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Medical Nutrition Therapy for Gastrointestinal Tract Disorders.

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Presentation on theme: "Medical Nutrition Therapy for Gastrointestinal Tract Disorders."— Presentation transcript:

1 Medical Nutrition Therapy for Gastrointestinal Tract Disorders

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3 Esophagus  Tube from pharynx to stomach  Upper esophageal sphincter (UES or cardiac sphincter) closed except when swallowing  Lower esophageal sphincter (LES) closes entrance to stomach; prevents reflux of stomach contents back into esophagus

4 Common Symptoms of Gastrointestinal Disease

5 Cancer of the Oral Cavity, Pharynx, Esophagus  Existing nutritional problems and eating difficulties caused by the tumor mass, obstruction, oral infection and ulceration, or alcoholism  Chewing, swallowing, salivation, and taste acuity are often affected.  Weight loss is common.

6 Gastroesophageal Reflux Disease (GERD)  Backward flow of the stomach and/or duodenal contents into the esophagus  Burning sensation after meals; heartburn  Possible discomfort during and after eating, change in eating habits, especially in the evening

7 Hiatal Hernia  An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm  Heartburn after heavy meals or with reclining after meals  May worsen GERD symptoms

8 Anatomy of Esophagus and Hiatal Hernia

9 Nutritional Care for GERD  Maintain upright posture during and minutes after eating  Avoid eating within 2-3 hours before bedtime  Avoid clothing that is tight in the abdominal area  Stop smoking (lower LES pressure)  Limit caffeine intake Source: Am Diet Assoc. Manual of Clinical Nutr, 6 th Edition.

10 Nutritional Care for GERD  Avoid chocolate  Limit/avoid alcohol intake  Achieve and maintain a healthy weight  Elevate the head of bed (6-8 inches) when sleeping  Try problem foods in small quantities as part of a meal. Source: Am Diet Assoc. Manual of Clinical Nutr, 6 th Edition.

11 Medications Used to Tx GERD Antacids  Mylanta, Maalox: neutralize acids  Gaviscon: barrier between gastric contents and esophageal mucosa  H2 receptor antagonists (reduce acid secretion)  Cimetadine, ranitidine, famotidine, nizatidine  Omeprazole (Prilosec) short term

12 Medications Used to Tx GERD Promotility Agents (enhance esophageal clearing and gastric emptying)  Cisapride, bethanechol

13 Surgical Treatment of GERD  Fundoplication: Fundus of stomach is wrapped around lower esophagus to limit reflux

14 Illustration of Fundoplication Source: om/ac/adamsurg.nsf/page/ #

15 Nausea & Vomiting  Prolonged vomiting = hyperemesis –Loss of nutrients, fluids, electrolytes –Dehydration, electrolyte imbalance, wt. loss  Meds: –Antinauseants –Antiemetics

16 Nausea & Vomiting Dietary Measures  NPO for several hours  Clear liquids if tolerated, then progress as tolerated  IV fluids if liquids not tolerated  Parenteral nutrition if severe, though increasingly enteral nutrition is used for hyperemesis of pregnancy

17 Diseases of Stomach  Indigestion  Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: —Alcohol —Aspirin —Nonsteroidal antiinflammatory agents

18 Indigestion (Dyspepsia) Symptoms  Abdominal pain  Bloating  Nausea  Regurgitation  Belching

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20 Dyspepsia Treatment  Avoid offending foods  Eat slowly  Chew thoroughly  Do not overindulge

21 Gastritis  Normally gastric & duodenal mucosa protected by: –Mucus –Bicarbonate (acid neutralized) –Rapid removal of excess acid –Rapid repair of tissue

22 Gastritis  Erosion of mucosal layer  Exposure of cells to gastric secretions, bacteria  Inflammation & tissue damage

23 Gastritis  Helicobacter Pylori (H. pylori) –Bacteria, resistant to acid –Damages mucosa –Treat with bismuth, antibiotics, antisecretory agents –Causes ~92% duodenal ulcers; 70% gastric ulcers

24 Atrophic Gastritis  Loss of parietal cells in stomach –Hypochloria =  in HCl production –Achlorhydria = loss of HCl production –Decrease or loss of intrinsic factor production Malabsorption of vitamin B 12 Pernicious anemia vitamin B 12 injections or nasal spray

25 Peptic Ulcer Disease (PUD)  Gastric or duodenal ulcers  Asymptomatic or sx similar to gastritis or dyspepsia  Danger of hemorrhage, perforation, penetration into adjacent organ or space –Melena = black, tarry stools from GI bleeding

26 Characteristics and Comparisons Between Gastric and Duodenal Ulcers  Gastric ulcer formation involves inflammatory involvement of acid- producing cells but usually occurs with low acid secretion; duodenal ulcers are associated with high acid and low bicarbonate secretion.  Increased mortality and hemorrhage are associated with gastric ulcers.

27 Gastric and Duodenal Ulcers

28 Peptic Ulcer Disease (PUD) Definition and Etiology  Erosion through mucosa into submucosa –H. pylori –Aspirin, NSAIDs –Stress: Severe burns, trauma, surgery, shock, renal failure, radiation

29 Peptic Ulcer Disease (PUD) Medical Management  Plays a more important role than diet –  or stop aspirin, NSAIDs –Use antibiotics, antacids –Use sucralfate (Carafate) = gastric mucosa protectant – forms barrier over ulcer

30 Peptic Ulcer Disease (PUD) Behavioral Management  Avoid tobacco Risk factor for ulcer development  complications – impairs healing, increases incidence of recurrence Interferes with tx Risk of recurrence, degree of healing inhibition correlate with number of cigarettes per day

31 Peptic Ulcer Disease Treatment with Diet  Reduce decaffeinated and regular coffee, cocoa, and tea intake  Avoid alcohol or pepper  Avoid low-pH juices if they cause problems (generally pH in foods is not an issue)  Avoid large meals, especially right before bedtime  Reduce decaffeinated and regular coffee, cocoa, and tea intake  Avoid alcohol or pepper  Avoid low-pH juices if they cause problems (generally pH in foods is not an issue)  Avoid large meals, especially right before bedtime

32 Peptic Ulcer Disease Treatment with Diet  Meal frequency is controversial: small, frequent meals may increase comfort but may also increase acid output  There is little evidence to support eliminating specific foods unless they cause repeated discomfort  Overall good nutritional status helps  H. pylori

33 Gastric Surgery  Indicated when ulcer complicated by: –Hemorrhage –Perforation –Obstruction –Intractability (difficult to manage, cure) –Pt unable to follow medical regimen  Ulcers may recur after med. or surgical tx

34 Gastric Surgery  Resective surgical procedures  “anastamosis” – connection of two tubular structures  Gastrectomy – surgical removal of part or all of stomach –Hemigastrectomy = half –Partial gastrectomy –Subtotal gastrectomy = 30-90% resected

35 Gastric surgical procedures. Fig p. 661.

36 Gastric Surgery  Billroth I = gastroduodenostomy –Partial gastrectomy – anastomosis to duodenum –To remove ulcers, other lesions (cancer)  Billroth II = gastrojejunostomy –Partial gastrectomy - anastomosis to jejunum  Allows resection of damaged mucosa  Reduces number of acid producing cells  Reduces ulcer recurrence

37 Gastric Surgery  Total gastrectomy –Removal of entire stomach –Rarely done = negative impact on digestion, nutritional status –In extensive gastric cancer & Zollinger- Ellison syndrome not responding to medical management –Anastomosis from esophagus to duodenum or jejunum

38 Zollinger-Ellison Syndrome  PUD caused by “gastrinoma” –Gastrin producing tumor in pancreas –Gastrin = hormone stimulates HCl prod –Causes mucosal ulceration –50 – 70% are malignant –Any part of esoph., stomach, duod., jejun. –Removal of tumor, gastrectomy

39 Gastric surgical procedures. (cont.) Fig p. 661.

40 Pyloroplasty  Surgical enlargement of pylorus or gastric outlet  To improve gastric emptying with obstructions or when vagatomy interferes with gastric emptying  May contribute to Dumping Syndrome  Ulcer recurrence is common

41 Roux-en-Y  Gastric partitioning – distal ileum, proximal jejunum  Often for “bariatric” purposes (wt. loss)  Wt loss for 12 – 18 wks with 50 – 60% excess wt. Loss

42 Roux-en-Y  Nutritional Goals: –Prevent deficiencies –Promote eating, lifestyle changes to maintain losses –Mechanical soft diet ~ 3 mo., then solid foods –Small amounts – 1 oz. To 1 cup –Overeating = N & V, reflux

43 Vagotomy  Severing all or part of the vagus nerves to the stomach  With partial gastrectomy or pyroplasty  Significant decrease in acid secretion  “truncal vagotomy” – no vagal stimulation to liver, pancreas, other organs, stomach  “selective vagotomy” or “parietal cell vagotomy” – eliminates stimulation to stomach

44 Diet Post Gastric Surgery  Ice chips allowed hours after surgery. Some tolerate warm water better than ice chips or cold water  Clear liquids such as broth, bouillon, unsweetened gelatin, diluted unsweetened fruit juice  Initiate postgastrectomy diet and gradually progress to general diet as tolerated  Monitor iron, B12, and folic acid status

45 Dumping Syndrome  Complex physiologic response to the rapid emptying of hypertonic contents into the duodenum and jejunum  Dumping syndrome occurs as a result of total or subtotal gastrectomy and is associated with mild to severe symptoms including abdominal distention, systemic systems (bloating, flatulence, pain, diarrhea), and reactive hypoglycemia.

46 Dumping Syndrome  Rapid movement of hypertonic chyme into jejunum  Fluid drawn into bowel by osmosis to dilute concentrated mass of food  Volume of circulating blood decreases Tachycardia (rapid heart rate) Dizziness, flushing Diaphoresis (profuse sweating) Orthostatic hypotension

47 Dumping Syndrome – Dietary Treatment  Small meals spread throughout day  High protein (20%), moderate fat (30 – 40%), complex CHO as tolerated  Very small amts of concentrated sweets  Food and drink should be moderate in temperature  Use caution with high fiber foods – use pectin to decrease transit time, glucose absorption  Take liquids between meals in small amounts (1/2 to 1 cup)

48 Dumping Syndrome Dietary Treatment  Lactose  transit – poorly tolerated  Medium-chain triglycerides-steatorrhea  Eat slowly, chew food thoroughly  If dumping is a problem, have patient lie down minutes after meals to retard transit to small bowel Source: Am Diet Assoc. Manual of Clinical Nutr, 6 th Edition.

49 Malabsorption, steatorrhea  Post-surgical complications affecting nutrition: Fat soluble vitamins, calcium Folate, B 12 (loss of intrinsic factor) Iron – better absorbed with  acid –Supplement may help

50 Drugs Commonly Used to Treat Gastrointestinal Disorders  Antacids: lower acidity  Cimetidine (Tagamet), ranitidine (Zantac): block acid secretion by blocking histamine H 2 receptors  Prostaglandins  Sucralfate: coats and protects surface  Colloidal bismuth: coats and protects surface  Carbenoxolone: strengthens mucosal barrier  Tinidazole: antibiotic

51 Diseases of Stomach—cont’d  Chronic gastritis Precedes gastric lesion like cancer or ulcer H. pylori infection may cause Sx—Indigestion, loss of appetite, feeling full, belching, epigastric pain, nausea, vomiting

52 Diseases of Stomach—cont’d Rx: Avoid foods not tolerated; soft consistency; regular meals; chew foods —Avoid highly seasoned foods; avoid excess liquid at meals  Atrophic gastritis: —Stomach cells atrophy —Loss of parietal cells—achlorhydria —Lose IF for B 12 absorption

53 Disorders of the Stomach— Nutritional Care  Lifestyle changes are an important component of the nutrition care plan.  Patients with dyspepsia should avoid high- fat foods, sugar, caffeine, spices, and alcohol.

54 Diabetic Gastroparesis (Gastroparesis Diabeticorum)  Delayed stomach emptying of solids  Etiology—autonomic neuropathy  Nausea, vomiting, bloating, pain  Insulin action and absorption of food not synchronized  Prescribe small frequent meals (may need liquid diet)  Adjust insulin

55 Summary  Upper GI disorders—H. pylori plays an important role  Maintain individual tolerances as much as possible.


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