Nutrition & Refeeding Syndrome

Malnutrition is extremely common in hospitalised patients, especially those with gastroenterology and liver disease.
Poor nutrition delays recovery, increases complications, and prolongs admissions.

Refeeding syndrome is a potentially life-threatening complication that occurs when nutrition is restarted too quickly in malnourished patients.

This guide focuses on how to recognise risk early, feed safely, and prevent avoidable harm on the ward.

✅ First principle

Always ask:

Is this patient malnourished or at risk of refeeding?

Because:

  • Malnutrition is common
  • Refeeding syndrome is preventable
  • Most harm comes from missing it

Don’t wait for electrolytes to crash before thinking about nutrition.

🟡 Why nutrition matters in GI patients

Common high-risk groups you will see:

  • Cirrhosis
  • Alcohol-related liver disease
  • Chronic pancreatitis
  • IBD flares
  • Cancer
  • Prolonged NBM
  • Frail elderly
  • Patients not eating for days

These patients are often:

  • Catabolic
  • Muscle wasting
  • Hypoalbuminaemic
  • Nutritionally depleted

Even if BMI looks “normal”.

✅ Step 1 – Screen every patient (simple habit)

At admission, ask:

  • How much have they eaten recently?
  • Any weight loss?
  • How long NBM?
  • BMI low?
  • Alcohol excess?

If concerned → refer dietitian early.

Early dietitian input prevents many problems.

🟠 What is refeeding syndrome?

Refeeding syndrome is:

Dangerous electrolyte and fluid shifts that occur when feeding is restarted after starvation.

During starvation:

  • Body adapts to low insulin
  • Electrolytes depleted

When feeding restarts:

  • Insulin rises
  • Electrolytes shift into cells
  • Blood levels crash

Result:

  • Hypophosphataemia
  • Hypokalaemia
  • Hypomagnesaemia
  • Fluid overload

This can cause:

  • Arrhythmias
  • Seizures
  • Respiratory failure
  • Death

✅ Who is high risk for refeeding? (very important)

Think risk first, not labs.

High-risk patients:

  • Little/no intake >5 days
  • Significant weight loss
  • BMI <18.5
  • Alcohol dependence
  • Chronic illness
  • Cancer
  • Elderly/frail
  • Low baseline electrolytes

Classic scenario:

Alcoholic cirrhosis patient who hasn’t eaten for a week

Assume high risk.

✅ Step 2 – Check baseline bloods before feeding

Before starting feeds:

Check:

  • U&E
  • Phosphate
  • Magnesium
  • Potassium
  • Glucose

Never start aggressive feeding without checking these.

✅ Step 3 – Start feeding slowly (this is key)

Common junior mistake:
Giving full meals or full NG feeds immediately.

For high-risk patients:

👉 Start low and increase gradually

Typical practice:

  • Start ~10–20 kcal/kg/day
  • Increase over 4–7 days

Dietitians guide this.

Slow is safe.

✅ Step 4 – Replace vitamins first

Always give:

  • Thiamine (especially alcohol-related disease)

Before and during feeding.

Prevents:

  • Wernicke’s encephalopathy

Never forget thiamine in alcohol-dependent patients.

✅ Step 5 – Monitor closely

For first 3–5 days:

Check:

  • Daily U&E
  • Daily phosphate
  • Magnesium
  • Potassium
  • Fluid balance
  • Weight
  • Observations

Electrolytes often drop within 24–72 hours.

Don’t wait for symptoms.

🚨 Red flags for refeeding syndrome

  • Phosphate falling
  • Potassium falling
  • Magnesium falling
  • Fluid overload
  • Arrhythmias
  • Weakness
  • Confusion

If seen:
👉 slow feeds
👉 replace electrolytes
👉 senior review

✅ Practical ward management

If you suspect or see refeeding:

  • Slow or pause feeding
  • Replace electrolytes aggressively
  • Involve dietitian
  • Cardiac monitoring if severe
  • Senior review

Do not continue full feeds while numbers crash.

🟢 General nutrition principles for GI patients

Even without refeeding risk, nutrition matters daily.

Practical steps:

  • Early dietitian referral
  • High-protein diet
  • Oral supplements (Fortisip etc.)
  • Avoid unnecessary prolonged NBM
  • NG/PEG if poor intake
  • Treat nausea/pain so patients can eat

Nutrition is treatment, not an afterthought.

🟡 Special notes for common GI patients

Cirrhosis:

  • High protein (don’t restrict protein unnecessarily)
  • Late evening snack reduces catabolism

Pancreatitis:

  • Early enteral feeding preferred
  • Don’t keep NBM longer than needed

IBD:

  • High calorie needs
  • Correct deficiencies

Alcohol-related disease:

  • Thiamine always

❌ Common mistakes juniors make

  • Forgetting nutrition entirely
  • Feeding too quickly
  • Not checking phosphate
  • Missing thiamine
  • Waiting for severe symptoms
  • Prolonged unnecessary NBM

Most refeeding syndrome is preventable.

✅ Simple ward checklist

When restarting feeds:

  1. High risk?
  2. Check electrolytes
  3. Give thiamine
  4. Start slow
  5. Monitor daily

That’s it.

✅ Take-home concept

Malnutrition delays recovery.
Refeeding too fast can kill.
Feed early, feed safely, and monitor closely.