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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


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, 6th 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, 6th 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

15 Nausea & Vomiting Prolonged vomiting = hyperemesis Meds:
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


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 B12 Pernicious anemia vitamin B12 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

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, 6th Edition.

49 Malabsorption, steatorrhea
Post-surgical complications affecting nutrition: Fat soluble vitamins, calcium Folate, B12 (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 H2 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 B12 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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