Presentation on theme: "Medical Nutrition Therapy for Gastrointestinal Tract Disorders."— Presentation transcript:
Medical Nutrition Therapy for Gastrointestinal Tract Disorders
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
Common Symptoms of Gastrointestinal Disease
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.
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
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
Anatomy of Esophagus and Hiatal Hernia
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.
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.
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
Medications Used to Tx GERD Promotility Agents (enhance esophageal clearing and gastric emptying) Cisapride, bethanechol
Surgical Treatment of GERD Fundoplication: Fundus of stomach is wrapped around lower esophagus to limit reflux
Illustration of Fundoplication Source: om/ac/adamsurg.nsf/page/ #
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
Diseases of Stomach Indigestion Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: —Alcohol —Aspirin —Nonsteroidal antiinflammatory agents
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
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
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.
Gastric and Duodenal Ulcers
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
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
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
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
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
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
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
Gastric surgical procedures. Fig p. 661.
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
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
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
Gastric surgical procedures. (cont.) Fig p. 661.
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
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
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
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
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
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.
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
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)
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.
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
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
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
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
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.
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
Summary Upper GI disorders—H. pylori plays an important role Maintain individual tolerances as much as possible.