Lecture notes for medical students

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2. Learning Objectives

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction
• The term ‘malnutrition’ has no universally
accepted definition.
• It has been used to describe a deficiency,
excess or imbalance of a wide range of
nutrients, resulting in a measurable adverse
effect on body composition, function and
clinical outcome.1
• Although malnourished individuals can be
under- or overnourished, ‘malnutrition’ is
often used synonymously with
‘undernutrition’, as in this lecture.

6. Introduction
• Malnutrition is a common, under-
recognised and undertreated problem facing
patients and clinicians.
• It is both a cause and consequence of
disease and exists in institutional care and
the community.

7. History

8. History
• In the 1930s surgeons observed that patients
who were starved or underweight had a
higher incidence of postoperative
complications and mortality.
• A large number of studies have
subsequently supported this original
observation.

9. History
• Similar complaints
• Urethral instrumentation/ operations
• UTIs

10. Aetiology

11. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

12. Aetiology
• Poverty
• Social isolation
• Substance misuse
• Reduced dietary intake
• Reduced absorption of macro- and/or
micronutrients
• Increased losses or altered requirements
• Increased energy expenditure (in specific disease
processes)

13. Reduced Dietary intake
•

14. Reduced Dietary intake
• The single most important aetiological factor
• Due to reductions in appetite sensation as a result
of changes in cytokines, glucocorticoids, insulin
and insulin-like growth factors.
• The problem may be compounded in hospital
patients by failure to provide regular nutritious
meals in an environment where they are protected
from routine clinical activities, and where they are
offered help and support with feeding when
required

15. Reduced Dietary intake
• Dysphagia,
• Anorexia nervosa,
• Depression,
• Alcoholism
• NBM perioperative
• However, the most common cause of in-hospital
malnutrition is poor food served without assistance to frail
individuals and timed for the benefit of personnel rather
than of the patients.
• Patients are also given nothing by mouth for the
Most trivial reasons (e.G., Radiologic studies) and diets are
often not advanced rapidly even after minor operations.

16. Reduced absorption

17. Reduced absorption
• Inflammatory bowel disease,
• Coeliac disease
• Short bowel syndrome,
• Protein-losing enteropathies.

18. Increased losses or altered
requirements

19. Increased losses or altered
requirements
Excessive and/or specific nutrient losses; their
nutritional requirements are usually very different
from normal metabolism-
• Cancer
• Surgery
• Sepsis
• Enterocutaneous fistulae
• Burns

20. Energy expenditure
• .

21. Energy expenditure
• It was thought for many years that increased energy
expenditure was predominantly responsible for disease-
related malnutrition.
• There is now clear evidence that in many disease states
total energy expenditure is actually less than in normal
health.
• The basal hypermetabolism of disease is offset by a
reduction in physical activity, with studies in intensive care
patients demonstrating that energy expenditure is usually
below 2,000 kcal/day.
• The exception is patients with major trauma, head injury or
burns where energy expenditure may be considerably
higher, although only for a short period of time.

22. Aetiology of Aetiology
•

23. Aetiology of Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

24. Pathophysiology

25. Pathophysiology:Consequences
of malnutrition
• Malnutrition affects the function and
recovery of every organ system.

26. Metabolic and hormonal changes

27. Metabolic and hormonal changes
• In early starvation body switches from
using carbohydrate to using fat and protein
as the main source of energy,
• Basal metabolic rate decreases by as much
as 20-25%.

28. Metabolic and hormonal changes
• During prolonged fasting, hormonal and metabolic
changes are aimed at preventing protein and
muscle breakdown.
• Muscle and other tissues decrease their use of
ketone bodies and use fatty acids as the main
energy source.
• This results in an increase in blood levels of
ketone bodies, stimulating the brain to switch from
glucose to ketone bodies as its main energy
source.
• The liver decreases its rate of gluconeogenesis,
thus preserving muscle protein. .

29. Metabolic and hormonal changes
• During the period of prolonged starvation,
several intracellular minerals become
severely depleted.
• However, serum concentrations of these
minerals (including phosphate) may remain
normal.
• This is because these minerals are mainly in
the intracellular compartment, which
contracts during starvation.
• In addition, there is a reduction in renal
excretion.

30. Muscle function

31. Muscle function
• Weight loss due to depletion of fat and
muscle mass, including organ mass, is often
the most obvious sign of malnutrition.
• Muscle function declines before changes in
muscle mass occur, suggesting that altered
nutrient intake has an important impact
independent of the effects on muscle mass.
• Similarly, improvements in muscle function
with nutrition support occur more rapidly
than can be accounted for by replacement of
muscle mass alone

32. Muscle function
• If dietary intake is insufficient to meet
requirements over a more prolonged period
of time the body draws on functional
reserves in tissues such as muscle, adipose
tissue and bone leading to changes in body
composition.
• With time, there are direct consequences for
tissue function, leading to loss of functional
capacity and a brittle, but stable, metabolic
state

33. Muscle function
• Rapid decompensation occurs with insults
such as infection and trauma.
• Importantly, unbalanced or sudden
excessive increases in energy intake also
put malnourished patients at risk of
decompensation and refeeding syndrome.

34. Cardio-respiratory function

35. Cardio-respiratory function
• Reduction in cardiac muscle mass
• decrease in cardiac output has a corresponding impact on
renal function by reducing renal perfusion and glomerular
filtration rate.
• Micronutrient and electrolyte deficiencies (eg thiamine)
may also affect cardiac function, particularly during
refeeding.
• Poor diaphragmatic and respiratory muscle function
reduces cough pressure and expectoration of secretions,
delaying recovery from respiratory tract infections.
• Reduced ventilatory performance and prolonged ventilator
dependence.

36. Gastrointestinal function

37. Gastrointestinal function
• Chronic malnutrition results in changes in
– Pancreatic exocrine function,
– Intestinal blood flow
– Villous architecture and intestinal permeability.
• The colon loses its ability to reabsorb water and
electrolytes, and secretion of ions and fluid occurs
in the small and large bowel.
• This may result in diarrhoea, which is associated
with a high mortality rate in severely
malnourished patients..

38. Immunity and wound healing

39. Immunity and wound healing
• Diminished complement and
immunoglobulin production,
• Poor cellular immunity,
• impairment of variou aspects of leukocyte
action including chemotaxis, phagocytosis,
and oxidative burst.
• Poor tissue repair and wound healing

40. Clinical outcome

41. Clinical outcome
• Malnourished surgical patients have complication
and mortality rates three to four times higher than
normally nourished patients
• Longer hospital admissions
• there is clear evidence that nutrition support
significantly improves outcomes in these
patients

42. Psychosocial effects

43. Psychosocial effects
• Apathy
• Depression
• Anxiety
• Self-neglect.

44. The cost

45. The cost
• Malnutrition is also a major resource issue for
public expenditure.
• The costs associated with disease-related
malnutrition in the UK in 2007 were over £13
billion.
• The potential cost savings associated with
prevention and treatment of malnutrition are
considerable: a saving as small as 1%
represents £130 million per year.
• There is evidence that for specific situations
treating malnutrition produces cost savings
of 10–20% or more.

46. Take home messages

47. Take home messages
• Integration of nutrition into the overall
management of the patient
• Avoidance of long periods of preoperative
fasting
• Re-establishment of oral feeding as early as
possible after surgery
• Start of nutritional therapy early, as soon as
a nutritional risk becomes apparent
• Metabolic control e.G. Of blood glucose

48. Take home messages
• Reduction of factors which exacerbate
stress-related catabolism or impair
gastrointestinal function
• Minimize time on paralytic agents for
ventilator management in the postoperative
period
• Early mobilisation to facilitate protein
synthesis and muscle function.

49. Clinical Features
•

50. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

51. Demography

52. Demography
• Incidence & Prevalence
• Geographical distribution.
• Race
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

53. Demography
• Incidence & Prevalence-

54. Demography
• Geographical distribution.

55. Demography
• Race.

56. Demography
• Age

57. Demography
• Sex

58. Demography
• Socioeconomic status

59. Demography
• Temporal behaviour

60. Signs

61. Signs
• General Examination
• Systemic Examination
• Local Examination

62. Signs
• General Examination

63. Signs
• Systemic Examination

64. Signs
• Local Examination

65. Prognosis

66. Prognosis
• Morbidity
• Mortality rate
• 5 year survival in Malignancy

67. Investigations

68. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germ line Testing and Molecular Analysis
• Diagnostic Laparotomy.

69. Investigations in Malignancy
•

70. Investigations in Malignancy
• For diagnosis
• For staging
• For Screening
• For Monitoring

71. Diagnostic Studies

72. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

73. Prevention

74. Prevention
• Screening
• Risk reduction

75. Mythbusters
Myths Facts

76. Guidelines

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