1. Gastrointestinal and Accessory Organ Problems
Chapter 18
Gastrointestinal and Accessory Organ Problems
Problems with the GI system can have a major impact on a patient’s overall well-being.
Careful assessment can identify problems early to prevent more serious complications.
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2. Chapter 18
Lesson 18.1
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3. Key Concepts
Diseases of the gastrointestinal tract and its accessory organs interrupt the body’s normal cycle of digestion, absorption, and metabolism.
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4. Problems of the Mouth Dental problems Surgical procedures Tooth decay
Ill-fitting dentures
Mechanical soft diet helpful
Surgical procedures
Healing nutrients administered with high-protein, high-caloric milk shakes
(Cont'd…)
Dental problems are more common in the elderly and those of lower socioeconomic background.
See Table 18-1 for information on liquid feedings.
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5. Problems of the Mouth Oral tissue inflammation Salivary gland problems
(…Cont’d)
Oral tissue inflammation
Gingivitis
Stomatitis
Glossitis
Cheilosis
Salivary gland problems
Infections
Excess salivation
Xerostomia (permanent dry mouth)
(Cont'd…)
Problems with the oral tissues can be very painful and can cause significant malnutrition if left untreated.
To counteract decreased saliva production, eat more foods that have a higher liquid content. Artificial saliva can also be used.
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6. Problems of the Mouth Swallowing disorders
(…Cont’d)
Swallowing disorders
Dysphagia fairly common problem
Insufficient production of saliva
Dry mouth
Abnormal peristaltic motility of the esophagus
Complications of medication
Neurologic problems
(Cont'd…)
Affects 40%-60% of nursing home residents.
Seen in patients with head trauma, brain tumors, or strokes.
Also common in late-stage Alzheimer’s disease and Parkinson’s disease.
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7. Problems of the Mouth Warning signs of swallowing disorders
(…Cont’d)
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
(Cont'd…)
A common symptom of dysphagia is recurrent pneumonia from aspiration.
Careful monitoring of patients—especially those in a nursing home setting—can help identify dysphagia early.
Usually diagnosed by modified barium swallow study (MBS), a radiological exam that evaluates how patient swallows foods of different textures to detect aspiration or other problems
Treatment is usually a modification in the texture of the diet.
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8. Problems of the Esophagus
Central tube (esophagus)
Muscle spasms or uncoordinated contractions
Stricture (narrowing) of the tube
Lower esophageal sphincter problems
Achalasia or cardiospasm
Changes in smooth muscle
Nerve-muscle hormone control of peristalsis
(Cont'd…)
Esophageal disorders usually require medical intervention such as stretching or surgery.
Cardiospasm is misleading because it does not affect the heart.
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9. Problems of the Esophagus
(…Cont’d)
Lower esophageal sphincter problems
Swallowing problems
Frequent vomiting
Fullness in the chest
Weight loss from eating difficulty
Serious malnutrition
Pulmonary complications and infections caused by aspiration of food particles
(Cont'd…)
Complications can be very serious and usually require surgical intervention.
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10. Problems of the Esophagus
(…Cont’d)
Gastroesophageal reflux disease (GERD)
Caused by constant regurgitation of acid gastric contents into lower esophagus
Pregnancy, obesity, pernicious vomiting, or nasogastric tubes are factors
Constant irritation and inflammation (esophagitis)
Stenosis most common complication
(Cont'd…)
What is the classic symptom of GERD? (frequent and severe heartburn)
GERD is very common, but many people do not seek treatment.
Methods for controlling GERD include staying upright for two hours after meals and avoiding common irritants.
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11. Problems of the Esophagus
(…Cont’d)
Hiatal hernia
Portion of upper stomach protrudes through opening in the diaphragm membrane (hiatus)
Especially common in obese adults
85%-90% of patients achieve improvement of symptoms with weight loss.
May require surgery if hernia is very large.
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12. Hiatal Hernia in Comparison with Normal Stomach Placement
A. Normal stomach
Normal stomach placement below esophageal hiatus
(Cont'd…)
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13. Hiatal Hernia in Comparison with Normal Stomach Placement
(…Cont’d)
B. Paraesophageal hernia
Only a small portion of the stomach rises above the hiatus; no change in the position of the esophagus.
(Cont'd…)
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14. Hiatal Hernia in Comparison with Normal Stomach Placement
(…Cont’d)
C. Esophageal hiatal hernia
In obese persons, excessive fat tissue pushes on the stomach and forces it through the diaphragm.
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15. Peptic Ulcer Disease Caused by Helicobacter pylori infection
Tobacco smoking linked to PUD
Chronic use of nonsteroidal antiinflammatory drugs may contribute to development in some persons
Lesion usually occurs in duodenal bulb
(Cont'd…)
Imbalance between gastric acid and pepsin secretions and degree of tissue resistance to secretions and H. pylori infection.
H. pylori is responsible for 80%-90% of gastric and duodenal ulcers.
H. pylori are spiraling, rod-shaped bacteria that inhabit the GI area around the pyloric valve.
Not all carriers of the bacteria develop a peptic ulcer.
Can contribute to higher incidence of gastric cancer and lymphoma
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16. Peptic Ulcer Disease
(…Cont’d)
Stress during young- and middle- adult years may contribute
Symptoms include increased gastric muscle tone and painful contractions when stomach empty
Smoking, alcohol use should be eliminated
(Cont'd…)
Rest, relaxation, and sleep help ease symptoms.
For certain susceptible individuals, NSAIDs should be avoided.
How is PUD diagnosed? (confirmed by x-ray tests and visualization by gastroscopy)
Treatment goals are to:
alleviate symptoms
promote healing
prevent complications
eliminate the cause
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17. Peptic Ulcer Disease Drug therapy can manage peptic ulcer disease
(…Cont’d)
Drug therapy can manage peptic ulcer disease
Blocking agents control acid secretion
Mucosal protectors inactivate pepsin and produce gel-like substance to cover ulcer
Antibiotics control H. pylori
Antacids counteract or neutralize acid
(Cont'd…)
Treatments include:
Blocking agents include cimetidine (Tagamet), ranitidine (Zantac), and omeprazole (Prilosec).
Mucosal protector: sucralfate (Carafate)
Antibiotics: generally used in combination (amoxicillin, proton pump inhibitor, tetracycline, and metronidazole)
Antacids such as Mylanta and Maalox (magnesium-aluminum compounds)
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18. Peptic Ulcer Disease Dietary management Well-balanced, healthy diet
(…Cont’d)
Dietary management
Well-balanced, healthy diet
Avoid acid stimulation
Bland diets have been proven to be ineffective and lacking in adequate nutrition
Dietary management includes adjustments in the following areas: meal pattern, food quantity, milk intake, seasonings, dietary fiber, coffee, citric acid juices, alcohol, smoking, food environment
Each person can have different triggers to acid production.
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19. Small Intestine Diseases
Diarrhea
Intolerance to specific foods
Acute food poisoning
Viral infections
(Cont'd…)
Diarrhea—loose, watery stools occurring more than three times in one day
What is the main complication associated with diarrhea? (dehydration)
Chronic diarrhea can be life-threatening to young children or adults with weak immune systems.
Until diarrhea subsides, patients should avoid milk products and foods that are greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhea.
Health professional may recommend the BRAT diet (bananas, rice, apples, toast).
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20. Small Intestine Diseases
(…Cont’d)
Malabsorption
Maldigestion problems
Intestinal mucosal changes
Genetic disease
Intestinal enzyme deficiency
Cancer and its treatment
Metabolic defects
(Cont'd…)
Can cause many problems, from diarrhea to malnutrition.
Celiac sprue, cystic fibrosis, and inflammatory bowel disease are three diseases that cause malabsorption.
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21. Small Intestine Diseases
(…Cont’d)
Celiac sprue
Hypersensitivity to the protein gluten in certain grains
Steatorrhea and progressive malnutrition are secondary effects to gluten reaction
Nutrition management controls dietary gluten intake and prevents malnutrition
(Cont'd…)
Celiac disease damages the small intestine and interferes with absorption of nutrients from food.
The only treatment for celiac disease is to follow a gluten-free diet.
What are some foods that contain gluten? (foods prepared with wheat, rye, oat, or barley; luncheon meats)
More info:
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22. Small Intestine Diseases
(…Cont’d)
Cystic fibrosis
Genetic disease of childhood
Inhibits movement of chloride and sodium ions in the body tissue fluids
(Cont'd…)
Thick mucus in the lungs leads to damaged airways, difficulty breathing, and lung infections.
Thick secretions also obstruct the pancreas, preventing digestive enzymes from reaching the intestines to help break down and absorb food.
Causes malabsorption of undigested foods, liver disease, and increased salt concentration in the tissues.
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23. Small Intestine Diseases
(…Cont’d)
Cystic fibrosis
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
(Cont'd…)
More than 90% of CF patients take supplemental pancreatic enzymes.
Supplement salt by adding salt and salty snacks.
Use foods that are high in calories to promote weight gain.
Additional nutrition resources at:
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24. Small Intestine Diseases
(…Cont’d)
Inflammatory bowel disease
Applies to both ulcerative colitis and Crohn’s disease
Short-bowel syndrome results from repeated surgical removal of parts of the small intestine as disease progresses
Reduces absorption of nutrients
Diet gradually advanced to restore nutrient intake:
High protein (100 g/day)
High-energy ( kcal/day)
Increased vitamins and minerals (supplements)
The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea.
Patients should avoid foods that upset the intestines, such as highly seasoned foods, raw fruits and vegetables, or milk sugar (lactose).
Check out: (Crohn’s & Colitis Foundation of America)
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25. Large Intestine Diseases
Diverticular disease
Diverticulosis: formation of many small pouches (diverticula) along muscular mucosal lining
Diverticulitis caused by pockets becoming infected
(Cont'd…)
Diverticulosis is caused by progressive increase in pressure within the bowel; affects About 10% of Americans over the age of 40.
The condition becomes more common as people age. About half of all people over the age of 60 have diverticulosis.
Chronic diverticular disease is managed with increased dietary fiber.
Dominant theory is that a low-fiber diet is the main cause of diverticular disease.
What foods should be avoided with diverticular disease?
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26. Mechanism By Which Low-Fiber, Low-Bulk Diets Might Generate Diverticula
Fiber keeps stool soft and lowers pressure inside the colon so that bowel contents can move through easily.
The American Dietetic Association recommends 20 to 35 grams of fiber each day.
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27. Large Intestine Diseases
(…Cont’d)
Irritable bowel syndrome
Multicomponent disorder of physiologic, emotional, environmental, psychologic function
Common recurrent pain in abdomen
Small-volume bowel dysfunction
Excess gas formation
(Cont'd…)
One in five Americans has IBS, making it one of the most common disorders diagnosed by doctors.
It occurs more often in women than in men, and it usually begins around age 20.
More information:
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28. Large Intestine Diseases
(…Cont’d)
Irritable bowel syndrome
Individual approach to nutrition care essential
Increase dietary fiber
Recognize gas formers
Respect food intolerances
Reduce total fat content
Avoid large meals
Decrease air-swallowing habits
(Cont'd…)
Keeping a journal of foods that cause symptoms can be helpful.
Meals that are low in fat and high in carbohydrates can be helpful as well.
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29. Irritable Bowel Syndrome
If the muscles of the colon, sphincters, and pelvis do not contract in a coordinated way, the contents do not move smoothly, resulting in abdominal pain, cramps, constipation, or diarrhea.
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30. Large Intestine Diseases
(…Cont’d)
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
Dietary management calls for:
increased fiber
fruits that act as a natural laxative
adequate fluid intake
Many people think they are constipated when, in fact, their bowel movements are regular.
Constipation is one of the most common gastrointestinal complaints in the United States.
Engaging in daily exercise is also effective in preventing constipation.
Laxatives should be avoided, if possible, to prevent dependence.
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31. Chapter 18
Lesson 18.2
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32. Key Concepts
Allergic conditions produce sensitivity to certain food components.
Underlying genetic diseases may cause metabolic defects that block the body’s ability to handle specific food nutrients.
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33. Food Allergies
Allergic reaction is body’s immune system reacting to a protein as a threatening foreign object
Anaphylactic shock is the most severe form of allergic reaction
Common food allergens
Peanuts, tree nuts
Shellfish, fish
Milk, soy, egg, wheat
(Cont'd…)
Scientists estimate that approximately 11 million Americans suffer from true food allergies.
Avoidance is the only way to prevent an allergic reaction.
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34. Food Allergies
(…Cont’d)
Food elimination sometimes used to identify disagreeable foods
Dietitian can provide guidance on food substitutions or special food products
Recipes modified to maintain nutritional needs for growth
(Cont'd…)
Children tend to be less allergic as they get older.
What are the common symptoms of a reaction? (hives, nausea, diarrhea, and abdominal pain)
A food intolerance is an adverse food-induced reaction that does not involve the immune system.
More information:
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35. Genetic Disease & Food Intolerances
Phenylketonuria
Phenylalanine hydroxylase enzyme not produced in body
Causes profound mental retardation and central nervous system damage
Treated with low-phenylalanine diet using special formulas and low-protein food products
(Cont'd…)
Adherence to the diet is crucial in infancy and childhood.
Diet is revised over time as the child's nutritional needs change.
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36. Genetic Disease & Food Intolerances
(…Cont’d)
Galactosemia
Missing GALT cell enzyme that converts galactose to glucose
Causes liver and brain damage
Treated by galactose-free diet with special formulas for infants and lactose-free food guides
(Cont'd…)
Identified in newborn screening programs.
Treatment should begin immediately and must be followed for life.
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37. Genetic Disease & Food Intolerances
(…Cont’d)
Lactose intolerance
Deficiency of any of the disaccharides in small intestine
Produces wide range of GI problems
Milk and all lactose products avoided
Milk treated with commercial lactose product or soy milk are safe substitutes
Lactose intolerance is the inability to digest significant amounts of lactose, the predominant sugar of milk.
Common symptoms include nausea, cramps, bloating, gas, and diarrhea, which begin about 30 minutes to two hours after eating or drinking foods containing lactose.
As many as 75% of all African-Americans and American Indians and 90% of Asian Americans are lactose-intolerant.
Patients need to also avoid hidden lactose.
What are some examples of food that contain lactose? (milk, cheese)
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38. Biliary System Organs
Three major accessory organs: liver, gallbladder, and pancreas
Important in digestion; diseases affect normal GI function and how the body digests certain foods.
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39. Liver Disease Hepatitis
Inflammatory condition caused by virus, alcohol, drugs, toxins
Treatment based on bed rest and nutrition therapy
(Cont'd…)
Nutrition therapy includes these requirements:
high-protein, high-carbohydrate, moderate-fat, and high-energy
Forms of hepatitis include:
infectious hepatitis (hepatitis A)
serum hepatitis, or hepatitis B
toxic hepatitis (caused by toxins such as alcohol)
Treatment of hepatitis involves bed rest and restriction of activity for about a month, removal of liver toxins, and carefully supervised diet.
Untreated hepatitis can lead to extensive liver damage, coma, and death.
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40. Liver Structure
Because the liver performs so many critical functions, a healthy liver is critical to good health.
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41. Liver Diseases Cirrhosis
(…Cont’d)
Cirrhosis
Fatty cirrhosis associated with malnutrition and alcoholism
Fatty infiltration kills liver cells, leaving nonfunctioning scar tissue
(Cont'd…)
The most common cause of cirrhosis is alcoholism.
What is another cause of cirrhosis? (malnutrition)
Treatment involves efforts to stop the progress of the disease.
Nutrition therapy focuses on healing support:
protein as tolerated; low sodium; soft texture; optimal general nutrition
If cirrhosis is detected early, the individual may be able to live a normal life by avoiding alcohol and participating in healthy activities.
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42. Comparison of Normal Liver and Liver with Cirrhotic Tissue Changes
Cirrhosis is a condition in which liver cells are replaced by fibrous connective tissue.
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43. Liver Diseases Hepatic coma
(…Cont’d)
Hepatic coma
As cirrhosis continues, blood can no longer circulate normally through liver
Ammonia and nitrogen cannot be eliminated, which produces ammonia intoxication and coma
Treatment focuses on removing sources of excess ammonia
Known as hepatic encephalopathy because the ammonia goes to the brain
Patients should have low-protein diets and take a medication such as lactulose, which promotes removal of nitrogen from the body.
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44. Gallbladder Disease Cholecystitis Cholelithasis
Usually results from low-grade chronic infection
Continued infection alters solubility of bile ingredients
Cholelithasis
Cholesterol separates out and causes gallstones
Diet therapy centers on controlling fat intake
The disease is seen in about one in 10 people and is more frequent in women.
What are some symptoms of cholecystitis and cholelithasis?
Individuals may lead an essentially normal life without a gall bladder, although a low-fat diet may be advisable.
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45. Pancreatic Disease Pancreatitis
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
Pancreas produces two hormones, insulin and glucagon, which are responsible for the body’s metabolism of carbohydrates, lipids, proteins, and electrolytes (minerals).
People with pancreatitis should avoid alcohol and excess coffee, and follow a light diet used to reduce stimulation of pancreatic secretions.
Acute pancreatitis may be brought on by gallbladder disease, overeating, or excessive alcohol consumption. It is most common in persons 40 to 50 years of age and is a serious condition.
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