3Esophagus Tube from pharynx to stomach Upper esophageal sphincter (UES or cardiac sphincter) closed except when swallowingLower esophageal sphincter (LES) closes entrance to stomach; prevents reflux of stomach contents back into esophagus
5Cancer of the Oral Cavity, Pharynx, Esophagus Existing nutritional problems and eating difficulties caused by the tumor mass, obstruction, oral infection and ulceration, or alcoholismChewing, swallowing, salivation, and taste acuity are often affected.Weight loss is common.
6Gastroesophageal Reflux Disease (GERD) Backward flow of the stomach and/or duodenal contents into the esophagusBurning sensation after meals; heartburnPossible discomfort during and after eating, change in eating habits, especially in the evening
7Hiatal HerniaAn outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragmHeartburn after heavy meals or with reclining after mealsMay worsen GERD symptoms
9Nutritional Care for GERD Maintain upright posture during and minutes after eatingAvoid eating within 2-3 hours before bedtimeAvoid clothing that is tight in the abdominal areaStop smoking (lower LES pressure)Limit caffeine intakeSource: Am Diet Assoc. Manual of Clinical Nutr, 6th Edition.
10Nutritional Care for GERD Avoid chocolateLimit/avoid alcohol intakeAchieve and maintain a healthy weightElevate the head of bed (6-8 inches) when sleepingTry problem foods in small quantities as part of a meal.Source: Am Diet Assoc. Manual of Clinical Nutr, 6th Edition.
11Medications Used to Tx GERD AntacidsMylanta, Maalox: neutralize acidsGaviscon: barrier between gastric contents and esophageal mucosaH2 receptor antagonists (reduce acid secretion)Cimetadine, ranitidine, famotidine, nizatidineOmeprazole (Prilosec) short term
12Medications Used to Tx GERD Promotility Agents (enhance esophageal clearing and gastric emptying)Cisapride, bethanechol
13Surgical Treatment of GERD Fundoplication: Fundus of stomach is wrapped around lower esophagus to limit reflux
15Nausea & Vomiting Prolonged vomiting = hyperemesis Meds: Loss of nutrients, fluids, electrolytesDehydration, electrolyte imbalance, wt. lossMeds:AntinauseantsAntiemetics
16Nausea & Vomiting Dietary Measures NPO for several hoursClear liquids if tolerated, then progress as toleratedIV fluids if liquids not toleratedParenteral nutrition if severe, though increasingly enteral nutrition is used for hyperemesis of pregnancy
17Diseases of Stomach Indigestion Acute gastritis from: H. pylori tobacco, chronic use of drugs such as:—Alcohol—Aspirin—Nonsteroidal antiinflammatory agents
24Atrophic Gastritis Loss of parietal cells in stomach Hypochloria = in HCl productionAchlorhydria = loss of HCl productionDecrease or loss of intrinsic factor productionMalabsorption of vitamin B12Pernicious anemiavitamin B12 injections or nasal spray
25Peptic Ulcer Disease (PUD) Gastric or duodenal ulcersAsymptomatic or sx similar to gastritis or dyspepsiaDanger of hemorrhage, perforation, penetration into adjacent organ or spaceMelena = black, tarry stools from GI bleeding
26Characteristics 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.
28Peptic Ulcer Disease (PUD) Definition and Etiology Erosion through mucosa into submucosaH. pyloriAspirin, NSAIDsStress:Severe burns, trauma, surgery, shock, renal failure, radiation
29Peptic Ulcer Disease (PUD) Medical Management Plays a more important role than diet or stop aspirin, NSAIDsUse antibiotics, antacidsUse sucralfate (Carafate) = gastric mucosa protectant – forms barrier over ulcer
30Peptic Ulcer Disease (PUD) Behavioral Management Avoid tobaccoRisk factor for ulcer development complications – impairs healing, increases incidence of recurrenceInterferes with txRisk of recurrence, degree of healing inhibition correlate with number of cigarettes per day
31Peptic Ulcer Disease Treatment with Diet Reduce decaffeinated and regular coffee, cocoa, and tea intakeAvoid alcohol or pepperAvoid low-pH juices if they cause problems (generally pH in foods is not an issue)Avoid large meals, especially right before bedtime
32Peptic Ulcer Disease Treatment with Diet Meal frequency is controversial: small, frequent meals may increase comfort but may also increase acid outputThere is little evidence to support eliminating specific foods unless they cause repeated discomfortOverall good nutritional status helps H. pylori
33Gastric Surgery Indicated when ulcer complicated by: HemorrhagePerforationObstructionIntractability (difficult to manage, cure)Pt unable to follow medical regimenUlcers may recur after med. or surgical tx
34Gastric Surgery Resective surgical procedures “anastamosis” – connection of two tubular structuresGastrectomy – surgical removal of part or all of stomachHemigastrectomy = halfPartial gastrectomySubtotal gastrectomy = 30-90% resected
36Gastric Surgery Billroth I = gastroduodenostomy Partial gastrectomy – anastomosis to duodenumTo remove ulcers, other lesions (cancer)Billroth II = gastrojejunostomyPartial gastrectomy - anastomosis to jejunumAllows resection of damaged mucosaReduces number of acid producing cellsReduces ulcer recurrence
37Gastric Surgery Total gastrectomy Removal of entire stomach Rarely done = negative impact on digestion, nutritional statusIn extensive gastric cancer & Zollinger-Ellison syndrome not responding to medical managementAnastomosis from esophagus to duodenum or jejunum
38Zollinger-Ellison Syndrome PUD caused by “gastrinoma”Gastrin producing tumor in pancreasGastrin = hormone stimulates HCl prodCauses mucosal ulceration50 – 70% are malignantAny part of esoph., stomach, duod., jejun.Removal of tumor, gastrectomy
39Gastric surgical procedures. (cont.) Fig p. 661.
40Pyloroplasty Surgical enlargement of pylorus or gastric outlet To improve gastric emptying with obstructions or when vagatomy interferes with gastric emptyingMay contribute to Dumping SyndromeUlcer recurrence is common
41Roux-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
42Roux-en-Y Nutritional Goals: Prevent deficiencies Promote eating, lifestyle changes to maintain lossesMechanical soft diet ~ 3 mo., then solid foodsSmall amounts – 1 oz. To 1 cupOvereating = N & V, reflux
43Vagotomy Severing all or part of the vagus nerves to the stomach With partial gastrectomy or pyroplastySignificant 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
44Diet Post Gastric Surgery Ice chips allowed hours after surgery. Some tolerate warm water better than ice chips or cold waterClear liquids such as broth, bouillon, unsweetened gelatin, diluted unsweetened fruit juiceInitiate postgastrectomy diet and gradually progress to general diet as toleratedMonitor iron, B12, and folic acid status
45Dumping SyndromeComplex physiologic response to the rapid emptying of hypertonic contents into the duodenum and jejunumDumping 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.
46Dumping Syndrome Rapid movement of hypertonic chyme into jejunum Fluid drawn into bowel by osmosis to dilute concentrated mass of foodVolume of circulating blood decreasesTachycardia (rapid heart rate)Dizziness, flushingDiaphoresis (profuse sweating)Orthostatic hypotension
47Dumping Syndrome – Dietary Treatment Small meals spread throughout dayHigh protein (20%), moderate fat (30 – 40%), complex CHO as toleratedVery small amts of concentrated sweetsFood and drink should be moderate in temperatureUse caution with high fiber foods – use pectin to decrease transit time, glucose absorptionTake liquids between meals in small amounts (1/2 to 1 cup)
48Dumping Syndrome Dietary Treatment Lactose transit – poorly toleratedMedium-chain triglycerides-steatorrheaEat slowly, chew food thoroughlyIf dumping is a problem, have patient lie down minutes after meals to retard transit to small bowelSource: Am Diet Assoc. Manual of Clinical Nutr, 6th Edition.
49Malabsorption, steatorrhea Post-surgical complications affecting nutrition:Fat soluble vitamins, calciumFolate, B12 (loss of intrinsic factor)Iron – better absorbed with acidSupplement may help
50Drugs Commonly Used to Treat Gastrointestinal Disorders Antacids: lower acidityCimetidine (Tagamet), ranitidine (Zantac): block acid secretion by blocking histamine H2 receptorsProstaglandinsSucralfate: coats and protects surfaceColloidal bismuth: coats and protects surfaceCarbenoxolone: strengthens mucosal barrierTinidazole: antibiotic
51Diseases of Stomach—cont’d Chronic gastritisPrecedes gastric lesion like cancer or ulcerH. pylori infection may causeSx—Indigestion, loss of appetite, feeling full, belching, epigastric pain, nausea, vomiting
52Diseases of Stomach—cont’d Rx: Avoid foods not tolerated; soft consistency; regular meals; chew foods—Avoid highly seasoned foods; avoid excess liquid at mealsAtrophic gastritis:—Stomach cells atrophy—Loss of parietal cells—achlorhydria—Lose IF for B12 absorption
53Disorders 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.
54Diabetic Gastroparesis (Gastroparesis Diabeticorum) Delayed stomach emptying of solidsEtiology—autonomic neuropathyNausea, vomiting, bloating, painInsulin action and absorption of food not synchronizedPrescribe small frequent meals (may need liquid diet)Adjust insulin
55Summary Upper GI disorders—H. pylori plays an important role Maintain individual tolerances as much as possible.