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Chapter 18 Gastrointestinal and Accessory Organ Problems

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1 Chapter 18 Gastrointestinal and Accessory Organ Problems

2 Objectives: Identify problems of the upper gastrointestinal tract
Identify problems of the lower gastrointestinal tract Identify food allergies and intolerances Identify problems of the gastrointestinal accessory organs 2

3 Key Concepts Diseases of the gastrointestinal tract and its accessory organs interrupt the body’s normal cycle of digestion, absorption, and metabolism Food allergies result from sensitivity to certain proteins Underlying genetic diseases may cause metabolic defects that block the body’s ability to handle specific food nutrients.

4 Problems of the Mouth Dental problems Tooth decay
Ill-fitting dentures, loss of teeth  problems with eating, swallowing, and overall nutrition Mechanical soft diet helpful Post Surgical procedures E.g. fx. Jaw, head/neck surgeries Healing nutrients administered with high- protein, high-caloric milk shakes 4

5 Gingivitis/TMJ problems
5

6 Problems of the Mouth Oral tissue inflammation – malnutrition causes deterioration of oral tissues resulting in local infection or injury  pain and difficulty eating Gingivitis – inflammation of the gums + the tissues encircling the base of the teeth Stomatitis –inflammation of the oral mucous lining of the mouth Glossitis – inflammation of the tongue Cheilosis – a cracking and dry scaling process at the corners of the mouth affecting the lips and corner angles making opening the mouth to eat painful 6

7 Mouth ulcers may develop from 3 infections:
Herpes Simplex Virus  mouth sores on the inside mucous lining of the cheeks and lips or on the external portion of the lips (cold sores, blisters) Candida Albicans – a fungus causing similar sores on the oral mucosa (thrush) Hemolytic Streptococcus – bacteria causing canker sores Eating is painful and adequate nutrition becomes a major problem Nutritionally dense liquids  soft, nonacidic and nonspicy, room temperature foods

8 Salivary gland problems
Infections – e.g. virus that attacks the parotid gland (mumps) Excess salivation – e.g. Parkinson’s, local mouth infections, injury and drug reactions Xerostomia (permanent dry mouth) – sometimes in middle-aged and elderly adults often associated with RA, radiation therapy, drug side effect

9 Problems of the Mouth Swallowing disorders
Dysphagia (difficulty swallowing) fairly common problem Variety of causes: Insufficient production of saliva Dry mouth Abnormal peristaltic motility of the esophagus Complications of medication Neurologic problems 9

10 Problems of the Mouth Swallowing Disorders cont.
To treat dysphagia, the problem must be identified as either mechanical obstruction or a neuromuscular disorder Dysfunctional swallowing  aspirate food particles Swallowing disorders common in trauma, brain injury, and stroke patients Diet adaptations may be necessary Special feeding techniques

11 Warning signs of swallowing disorders:
Problems of the Mouth Warning signs of swallowing disorders: Reluctance to eat certain food consistencies or any food at all Very slow chewing or eating Fatigue from eating Frequent throat clearing Complaints of food “sticking” in throat Holding pockets of food in cheeks Painful swallowing Regurgitation, coughing, choking 11

12 Problems of the Esophagus
Central tube (esophagus) – problems interrupt normal swallowing: Muscle spasms or uncoordinated contractions Stricture (narrowing) of the tube Lower esophageal sphincter problems May come from changes in the smooth muscle itself or from the nerve-muscle hormone control of peristalsis 12

13 Problems of the Esophagus
Lower Esophageal Sphincter Problems cont. Achalasia or cardiospasm –spasms occur when the LES muscles maintain an excessively high muscle tone, even while resting, thus failing to open normally when a person swallows Sx. – swallowing problems, frequent vomiting, feeling of fullness in chest, weight loss from eating difficulty, serious malnutrition, pulmonary complications Treatment – surgical – dilate the LES or slit the muscle Diet: oral liquids and progress to regular diet

14 Mixture of liquid antacid
GI Cocktail Mixture of liquid antacid Viscous lidocaine Donnatol Useful as part of the diagnostic protocol for patients complaining of chest pain 14

15 Problems of the Esophagus
Gastroesophageal Reflux Disease (GERD) Caused by constant regurgitation of acid gastric contents into lower esophagus  esophagitis Pregnancy, obesity, pernicious vomiting, or nasogastric tubes are factors Gastric acid and pepsin cause tissue erosion Stenosis (narrowing or stricture) most common complication + peptic ulcer 15

16 Problems of the Esophagus
GERD cont. Treatment: Weight management Acid control Low-fat diet Sleep with HOB elevated 16

17 Normal Stomach 17

18 Hiatal hernia Hiatal hernia
Portion of upper stomach protrudes through opening in the diaphragm membrane (hiatus) Especially common in obese adults

19 Peptic Ulcer Disease Incidence:
Lifetime prevalence of PUD is approx. 10%, occurring simultaneously in men and women Seen mostly in middle adulthood between the ages of 45-55 80-90% caused by Helicobacter pylori (H. pylori) infection (bacteria) Persons with chronic H. Pylori are at greater risk for gastric cancer Tobacco smoking linked to PUD 19

20 Peptic Ulcer Disease Chronic use of nonsteroidal anti-inflammatory (NSAID) drugs may contribute to development in some persons  irritate the gastric mucosa  bleeding, erosion, and ulceration 20

21 Physical Factors: Lesion can occur in the lower esophagus, stomach, or the first portion of the duodenum Most occur in the first portion of the duodenum (duodenal bulb) because the gastric contents emptying there are more concentrated The lesion results from an imbalance between: 1. the amount of gastric acid and pepsin secretions plus the extent of H. pylori infection 2. the degree of tissue resistance to these secretions and infection

22 Psychological Factors:
Stress during young- and middle- adult years may contribute Stress of emergency trauma and injury Long term rehab processes Clinical symptoms: Increased gastric muscle tone and painful contractions when stomach empty Hemorrhage Dx. Confirmed by radiographs and gastroscopy

23 Peptic Ulcer Disease 23

24 Peptic Ulcer Disease Medical Management: 4 basic goals:
Alleviate the symptoms Promote healing Prevent recurrences by eliminating the cause Prevent complications 24

25 Peptic Ulcer Disease Treatment:
REST: adequate rest, relaxation, and sleep – enhances the body’s healing process Anxiety Management: incorporate positive coping skills into daily life encourage pts. to talk about anxieties, anger, frustrations Appropriate physical activity Smoking, alcohol use should be eliminated Some common drugs (e.g. ASA, NSAIDS) should be avoided

26 Drug therapy Blocking agents that control acid secretion Tagamet, Zantac Proton Pump Inhibitors – inhibit HCl production Omeprazole, Pantoprazole Mucosal protectors inactivate pepsin and produce gel-like substance to cover ulcer Sucralfate (Carafate) Antibiotics control H. pylori Amoxicillin, Tetracycline, Metronidazole Antacids counteract or neutralize acid

27 Peptic Ulcer Disease Dietary management Well-balanced, healthy diet
Avoid acid stimulation Food quantity Milk intake Seasonings Dietary Fiber Avoid caffeine, citric acid juices, alcohol Avoid smoking Bland diets have been proven to be ineffective and lacking in adequate nutrition 27

28 Small Intestine Diseases
Malabsorption syndromes are characterized by a defect in the absorption of fats, proteins, carbohydrate, vitamins, minerals, and/or water. 28

29 Small Intestine Diseases
Malabsorption results from a disturbance in the normal digestive process and the defect may include any of the following processes: Digestion of macronutrients (CHO, proteins, fats) Terminal digestion at the brush border mucosa Transport Chronic Diarrhea/Steatorrhea – most common symptom of malabsorption disorders

30 Small Intestine Diseases
Malabsorption -Causes: Maldigestion problems – pancreatic disorders, bacterial overgrowth, Inflammatory bowel disease Intestinal mucosal changes – mucosal surface alterations; surgery Genetic disease – e.g. cystic fibrosis (pancreatic insufficiency, lack of pancreatic enzymes Intestinal enzyme deficiency – e.g. lactose intolerance Cancer and its treatment – effects of radiation and chemotherapy Metabolic defects – absorbing surface effects of pernicious anemia and gluten-induced mucosal disease 30

31 Small Intestine Diseases
3 common malabsorption conditions: Cystic Fibrosis Inflammatory Bowel Disease Diarrhea

32 Small Intestine Disease
Cystic Fibrosis Most fatal genetic disease in North America Metabolic defect characterized as a pulmonary disease with a profound GI impact Life expectancy now to adulthood Inhibits movement of chloride and sodium ions in the body tissue fluids These ions become trapped in cells causing thick mucous to form that clogs ducts and passageways CF symptoms: Thick mucous in the lungs  damaged airways  difficulty breathing and lung infections

33 Small Intestine Disease
Cystic Fibrosis symptoms cont. Pancreatic Insufficiency  lack of normal pancreatic enzymes and progressive loss of insulin-producing beta cells  diabetes mellitus Malabsorption of undigested food nutrients  malnutrition and stunted growth Liver disease from progressive degeneration of functional liver tissue d/t clogged bile ducts Salt concentration increased in body perspiration  salt depletion

34 Cystic Fibrosis

35 Symptoms of CF Clinical manifestations: very salty-tasting skin;
persistent coughing, at times with phlegm; frequent lung infections; wheezing or shortness of breath; poor growth/weight gain in spite of a good appetite; and frequent greasy, bulky stools or difficulty in bowel movements 35

36 36

37 Small Intestine Diseases
Cystic fibrosis cont. Nutrition Management Treated with pancreatic replacement products Children with CF require 105% - 150% of recommended nutrients for their age Nutritionally adequate high-protein, normal-to-high fat diet recommended Regular Nutritional Assessment, Education, and follow up care 37

38 Intestine Diseases Inflammatory Bowel Disease
Applies to both Ulcerative Colitis and Crohn’s disease Related condition: Short-bowel syndrome - results from repeated surgical removal of parts of the small intestine as disease progresses Reduces absorption of nutrients because absorbing surfaces are reduced Considered “idiopathic” diseases because their etiology is unknown 38

39 Intestinal Diseases Inflammatory Bowel Disease cont.
Crohn’s Disease: most commonly localized in the ileum and colon Inflammation may skip sections of the GI tract and affect more than 1 section at a time Ulcerative Colitis: limited to the colon Symptoms include: diarrhea with blood and mucous, abdominal pain, cramping Progressive from the anus

40 Intestinal Diseases All inflammatory bowel conditions can have severe nutritional results as more and more of the absorbing surface area becomes involved.

41 Intestinal Disease Inflammatory Bowel Disease cont.
Restoring positive nutrition is a basic requirement for tissue healing and health Elemental Formulas of amino acids, glucose, fat, minerals, and vitamins are more easily absorbed and support initial healing in response to antibacterial and anti-inflammatory medications. Principles of continuing dietary management: High protein (omitting milk at first) High energy kcal/day Increased vitamins and minerals

42 Intestinal Disease Diarrhea
Typically not a disease of the small intestine A symptom or result of another underlying cause May result from: Intolerance to specific foods Acute food poisoning from a specific food-borne organism or toxin Viral infections

43 Small Intestine Diseases
Diarrhea cont. Organisms include: Parasites: Giardia, Cryptsporidium, Entamoeba Bacteria: Campylobacter, Clostridium Difficile, E. coli, Listeria Monocytogenes, Salmonella, Shigella Virus: HIV, rotovirus Chronic diarrhea can be life-threatening for infants, young children and those with compromised immune systems  dehydration and nutrient loss Fluid and electrolyte replacement needed

44 Large Intestine Diseases
Diverticular disease Diverticulosis: lower intestinal condition Formation of many small pouches (diverticula) along muscular mucosal lining Develop at points of weakened muscles in the bowel wall Diverticulitis caused by pockets becoming infected 44

45 45

46 Large Intestine Diseases
Diverticular Disease cont. Symptoms: as the inflammatory process advances: Increase pain localized in LLQ of abdomen N/V/D, distention, intestinal spasm Fever Perforation  surgery Nutritional Therapy – increase dietary fiber; avoid nuts, seeds

47 Large Intestine Diseases
Irritable bowel syndrome Multicomponent disorder of physiologic, emotional, environmental, psychologic function 3 major types of symptoms: Chronic recurrent pain in abdomen Small-volume bowel dysfunction (constipation, diarrhea, or both) Excess gas formation 47

48 Irritable Bowel Syndrome
48

49 Large Intestine Diseases
Irritable bowel syndrome Individual approach to nutrition care essential Food Plan Basic Principles: Increase dietary fiber Recognize gas formers Respect food intolerances Reduce total fat content Avoid large meals Decrease air-swallowing habits 49

50 Large Intestine Diseases
Constipation Common short-term problem Nervous tension and worry Changes in routines Constant laxative use Low-fiber diets Lack of exercise Dietary management rather than laxatives 50

51 Food Allergies and Intolerances
Allergic reaction is body’s immune system reacting to a protein as a threatening foreign object “Allergy”: from 2 Grk. words meaning “altered reactivity” and refers to the abnormal reactions of the immune system to a number of substances in the environment. 51

52 Food Allergies and Intolerances
Most common food allergens include proteins in: Cow’s milk Eggs Peanuts Wheat Soy Fish/shellfish Tree nuts

53 Food Allergies and Intolerances
If a child is showing signs of allergic reaction, a process of food elimination is sometimes used to identify disagreeable foods. If a given food causes an allergic reaction, the food is identified as an allergen and eliminated from use. The food may be tried again later to see if it still causes the same reaction, validating the initial response.

54 Food Allergies Recognizing s/sx of allergic reactions may save a life
Anaphylaxis is the most severe response to an allergen Swelling of the face and throat Respiratory distress Decreased blood pressure Death 54

55 Food Allergies and Intolerances
Most common symptoms of food allergies are: Hives, nausea, diarrhea, and abdominal pain Dietitian can provide guidance on food substitutions or special food products Recipes modified to maintain nutritional needs for growth

56 Large Intestine Diseases
Celiac Sprue/Celiac Disease The cause: Hypersensitivity to the protein gluten in certain grains – wheat, barley, rye GI tract has damaged mucosal surface  villi and microvilli that are malformed and deficient in number Steatorrhea (approx. 80% of fat appears in the stool) and progressive malnutrition are secondary effects to gluten reaction 56

57 Small Intestine Diseases
Celiac Sprue cont. Nutrition management: Goal: to control dietary gluten intake and prevent malnutrition Avoid wheat, rye, oats, barley Adhering to a low-gluten or gluten-free diet is the only effective tx. in maintaining a healthy mucosa Must be followed for life Possible vitamin supplementation 57

58 Problems of the GI Accessory Organs
3 major accessory organs: Liver Gallbladder Pancreas Produce digestive agents Diseases of these organs affect GI function and cause problems with the handling of specific foods

59 Liver Function Essential functions: Bile production
Synthesis of proteins and blood clotting factors Metabolism of hormones, medications, macronutrients and micronutrients Regulation of blood glucose levels Urea production to remove the waste products of normal metabolism

60 Liver Disease Steatohepatitis
“the silent liver disease” – inflammation and fat accumulation Exact cause is unknown Most often associated with alcohol abuse However, approx. 2-5% of Americans who drink little are also affected. “Nonalcoholic steatohepatitis”. Higher incidence for individuals with diabetes or obesity.

61 Liver Disease Hepatitis
Acute Hepatitis is an inflammatory condition caused by viruses, alcohol, drugs, or toxins Virus often transmitted via the oral-fecal route The carrier is usually contaminated food or water Other modes of transmission: blood transfusion, contaminated syringes, needles 61

62 Liver Disease Hepatitis cont.
Symptoms: anorexia, jaundice, underlying malnutrition Treatment : rest, nutrition therapy Nutritional Therapy: Adequate protein, high CHO, low fat, high kcals; Progress from liquid feedings  full diet

63 Liver Diseases Cirrhosis Often a chronic state
Fatty cirrhosis associated with malnutrition and alcoholism Fatty infiltration kills liver cells, leaving nonfunctioning scar tissue Low plasma protein levels  ascites (fluid collection in the abdomen) Scar tissue impairs blood circulation elevated venous pressure esophageal varices Rupture of varices  massive hemorrhage 63

64 Liver Disease Nutritional Therapy Protein according to tolerance
If no s/sx hepatic coma, g of protein per day to correct severe malnutrition, heal liver tissue, and restore plasma protein Low sodium Soft texture Optimal general nutrition : No alcohol

65 Liver Disease Hepatitis cont.
Treatment based on bed rest and nutrition therapy: High protein, high CHO, moderate fat, high energy; liquid diet  full diet as tolerated

66 Liver Diseases Hepatic Encephalopathy
As cirrhosis continues, the blood, carrying its ammonia load, cannot get to the liver for its normal removal of the ammonia and nitrogen Ammonia intoxication and coma occur Blood by passes the liver through collateral circulation and goes brain Hepatic encephalopathy  apathy, confusion, inappropriate behavior, drowsiness, and coma Treatment focuses on removing sources of excess ammonia – reduce protein intake 66

67 Advanced Liver Disease
67

68 Gall Bladder Disease Basic function of the Gall bladder: to concentrate and store bile Releases concentrated bile into small intestine in response to fat Bile emulsifies fat and then carries it into the cells of the intestinal wall for continued metabolism 68

69 Gallbladder Disease Cholecystitis – inflammation of the GB
Usually results from low-grade chronic infection Continued infection alters solubility of bile ingredients, cholesterol separated out, and forms gallstones  cholelithiasis When infection, stones or both are present, the normal contraction of the GB (triggered by fat entering the intestine) causes pain May need surgery for treatment: Cholecystectomy Diet therapy centers on controlling fat intake 69

70 Gallstones 70

71 Pancreatic Disease Pancreas:
Key organ in normal digestion and metabolism Digestive enzymes and bicarbonates Breakdown carbohydrates, proteins, and fats Blood glucose regulation Glucagon Insulin 71

72 Pancreatic Diseases Diabetes mellitus Acute pancreatitis
Chronic pancreatitis Pancreatic enzyme deficiency Pancreas tumor 72

73 Pancreatic Disease Pancreatitis – acute inflammation of the pancreas occurs when the very enzyme that the pancreas produces (trypsin) digests the organ tissue Symptoms: Severe pain Recurrent episodes Excessive alcohol and gallstones are the major causes

74 Pancreatic Disease Pancreatitis cont.
Obstruction of common duct causes enzymes and bile to back up into pancreas Results in acute inflammation as enzymes digest organ tissue Caused by gallstones and excessive alcohol consumption Treatment includes: fluid and electrolyte replacement, antibiotics, pain med, sometimes gastric suctioning Avoid alcohol and caffeine 74


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