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Vitamins and Minerals for the Gastroenterologist

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Vitamins and Minerals for the Gastroenterologist VitaminsVitamins andand MineralsMinerals forfor thethe GastroenterologistGastroenterologist AmyAmy Tiu,Tiu, MDMD Feb.Feb. 9,9, 20062006 7:00AM7:00AM conferenceconference ObjectivesObjectives DescriptionDescription fatfat--solublesoluble andand waterwater solublesoluble vitaminsvitamins TraceTrace mineralsminerals (zinc,(zinc, selenium,selenium, iodide,iodide, copper,copper, chromium)chromium) DeficiencyDeficiency andand ToxicityToxicity SourcesSources andand RecommendationsRecommendations ClinicalClinical implicationimplication HistoryHistory 18351835 BritishBritish ParliamentParliament passedpassed thethe MerchantMerchant SeamanSeaman’’ss ActAct thatthat requiredrequired lemonlemon juicejuice toto bebe includedincluded inin thethe rationsrations ofof sailorssailors toto preventprevent scurvyscurvy 19121912 CasimirCasimir FunkFunk coinedcoined thethe termterm vitaminevitamine DailyDaily ValuesValues (DV(DV waswas RDA)RDA) establishedestablished byby thethe NationalNational AcademyAcademy ofof SciencesSciences andand NationalNational ResearchResearch CouncilCouncil asas thethe amountamount toto preventprevent grossgross deficiencydeficiency syndromessyndromes WhichWhich foodfood hashas thethe mostmost vitaminvitamin A?A? Sweet potatoes Beef liver Cantoloupe 1 RE = 10 IU MVI = 3500 IU TPN = 3300 IU VitaminVitamin AA Prevents xerophthalmia (abnormalities in corneal and conjunctival development) Phototransduction Cellular differentiation and integrity of the eye Ancient Egyptians used liver to treat night blindness VitaminVitamin AA DeficiencyDeficiency MainMain featurefeature (nyctalopia)(nyctalopia) Vitamin NightNight blindnessblindness A IssuesIssues RetinalRetinal formationformation ofof rhodopsinrhodopsin OtherOther featuresfeatures Corneal,Corneal, conjunctivaconjunctiva Dermatitis,Dermatitis, keratomalaciakeratomalacia PhrynodermaPhrynoderma (follicular(follicular hyperkeratosis)hyperkeratosis) BlockageBlockage ofof hairhair folliclesfollicles withwith plugsplugs ofof keratinkeratin Dry,Dry, scaly,scaly, roughrough ForearmsForearms andand thighsthighs GIGI patientspatients atat riskrisk ofof VitaminVitamin AA deficiencydeficiency CrohnCrohn’’ss (small(small bowel)bowel) CeliacCeliac spruesprue CholestaticCholestatic liverliver diseasedisease PancreaticPancreatic deficiencydeficiency ShortShort gutgut CysticCystic fibrosisfibrosis VitaminVitamin AA toxicitytoxicity Arctic explorers who feasted on polar bear liver (10 million IU/lb) acute overdose with n/v; fatigue, weakness, headache, anorexia Dermatitis, xerosis, hair loss, joint pain, hyperostosis, hepatomegaly, pseudotumor VitaminVitamin AA toxicity:toxicity: 33 syndromessyndromes AcuteAcute (>660,000(>660,000 units):units): n/v;n/v; vertigo;vertigo; blurryblurry vision;vision; drowsiness,drowsiness, malaisemalaise ChronicChronic (higher(higher thanthan 10X10X dailydaily values):values): ataxia;ataxia; alopecia;alopecia; hyperlipidemia;hyperlipidemia; hepatotoxicity,hepatotoxicity, bonebone andand mskmsk pain;pain; visualvisual impairments;impairments; increaseincrease riskrisk osteoporoticosteoporotic fracturesfractures (need(need toto avoidavoid >5000>5000 units)units) TeratogenicTeratogenic:: firstfirst trimester;trimester; spontaneousspontaneous abortion;abortion; fetalfetal anomaliesanomalies WhatWhat vitaminvitamin waswas addedadded inin thisthis experimentexperiment toto makemake thethe ratsrats fertile?fertile? 19221922 EvansEvans andand BishopBishop discovereddiscovered aa substancesubstance thatthat waswas deficientdeficient inin ratsrats fedfed aa dietdiet thatthat containedcontained lardlard andand thatthat resultedresulted inin infertilityinfertility WhenWhen theythey addedadded aa lipidlipid extractextract thethe ratsrats becamebecame sterile.sterile. VitaminVitamin EE (Tocopherol)(Tocopherol) EightEight naturallynaturally occurringoccurring compoundscompounds (alpha,(alpha, beta,beta, gamma,gamma, andand delta)delta) FreeFree radicalradical scavenger,scavenger, protectingprotecting polyunsaturatedpolyunsaturated fattyfatty acidsacids (PUFA),(PUFA), aa majormajor structuralstructural componentcomponent ofof cellcell membranesmembranes fromfrom peroxidationperoxidation VitaminVitamin EE ••ReducedReduced plasmaplasma andand hepatichepatic vitaminvitamin EE levelslevels havehave beenbeen reportedreported inin liverliver diseasedisease ••VitaminVitamin EE hashas antioxidant/antioxidant/ antianti--inflammatoryinflammatory propertiesproperties VitaminVitamin EE 10000 protectsprotects againstagainst 9000 8000 CClCCl44 7000 6000 hepatotoxicityhepatotoxicity T 5000 AL 4000 3000 2000 1000 0 CCl4 None 1 mg 3 mg Treatment Zern’s lab, Am. J Physiol 267, 1994 VitaminVitamin EE deficiency:deficiency: RARERARE AtAt risk:risk: cirrhosis,cirrhosis, cholestaticcholestatic liverliver disease,disease, cysticcystic fibrosis,fibrosis, smallsmall bowelbowel bacterialbacterial overgrowth,overgrowth, pancreaticpancreatic insufficiency,insufficiency, glutengluten sensitivesensitive enteropathy,enteropathy, regionalregional enteritisenteritis DeficiencyDeficiency proportionalproportional toto magnitudemagnitude andand durationduration ofof steatorrheasteatorrhea SkeletalSkeletal myopathy,myopathy, spinocerebellarspinocerebellar ataxia,ataxia, pigmentedpigmented retinopathy;retinopathy; hemolytichemolytic anemiaanemia (G(G--66--PD)PD) deficiency;deficiency; areflexiaareflexia VitaminVitamin EE toxicity:toxicity: UnusualUnusual MayMay interfereinterfere withwith vitaminvitamin K,K, arachidonicarachidonic acidacid metabolismmetabolism LargeLarge oraloral supplementssupplements associatedassociated withwith necrotizingnecrotizing enterocolitisenterocolitis inin infantsinfants Headache,Headache, MyopathyMyopathy VitaminVitamin EE VitaminVitamin EE supplementationsupplementation withwith aa dosedose >> 400400 IU/dayIU/day waswas associatedassociated withwith aa significantlysignificantly increasedincreased riskrisk ofof allall--causecause mortalitymortality (95%(95% CICI 33--7474 perper 10,00010,000 persons);persons); (meta(meta analysisanalysis ofof 1919 RCTsRCTs)) NoteNote 11 mgmg (alpha(alpha tocopheroltocopherol equivalent)equivalent) equalsequals 1.491.49 IUIU RecRec:: 1010 mg/daymg/day forfor men;men; 88 mg/daymg/day forfor womenwomen MVIMVI == 3030 IU;IU; TPNTPN == 1010 IUIU VitaminVitamin KK 19301930 IsolatedIsolated byby DoisyDoisy andand colleaguescolleagues ““antihemorrhagicantihemorrhagic factorfactor”” HenrickHenrick DamDam foundfound itit capablecapable ofof reversingreversing dietarydietary inducedinduced bleedingbleeding disordersdisorders inin chickschicks VitaminVitamin K:K: 33 formsforms PhylloquinonePhylloquinone:: greengreen plantsplants MenaquinoneMenaquinone:: formedformed asas thethe resultsresults ofof bacterialbacterial actionaction inin thethe intestinalintestinal tracttract WaterWater--solublesoluble formform (K1(K1 andand K2)K2) NoneNone ofof thethe formsforms areare storedstored inin appreciableappreciable amountsamounts DestroyedDestroyed byby alkalialkali andand lightlight VitaminVitamin KK metabolismmetabolism RequiresRequires pancreaticpancreatic andand biliarybiliary functionfunction forfor intactintact absorptionabsorption ProteinProtein boundbound andand requiresrequires pancreaticpancreatic enzymesenzymes inin thethe smallsmall intestineintestine forfor liberationliberation VitaminVitamin KK functionfunction CofactorCofactor forfor carboxylasecarboxylase VitaminVitamin KK essentialessential forfor activityactivity ofof clottingclotting factorsfactors 7,9,107,9,10 prothrombin,prothrombin, andand anticoagulantanticoagulant proteinprotein CC andand SS VitaminVitamin KK deficiencydeficiency Risk:Risk: TPN,TPN, longlong termterm antibioticsantibiotics EasyEasy bruisabilitybruisability,, mucosalmucosal bleeding,bleeding, splintersplinter hemorrhages,hemorrhages, melena,melena, hematuriahematuria HemorrhagicHemorrhagic diseasedisease ofof thethe newborn:newborn: developsdevelops withinwithin thethe firstfirst weekweek ofof lifelife DVDV isis 6565 toto 8080 micrograms/daymicrograms/day whichwhich cancan bebe achievedachieved withwith dietarydietary intakeintake TPNTPN == 150150 microgramsmicrograms MVIMVI == 2525 microgramsmicrograms VitaminVitamin KK ToxicityToxicity Infants:Infants: hemolytichemolytic anemia;anemia; hyperbilirubinemia,hyperbilirubinemia, jaundice,jaundice, andand kernicteruskernicterus WithWith rapidrapid IVIV infusioninfusion possiblepossible flushingflushing andand cardiovascularcardiovascular collapsecollapse VitaminVitamin DD (calciferol)(calciferol) FirstFirst recognizedrecognized byby McCollumMcCollum asas thethe componentcomponent ofof codcod liverliver oiloil thatthat waswas cablecable ofof curingcuring ricketsrickets RoleRole inin calciumcalcium homeostasishomeostasis andand bonebone metabolismmetabolism MayMay havehave aa rolerole inin inhibitinginhibiting thethe carcinogeniccarcinogenic effectseffects ofof bilebile acidsacids throughthrough calciumcalcium bindingbinding inin thethe bowelbowel lumenlumen MetabolismMetabolism Skin photoisomerization from D to D3 Liver hydroxylates vitamin D Kidney further hydroxylates Active form CausesCauses ofof VitaminVitamin DD deficiencydeficiency DecreasedDecreased intake/intake/ InsufficiencyInsufficiency sunlightsunlight FatFat malabsorptionmalabsorption (celiac(celiac disease,disease, pancreaticpancreatic insufficiency,insufficiency, IBD,IBD, cysticcystic fibrosis,fibrosis, postpost-- gastrectomygastrectomy states,states, andand
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