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Neurology & the Gut: Study day resources

Neurology and the Gut: Exploring the nutritional management of gastrointestinal dysfunction in neurological disorders



On the 19th May 2017 we held a study day on Neurology and the Gut. If you were unable to attend or would simply like to refresh your memory you can view all the session videos here as well as read a comprehensive review of the day itself.

The day itself was accredited for CPD by the BDA and was aimed at healthcare professions, specifically dietitians who see patients with neurological disorders in their day-to-day practice.

We have provided a downloadable CPD reflection form below, in order for you to complete alongside the resources on this page.

Study Day Summary:

This study day explored the intricate relationship between the brain and the gut, and how the nervous system controls and regulates the digestive process. The link between neurological disorders, gastrointestinal symptoms and the gut microbiome were discussed, as well as the dietetic management of gut-related problems in Parkinson’s disease.





Title of Session:

Neurological Disorders and Gut Function – Physiology in Clinical Practice

Presenter:

Dr. Anton Emmanuel, The National Hospital for Neurology and Neurosurgery

Summary:

This session explored colonic function and how it is controlled by neurons. Four key factors were highlighted that control the gut: autonomic, behavioural, subconscious and central nervous system (CNS) control. We were reminded of gut transit time, for example the transit in the small bowel is 2-6 hours and in the colon it is 16-20 hours.
The session also discussed gastroparesis, a condition which poses several clinical challenges for medical staff and dietitians when trying to maximise nutritional intake and improve nutritional status. In gastroparesis Dr. Emmanuel advised that patients may be fed post-pylorically which is something we follow in our hospital trust, and in our experience tends to have more favorable outcomes for patients who are tube fed. We also learnt that the fourth biggest cause of mortality in insulin dependent diabetes is aspiration. This reaffirms the important relationship between the gut and neurons.

Key take home messages:

  • Multiple Sclerosis (MS) patients report that bowel dysfunction disturbs them the most
  • Two thirds of MS patients suffer from constipation
  • Hyperglycaemia can delay gastric emptying



Title of Session:

The Gut Bacteria and Neurological Disease

Presenter:

Dr. Nikhil Sharma, The National Hospital for Neurology and Neurosurgery

Summary:

We are all aware of MND and the detrimental effects it can have on our patients. It affects a particular part of the brain and can progress rapidly. It creates motor dysfunction in a particular area and then progresses to other vital systems such as bulbar, respiratory, arms and legs. Unfortunately there is no cure for MND and it is managed with the use of Riluzole.
This session discussed the microbiome and microglia relationship. Dr. Sharma explained how microglia (cells in the brain that control inflammation) are central to neurodegeneration. He provided a fascinating overview of his current research project in Motor Neurone Disease (MND).
This project was about transferring microbiome into MND patients to see if there would be any changes in the microglia in this group of patients. The sample size was thirty seven patients in total. It would be interesting to see whether there is a relationship between the microbiome and microglia in other neurological conditions, as well as MND.




Title of Session:

GI Dysfunction in the Traumatic Brain Injured Patient

Presenter:

Ella Segaran, Advanced Dietitian for Critical Care, St Mary’s Hospital Imperial College Health Care NHS Trust

Summary:

Ella discussed in detail about how to approach enteral tube feeding in traumatic brain injured patients. She advised us to treat each patient individually, highlighting the importance of identifying which phase of critical illness the patient is in, and adjusting dietetic plans according to this. She taught us about limiting calories in the early stage and to increase calorific intake during the stable and then the recovery phase. She discussed in detail gastric residual volumes (GRV) in this group of patients and related this to a study by Saran (2015), and discussed whether GRVs actually matter.

lla went on to discuss enteral nutrition intolerance (ENI) and how to manage it. In particular, to review the agreed cut-off volumes for GRVs, and consider elevation of the patient’s bed and pro-active administration of laxatives from day two. Ella discussed common interruptions in the critical care environment that can cause disruption of enteral nutrition delivery in traumatic brain injury patients. These are: patients being listed for procedures and put nil by mouth, delays in procedures, radiological investigations, and patient agitation which may lead to the inadvertent removal of the feeding tube

Key take home messages:

  • Learning to recognise which clinical phase the patient is in and then adjusting your dietary plan accordingly is important.
  • Gastric emptying time with Midazolam is approximately 150 minutes, while gastric emptying time with Propofol is approximately 50 minutes.
  • Erythromycin is a more powerful prokinetic in traumatic brain injury patients
  • A study by Steven Taylor in 2016 concluded that post pyloric feeding is more superior than Metoclopramide and Erythromycin in this group of patients
  • Critical care dietitians can record the total length of time in minutes or days of enteral feeding interruptions and relate these figures to length of stay or clinical complications
  • The Pep UP study highlighted strategies to improve enteral nutrition delivery in the ICU.



Title of Session:

Dietary Management of Bowel Dysfunction in Parkinson’s Disease

Presenter:

Karen Green, Senior Specialist Dietitian, The National Hospital for Neurology and Neurosurgery

Summary:

This session focused on Parkinson’s disease, where we were introduced to the several different stages of the condition.

  • Stage 1: Mild symptoms
  • Stage 2: Bilateral symptoms
  • Stage 3: Slow physical movement
  • Stage 4: Severe symptoms
  • Stage 5: End stage Parkinson’s

Karen discussed some of the common and well-known GI side effects of Parkinson’s disease, such as dysphagia, constipation and gastroparesis. She shared experiences from her clinical practice and the common diet-related issues she manages on a regular basis. The session reaffirmed the key principles of current dietetic practice in this disease area.

 

Key take home messages:

  • There are many different stages of Parkinson’s disease that can result in varying nutritional consequences
  • Gastroparesis, dysphagia, constipation and small intestinal bacterial overgrowth are some of the gastrointestinal problems that may affect a patient with Parkinson’s disease.
  • Patients should be monitored regularly for GI dysfunction

Dr Anton Emmanuel provides a thought-provoking update on the relationship between the brain and the gut. Drawing on his extensive experience in neurogastroenterology, and exploring emerging research in the field, he provides expert insight in to this evolving-discipline. The pathophysiology of gastrointestinal dysfunction in neurological disorders, such as Multiple Sclerosis, is examined.

 


Dr Nikhil Sharma explores the role of the gut microbiome in neurological disorders, and offers fascinating insight into his forthcoming research involving faecal microbiota transplantation in motor neurone disease.



Ella Segaran provides her perspective on gastrointestinal dysfunction in acute neurological disorders, focusing on critically ill traumatic brain injured patients. By drawing on her own experience as well as appraising the current evidence base, she offers practical solutions for improving the nutritional care of this vulnerable patient group.



Karen Green is well known in dietetics for her contribution to the Manual of Dietetic Practice and BDA Best Practice Guidelines on Parkinson’s disease. In this lecture, she explores the impact of Parkinson’s disease on the gut, including the management of gastroparesis, constipation and small intestinal bacterial overgrowth.




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