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This difference in osmolality of 42 mmoll is due to

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This difference in osmolality of 42 mmol/L is due to unmeasured osmotically active substances(such as glucose) which are seen in secretory diarrhoea. It is caused by toxins such asVibriocholeraeandE. coli.Hormonal causes such as Zollinger–Ellison and vasoactive intestinalpolypeptides could cause a similar picture but are not consistent with clinical details provided.
17: NUTRITION AND FLUID THERAPY133Acidosis14. BStarvation ketosis is commoner in children due to low glycogen stores. The child is able tomaintain normoglycaemia due to effective gluconeogenesis. The slightly high glucose could alsobe due to the effect of counter-regulatory hormones, such as cortisol and glucagon, that arereleased during stress. Mounting a ketone response is appropriate in this situation as the brain andmuscles are able to utilize this as a source of energy. The associated metabolic acidosis shows ananion gap of 40 mmol/L (a third of this is accounted for by glucose and beta-OH-butyrate) andthus other ketone bodies such as acetoacetate may be responsible.Metabolic consequences of vomiting15. A, B, EWater and Na loss results in a reduction in intravascular volume. This will elevate the urea andcreatinine. This also triggers release of ADH, which increases urinary osmolality. There is renalreabsorption of Na, and fractional excretion of Na is reduced to <1 per cent. The plasma chloridecan give a clue to the cause of loss. Hypochloraemia is common in vomiting and hyperchloraemiais seen in diarrhoea.Acid–base balance16. A, C, D, EAnion gap is a measure of anions other than chloride and bicarbonate and is calculated as:(NaK)(ClHCO3). The major cations in the body are Na (140 mmol/L) and K (4 mmol/L).Ca and Mg are the other cations.The major anions are chloride (100 mmol/L) and HCO3(27 mmol/L). Proteins and phosphateare among the other anions. Normal anion gap is around 8–16. It is elevated in metabolic acidosis,such as DKA, lactic acidosis, renal failure, salicylate and ethanol intoxication. It can be reducedwhen there are paraproteinaemia states.Answers: Extended matching questions1. Risk of refeeding syndrome1CRefeeding syndrome occurs due to severe fluid and electrolyte shifts and their associatedcomplications in malnourished patients undergoing feeding by the oral, enteral or parenteralroute. Underlying malnutrition, low BMI, pre-existing abnormalities and electrolyte abnormalitiesincrease risk. These are absent in the case above.2ABMI < 16 kg/m2, unintentional weight loss greater than 15 per cent in recent months and nonutritional intake for more than 10 days are, individually, high-risk features for the development ofrefeeding syndrome.3BCaution must be exercised in patients with alcohol-induced liver disease, especially if associatedwith BMI < 18.5 kg/m2or unintentional weight loss of 10 per cent of their body weight in the last3–6 months or if they are on chemotherapeutic agents, insulin or diuretics.

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