GASTROINTESTINAL DISEASE 2

Inflammatory bowel disease (IBD) :

chrons disease dan ulcerative colitis,
Celiac Disease

Meike Mayasari, S.Gz, MPH, Dietisien

Nutrition Screening Tools
Nutrition screening tools quickly evaluate a patient’s
nutritional status to identify malnourished or at-risk
patients
– Malnutrition Screening Tool (MST)
– Malnutrition Universal Screening Tool2(MUST)
– DETERMINE checklist for screening and assessment
– Nutritional Risk Index (NRI)
– Nutritional Risk Screening-2002 (NRS 2002)
– Mini Nutritional Assessment (MNA, MNA-SF)
– CMTF Screening tool
 Celiac Disease
(Gluten-Sensitive Enteropathy)
• Celiac disease ditandai oleh atrovi vili usus
bagian proksimal akibat menelan makanan yang
mengandung glutenkehilangan
vilipengurangan permukaan absorpsi
• Gluten: protein dengan berat molekul besar,
ditemukan dalam gandum hitam (rye), oat,
barley dan terutama gandum.
• Mekanismetdk diketahui, diduga tidak
memupunyai peptidase spesifik (untuk
detoksifikasi peptida gluten)
Symptoms and Conditions Associated with Celiac Disease

1) Nutritional
• Anemia (iron or folate, rarely B12)
• Osteomalacia, osteopenia, fractures (vitamin D
deficiency, inadequate calcium absorption)
• Coagulopathies (vitamin K deficiency)
• Dental enamel hypoplasia
• Delayed growth, delayed puberty, underweight
• Lactase deficiency
2) Extraintestinal
• Lassitude, malaise (sometimes despite lack of
anemia)
• Arthritis, arthralgia
• Dermatitis herpetiformis
• Infertility, increased risk of miscarriage
• Hepatic steatosis, hepatitis
• Neurologic symptoms (ataxia, polyneuropathy,
seizures); may be partly
• nutrition related
• Psychiatric syndromes
3) Associated Disorders
• Autoimmune diseases: type 1 diabetes,
thyroiditis, hepatitis, collagen vascular disease
• Gastrointestinal malignancy
• IgA deficiency

Kupfer SS, Jabri B: Pathophysiology of celiac disease, Gastrointest Endosc Clin N Am 22:639,
2012.
A, Peroral jejunal biopsy specimen of diseased mucosa shows severe atrophy
and blunting of villi, with a chronic inflammatory infiltrate of the lamina
propria.
B, Normal mucosal biopsy.
(From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 7,
Philadelphia, 2005, Saunders.)
Pathophysiology Celiac Disease
Nutrition ASSSESSMENT
Antropometri
BB, TB, IMT, LILA, Weight loss
Biokimia
Hb, levels of ferritin, red blood cell, folate, and 25-OH
vitamin D. vitamins such as fat-soluble vitamins (A, E, K)
and minerals (zinc) should be checked if signs of nutrient
deficiencies
Klinis
Diare, malabsorption, signs of nutrient deficiencies (e.g.,
nightblindness, neuropathy, prolonged prothrombin
time),
Assess appearance of hair, skin, nails, and body shape
and physical activity
Dietary
• Riwayat makan dan minum yang berhubungan
dengan konsumsi gluten, termasuk merk makanan
kemasan.
• Asupan kalori, protein dan mikronutrien adekuat
(diet bebas lemak meningkatkan risiko defisiensi Ca,
serat, vitamin D, niasin, Fe dan Vitamin B12
kurangnya fortifikasi pada makanan kemasan bebas
gluten termasuk roti dan pasta),
• Cek kemungkinan adanya cross contamination
+resep obat :pastikan free gulten
+RPK, RPD, gejala
Potential nutrition diagnoses
• NI 1.3 Kelebihan asupan kalori peningkatan BB
risiko overweight
• NI 5.8.5 Asupan serat inadekuat
• NI 5.9.1 Asupan vitamin D inadekuat
• NI 5.10.1 Asupan mineral (Fe)/ Ca inadekuat
• NC 1.4 Gangguan fungsi GI
• NC 2.1 Utilisasi zat gizi terganggu
• NC 3.1 Underweight
• NB. 1.1 Kurang pengetahuan terkait makanan dan gizi
• NB.1.4 Kurang dapat menjaga/ monitoring diri
(konsumsi gluten secara tidak sengaja di restoran ,
konsumsi gluten dengan sengaja)
• NB 1.7 Pemilihan makanan yang salah
 Care Management of Celiac Disease

Medical Management
• Electrolyte and fluid replacement
• Management of other co-morbid conditions

Nutrition Management/ Intervention

• Delete gluten sources (wheat, rye, barley) from diet
• Vitamin and mineral supplementation
• Substitute with corn, potato, rice, soybean, tapioca,
arrowroot, and other non-gluten flours
• Calcium and vitamin D administration
• Read food labels carefully for hidden gluten containing
ingredients
• Supplementation with -3 fatty acids
• Guidance to support groups and reliable internet
resources
 Do not eat any foods containing any of the
following ingredients:
• Wheat (all types)
• Barley
• Rye
• Malt
• Oats (unless gluten free)

These ingredients are found in many food

products, including flours, bread products,
pasta, breakfast cereals, cakes, and cookies.
Medical Nutrition Therapy
• Basic Gluten Free Diet
Nutrition education for the gluten-free diet
• Label reading: list of ingredients that must be avoided, review of
labeling laws, surprising
sources of gluten, cross-contamination procedures, nutrition claims
(eg, gluten-free, wheatfree, low gluten, made in the same facility as
wheat), sources of important nutrients such as calcium, vitamin D,
iron, fiber
• Recommendations for portions and variety of foods from all food
groups
• Heart-healthy recommendations to prevent high cholesterol
• High fiber, as tolerated, to prevent weight gain and constipation
• Review of gluten-free grains: 50% of grains consumed should be
whole grains
• Discuss risk of vitamin deficiencies
• Encourage healthful gluten-free food choices
 Nutrition education for the gluten-free diet
• Discuss risks associated with ingesting gluten
• Discuss vitamin supplementation as needed
• Discuss use of supplements such as probiotics, over-the-
counter remedies
• Discuss family testing
• Discuss restaurant eating, social situations, menu planning,
recipes, grocery shopping
• Coordinate care with other providers as needed
• Discuss other dietary restrictions within the confines of the
gluten-free diet: lactose-free diet,
• low-fructose diet, diabetes meal plan/carbohydrate
counting
• Implement weight-centered guidelines as needed: weight
control
Nutrition items to monitor at follow-up visits
• Anthropometry
BB, TB, BMI, weight loss
• Biochemical data, Medical Tests and Procedures
Outcomes
marker of nutrien deficiencies, antibody levels
• Physical and Clinical data
Medical status (eg, gastrointestinal, immune,
neurologic, psychological)
 Dietary
• Compliance with the gluten-free diet,
• label reading,
• restaurant habits ,
• diet history and gluten-free dietary pattern with specific
focus on intake of nutrients at risk of deficiency (iron,
calcium, vitamin D, B vitamins, fiber, folate, niacin, zinc),
• intake compared with recommendations,
• excessive sugar and fat from prepared gluten-free foods,
• caloric intake,
• vitamin intake
ISU DIET MUTAKHIR

According to the Academy of Nutrition and Dietetics

Evidence Analysis Library, “a small number of studies
in adults show a trend toward weight gain after
diagnosis; further research is needed in this area.
(Academy of Nutrition and Dietetics Evidence Analysis Library. Celiac Disease
Evidence Analysis Library Project. Available at: http://www.adaevidencelibrary.
com/. Accessed August 14, 2012)

There are reasons why individuals with celiac disease

might gain weight after diagnosis. Before diagnosis,
increased amounts of calories may have been necessary
to prevent or slow weight loss caused by malabsorption.
 INFLAMMATORY BOWEL DISEASES
(Crohn’s disease and Ulcerative Colitis)
• Gejala Ulcerative colitis : nyeri abdomen, diare
dan pendarahan rektum. Lesi utama berupa
reaksi peradangan daerah subepitel yang timbul
pada basis kripta lieberkuhn tukak pada
mukosa
• Lesi penyakit chron menyerang seluruh tebal
dinding usus
• Kolonoskopi dan biopsi dapat membedakan
ulcerative colitis dan chron’s disease
A, Normal colon. B, Ulcerative colitis. C, Crohn’s disease
Pathophysiology IBD
Nutrition Assesment

• Antropometri
BB, TB, BMI, weight loss, lean body mass
• Data biokimia yang menggambarkan status
cairan dan malnutrisi (albumin, prealbumin,
CRP, defisiensi (Hb, ferritin, B6, B12, karoten,
vitamin D, zink) test terkait dg malabsorpsi
• Fisik dan Klinis
Anoreksia, nausea, nyeri abdomen, diare
• Riwayat Diet
Perubahan diet, asupan makro dan
mikronutrien
W h y a re I B D p a tie n ts a t risk fo r m a l n u triti o n ?

• Loss of appetite
• Decreased food intake
• Food intolerances
• Increased nutrient requirements
• Side effects of medications
• Elimination diets
• In some cases, malabsorption of nutrients
• Surgery (reduced absortive area, excisions,
stoma, drains, short bowel syndrome)
Source: Wiskin, AE, Wootton, SA and Beattie RM, 2007
Nutrient absorption sites
What are the most common nutrient deficiencies in IBD?

• Energy
• Protein
• Iron
• Vitamin B12
• Folic Acid
• Calcium
• Vitamin D
 MASALAH/ DIAGNOSIS GIZI YANG MUNGKIN

DOMAIN Label diagnosis gizi

INTAKE NI 2.1 Asupan oral inadekuat

NI 5.2 Malnutrisi
CLINIS NC 1. 4 Gangguan fungsi GI
NC 2.1 Gangguan utilisasi zat gizi
NC 3.1 Underweight
NC 3.4 Penurunan BB yang tak direncanakan
BEHAVIOUR individual
Kebutuhan Zat Gizi
• Energy needs of patients with IBD are not
greatly increased (unless weight gain is desired).
• Protein requirements may be increased,
depending on the severity and stage of the
disease and the restoration requirements. To
maintain positive nitrogen balance, 1.3 to 1.5
g/kg/day of protein is recommended
• Suplemen vitamin A, C, D, asam folat, B12 , Fe,
Ca, Zn, Mg
Care Management
A) Medical Management
• Corticosteroids
• Anti-inflammatory agents
• Immunosuppressants
• Antibiotics
• Anticytokine medications
B) Surgical Management
• Bowel resection that can result in short bowel
syndrome (SBS)
C) Nutrition Management

Contoh Tujuan Diet pada IBD :

• Memperbaiki satus gizi kurang (tergantung
lamanya planning intervensi)
• Mengganti kehilangan zat gizi
• Memperbaiki ketidakseimbangan cairan dan
elektrolit
• Mencegah inflammasi lebih lanjut
• Mengistrirahatkan usus pada masa akut
Diet in IBD
Dietary intervention depends on:
Disease location
Phase -active/quiescent
Nature -presence of strictures/fistulae
Current medical treatment
Surgical intervention
Individual symptoms

No clear nutrition ‘formulation’ that works

for all patients
Recommendation- Diet Therapy
• Porsi kecil dan sering
• Lemak terbatas (masih kontroversi) kecuali jika ada reseksi
usus kecil . Jika kolon yang direseksi dan terdapat output
ileostomy yang banyak tidak ada alasan untuk restriksi lemak
• Pasien dipuasakan (NPO) pada masa akut atau obstruksi 
nutrisi parenteral
• Apabila fase akut teratasi bertahap nutrisi oral/ enteral
cair diet rendah sisa dan rendah serat gejala hilang,
makanan biasa
• Rendah atau bebas laktosa dan mengandung MCT intoleransi
laktosa dan malabsorpsi lemak
• Cairan dan elektrolit cukup
• Menghindari makanan yang menimbulkan perasaan kembung
gas
• Oral enteral formula (tube-feed if necessary)
• Use of foods that are well tolerated
• Multivitamin supplement containing folic acid,
B12, and B6
• Omega -3 fatty acid supplementation
• Consider use of prebiotics and probiotics
• Modify fiber intake as necessary
• Test for food intolerances
• Suplemen folat, B6 dan B12, Fe dan trace elements
untuk menggantikan simpanan atau untuk maintenance
karena maldigesti, malabsorpsi, interaksi obat dan
makanan atau asupan inadekuat (Owczarek et al, 2016).
• Diare dapat menyebabkan kehilangan zink, kalium, and
selenium.
• Pasien dengan pengobatan kortikosteroid intermitten
mungkin membutuhkan suplementasi kalsium dan
vitamin D
• Patients with IBD are at increased risk of osteopenia
and osteoporosis; 25-OH vitamin D levels and bone
density should be monitored routinely and vitamin D
supplemented appropriately (Hlavaty et al, 2015).
Nutrition Monitoring and Evaluation
1. Monitor progress
cek tingkat pemahaman dan tingkat kepatuhan
klien/ pasien
bandingkan implementasi dengan planning
2. Mengukur outcomes
• Antropometri : BB, TB, IMT, lean body mass
• Biokimia : albumin, prealbumin, CRP, Hb
• Fisik dan Klinis: mual, diare, nyeri abdomen,
anoreksia
• Dietary : asupan makan (energi, protein, lemak,
serat, vitamin dan mineral)
3. Evaluasi outcomes
bandingkan hasil dengan standar dan nilai
keberhasilan dari tujuan intervensi
 ISU DIET MUTAKHIR

• Omega-3 fatty acid supplements in Crohn’s

disease significantly reduce disease activity. Use of
omega-3 fatty acids or fish oil supplements in UC
appears to result in a significant medication-
sparing effect, with reductions in disease activity
and increased time in remission reported (Farrukh
and Mayberry, 2014).
• Use of foods and supplements containing
prebiotics and probiotic supplements continues to
be investigated for their potential to alter the gut
microbiota; however, the benefit of either remains
unproven (Sinegra et al, 2013).
TERIMA KASIH