Answers to Self-Assessment Questions - ACCP

3. Sundaram A, Koukia P, Apovian CM. Nutritional management
of short bowel syndrome in adults. J Clin Gastroenterol
2002;34:207–20.
38. Answer: A
R.C. is at high risk of developing a zinc deficiency
(Answer A) because of the fact that zinc will be lost in high
concentrations from the high-output jejunostomy; thus
Answer A is correct. Zinc concentrations in small bowel
output can be as high as 12 mg/L; thus, R.C. may be losing
as much as 18 mg of zinc per day in the jejunostomy fluid.
Vitamin B 12
(Answer B), folic acid (Answer C), and copper
(Answer D) are not substantially eliminated in the stool; thus
R.C.’s risk of zinc deficiency is substantially higher than
the risk of vitamin B 12
, folic acid, or copper deficiencies,
making Answer B, Answer C, and Answer D incorrect.
1. Parrish CR, Krenitsky J, Willcutts K, Radigan AE.
Gastrointestinal disease. In: Gottschlick MM, DeLegge MH,
Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N.
Nutrition Support Core Curriculum: A Case-based Approach
– The Adult Patient. Silver Spring, MD: American Society for
Parenteral and Enteral Nutrition, 2007, 508–39.
2. Buchman AL, Scolapio J, Fryer J. AGA technical review
on short bowel syndrome and intestinal transplantation.
Gastroenterology 2003;124:1111–34.
3. Sundaram A, Koukia P, Apovian CM. Nutritional management
of short bowel syndrome in adults. J Clin Gastroenterol
2002;34:207–20.
39. Answer: C
T.C. has developed hypoglycemia (blood glucose
concentration less than 60 mg/dL. The most appropriate
response to hypoglycemia after discontinuing the PN when
cycling in a young infant is to increase the ramp-down
time; therefore, Answer C (continue to ramp up over 1
hour; increase the ramp-down time to 2 hours) is the correct
answer. Answer A (do nothing) is not correct. A blood
glucose concentration less than 60 mg/dL can be associated
with complications, including changes in neurodevelopment;
therefore, allowing T.C.’s blood glucose concentration to
fall to 45 mg/dL after discontinuing PN is not appropriate.
Answer B (increase the ramp-up time to 2 hours; continue
to ramp down over 1 hour) is incorrect because the serum
glucose concentration at the maximum PN infusion rate is
acceptable (90 mg/dL), so no change in the ramp-up time is
needed; also, this option does not address the low glucose
after discontinuing the PN. Answer D (increase both the
ramp-up and ramp-down times to 2 hours) could be done;
however, it is not the best answer because the ramp-up time
does not need to be changed.
1. Kumpf VJ, Gervasio J. Complications of parenteral nutrition.
In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C,
Worthington P, eds. The A.S.P.E.N. Nutrition Support Core
Curriculum: A Case-based Approach – The Adult Patient.
Silver Spring, MD: American Society for Parenteral and
Enteral Nutrition, 2007, 323–39.
2. Bendorf K, Friesen CA, Roberts CC. Glucose response to
discontinuation of parenteral nutrition in patients less than 3
years of age. JPEN: J Parenteral Enteral Nutr 1996;20:120–2.
40. Answer: C
T.C. has been receiving a standard multivitamin
preparation in her PN formulation, but only zinc and
chromium, because the standard trace element preparation
was removed from her PN when her direct bilirubin was
elevated to 4 mg/dL. She is receiving about 40% of her
nutrition by the enteral route. Her direct bilirubin in clinic
today is 2.1 mg/dL, and she has a microcytic anemia. The
most appropriate response would be to draw a serum iron
panel and ferritin and copper concentrations (Answer C).
Deficiency of both iron and copper can cause microcytic
anemia. T.C. is receiving neither iron nor copper in her
PN formulation; thus she is at risk for deficiency of both.
Therefore, Answer C is correct. Answer A (add standard
pediatric trace elements to the PN formulation daily) is
incorrect because T.C.’s direct bilirubin is still elevated,
indicating cholestasis; thus, copper and manganese excretion
may be compromised. The trace element preparation
should not be added unless a deficiency of both copper
and manganese is documented. Answer B (draw a serum
iron panel and ferritin, vitamin B 12
, folate, and copper
concentrations) is incorrect because T.C. has been receiving
both vitamin B 12
and folate daily in her PN formulation, and
these nutrients are associated with macrocytic anemia, not
microcytic anemia. Answer D (start ferrous sulfate drops
orally) is not appropriate at this time because the cause of
the microcytic anemia has not been determined.
1. Chessman KH, Kumpf VJ. Assessment of nutrition status and
nutrition requirements. In: Dipiro JT, Talber RL, Yee GC,
Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A
Pathophysiologic Approach, 7 th edition. New York: McGraw
Hill Medical, 2008, 2349–66.
2. Btaiche IF, Khalidi N. Parenteral nutrition-associated liver
complications in children. Pharmacotherapy 2002;22:188–211.
3. Btaiche IF, Khalidi N. Metabolic complications of parenteral
nutrition in adults, part 2. Am J Health Syst Pharm
2004;61:2050–9.
Immunonutrition
41. Answer: D
The best EN intervention for J.B. immediately upon
admission is actually no enteral feeding (Answer D) because
J.B. is hemodynamically unstable and has been incompletely
resuscitated; thus Answer D is correct. However,
hemodynamic instability is a relative contraindication
to EN, and some institutions might begin EN in a patient
such as J.B. The immune-enhancing EN formulation with
omega-3 polyunsaturated fatty acids (PUFAs) 8.6 g/L and
antioxidants (Answer B) would be the best response only
if J.B. was hemodynamically stable so that feedings could
be initiated safely, so Answer B is incorrect. Answer A
(immune-enhancing EN formulation with arginine 10 g/L
and omega-3 PUFAs 3.6 g/L) and Answer C (immuneenhancing
EN formulation with arginine 16.3 g/L, glutamine
15 g/L, nucleotides 1.6 g/L, and omega-3 PUFAs 1.7 g/L) are
not correct choices because each contains arginine, which
has been associated with potential harm in patients with
sepsis.
Gastroenterology and Nutrition Answers
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Pharmacotherapy Self-Assessment Program, 6th Edition