerk CJ, de Wit NJ et al. Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ. 2009 Aug 27;339:b3154

Bohmer CJM, Lourens J, Tuynman HARE. Intolerance of lactose in Irritable Bowel Syndrome. Gastroenterology International 1998;11:199-204

Ringel Y, Sperber AD, Drossman DA. Irritable Bowel Syndrome: Ann Rev Med 2001;52:319-38

Smout AJPM. Oorzaken van obstipatie. Tijdschr Huisartsengeneesk (bijlage) 1999;16:7-10.22-3

Irritable Bowel Syndrome (IBS) / Spastic Colon was updated by Gerda Stougie, dietician at Diëtistenpraktijk MinderMeer, writing also on behalf of the dieticians’ network Maag Darm Lever (MDL) and Ukie Harkema, dietician at Diëtistenpraktijk Harkema en Krabshuis

Short Bowel Syndroom

General information:

Short Bowel Syndrome is intestinal failure occurring when there is no longer enough functional intestinal surface area, causing poor absorption and excessive loss of fluids, elektrolytes and nutrients. The criteria are:

ileostomy/jejunostomy leaving < 200 cm of small intestine remaining.
< 150 cm of small intestine with complete colon in situ
stoma/fistula production > 1.5 L per day.

Best time to refer to the dietician:

upon diagnosis of Short Bowel Syndrome (SBS)

Relevant information for the dietician:

Diagnosis: underlying disease, resection of the small intestine (length and site of resection) with presence or absence of stoma/fistula, remaining length of intestine and presence or absence of ileocecal valve and colon, rate of passage of intestinal contents
Symptoms:

short-term: increased stoma output or frequent watery stools, malnutrition, electrolyte imbalances, dehydration, thirst, vitamin and mineral deficiencies
long-term: kidney stones, gallstones, overgrowth of bacteria, osteoporosis

Laboratory results:

serum: sodium, potassium, chloride, magnesium, phosphate, calcium, bicarbonate, urea, creatinine, water-soluble and fat-soluble vitamin values
urinalysis: sodium
stool analysis: fat volume

Medication: motility inhibitors, antacids, bile salt binders, secretion inhibitors, prokinetics, laxatives, antibiotics, vitamin and mineral supplements
Other: height, (changes in) weight, stoma output/fistula output or frequency and/or amount of defecation, urine output

Aims of the diet:

improve/maintain nutritional status
achieve/maintain good fluid and electrolyte balance
treat/prevent vitamin and/or mineral deficiencies
reduce the frequency and/or quantity of defecation, stoma output or fistula output to a manageable level

For jejunocolic anastomosis patients, also:

prevent D-lactate acidosis
prevent (calcium oxalate) kidney stones.

Characteristics of the diet:

postoperative treatment: following bowel resection/ostomy, parenteral nutrition may be necessary during a shorter or longer period (> 1 year to lifelong), whereby oral and/or tube feeding is gradually increased, based on tolerance. The duration of parenteral support depends partly on the remaining functional intestine and the presence or absence of a colon.
Energy-enriched: basal metabolism (Harris & Benedict) + extra allowances, and 30-50% above that
Protein: can be given in polymeric form
Carbohydrates, fats:

normal amounts of mono- and disacharides, preference for polysacharides
soluble fibers are preferable
frequent meals

supplement vitamins and minerals as needed
if tube feeding is given, polymeric feeds are preferable.

Intact colon and > 1 meter of ileal resection

low-fat: MCT fat (medium chain triglycerides) can be an alternative source of energy
for hyperoxaluria and calcium oxalate calculi: a diet low in oxalate
if the resection is >60 cm of terminal ileum: supplement vitamin B12
high-sodium
supplement fluid intake with ORS, as needed.

Jejunostomy

no more than 500 ml hypotonic drinks per day, Other ORS.

Treatment time:

Care level 3*, see “Dietician’s working methods.”

Specific remarks:

In view of the complexity of the treatment, the SBS patient must be treated and monitored by a multidisciplinary team for the long term / lifelong.

References:

Buchman AL. Etiology and initial management of short bowel syndrome. Gastroenterology. 2006; 130 (2 suppl 1): S5-15

Forbes A. Virtual University: The compromised gut-intestinal failure. Challenges in treating intestinal failure and short bowel syndrome, e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e108–e113

Matarese LE, Steiger E. Dietary and medical management of short bowel syndrome in adult patients 3. J Clin Gastroenterol 2006 May;40(5 Suppl 2):S85-S93

Nightingale J, Woodward JM. Guidelines for management of patients with a short bowel. Gut 2006 Aug;55 suppl 4:iv1-12

Wanten G, Sauerwein HP et al. De behandeling van darmfalen bij volwassenen.

Dieetmaatregelen Ned Tijdschr Geneeskd. 2007;151:1819-24

Short Bowel Syndrome was updated by Jacqueline van den Broek, dietician at Universitair Medisch Centrum Nijmegen (UMCN) and Inge de Meer, dietician at Academisch Medisch Centrum (AMC).