1. Nutrition for Disorders of the Gastrointestinal Tract

2. Normal Function of Lower GI n Digestion n Absorption n Excretion n Digestion n Absorption n Excretion

3. Principles of Nutritional Care n Intestinal disorders & symptoms: –Motility –Secretion –Absorption –Excretion n Intestinal disorders & symptoms: –Motility –Secretion –Absorption –Excretion

4. Principles of Nutritional Care n Dietary modifications –To alleviate symptoms –Correct nutritional deficiencies –Address primary problem –Must be individualized n Dietary modifications –To alleviate symptoms –Correct nutritional deficiencies –Address primary problem –Must be individualized

5. Common Intestinal Problems n Intestinal gas or flatulence n Constipation n Diarrhea n Steatorrhea n Intestinal gas or flatulence n Constipation n Diarrhea n Steatorrhea Photo courtesy http://www.drnatura.com/

6. Constipation n Defined as hard stools, straining with defecation, infrequent bowel movements n Normal frequency ranges from one stool q 3 days to 3 times a day n Occurs in 5% to more than 25% of the population, depending on how defined n Defined as hard stools, straining with defecation, infrequent bowel movements n Normal frequency ranges from one stool q 3 days to 3 times a day n Occurs in 5% to more than 25% of the population, depending on how defined

7. Causes of Constipation - Systemic n Side effect of medication, esp narcotics n Metabolic Endocrine abnormalities, such as hypothyroidism, uremia and hypercalcemia n Lack of exercise n Ignoring the urge to defecate n Vascular disease of the large bowel n Systemic neuromuscular disease leading to deficiency of voluntary muscles n Poor diet, low in fiber n Pregnancy n Side effect of medication, esp narcotics n Metabolic Endocrine abnormalities, such as hypothyroidism, uremia and hypercalcemia n Lack of exercise n Ignoring the urge to defecate n Vascular disease of the large bowel n Systemic neuromuscular disease leading to deficiency of voluntary muscles n Poor diet, low in fiber n Pregnancy

8. Causes of Constipation - Gastrointestinal n Diseases of the upper gastrointestinal tract –Celiac Disease –Duodenal ulcer n Diseases of the large bowel resulting in: –Failure of propulsion along the colon (colonic inertia) –Failure of passage though anorectal structures (outlet obstruction) n Irritable bowel syndrome n Anal fissures or hemorrhoids n Laxative abuse n Diseases of the upper gastrointestinal tract –Celiac Disease –Duodenal ulcer n Diseases of the large bowel resulting in: –Failure of propulsion along the colon (colonic inertia) –Failure of passage though anorectal structures (outlet obstruction) n Irritable bowel syndrome n Anal fissures or hemorrhoids n Laxative abuse – Gastric cancer – Cystic fibrosis – Gastric cancer – Cystic fibrosis

9. Treatment of Constipation n Encourage physical activity as possible n Bowel training: encourage patient to respond to urge to defecate n Change drug regimen if possible if it is contributory n Use laxatives and stool softeners judiciously n Use stool bulking agents such as psyllium (metamucil) and pectin n Encourage physical activity as possible n Bowel training: encourage patient to respond to urge to defecate n Change drug regimen if possible if it is contributory n Use laxatives and stool softeners judiciously n Use stool bulking agents such as psyllium (metamucil) and pectin

10. MNT for Constipation n Depends on cause n Use high fiber or high residue diet as appropriate n If caused by medication, may be refractory to diet treatment n Depends on cause n Use high fiber or high residue diet as appropriate n If caused by medication, may be refractory to diet treatment

11. Copyright © 2000 by W. B. Saunders Company. All rights reserved.

13. High-Fiber Diets n Most Americans = 10 – 15 g/day n Recommended = 25 g/day n More than 50g/day = no added benefit, may cause problems n Most Americans = 10 – 15 g/day n Recommended = 25 g/day n More than 50g/day = no added benefit, may cause problems

14. Diarrhea n Characterized by frequent evacuation of liquid stools n Accompanied by loss of fluid and electrolytes, especially sodium and potassium n Occurs when there is excessively rapid transit of intestinal contents through the small intestine, decreased absorption of fluids, increased secretion of fluids into the GI tract n Characterized by frequent evacuation of liquid stools n Accompanied by loss of fluid and electrolytes, especially sodium and potassium n Occurs when there is excessively rapid transit of intestinal contents through the small intestine, decreased absorption of fluids, increased secretion of fluids into the GI tract

15. Diarrhea Etiology n Inflammatory disease n Infections with fungal, bacterial, or viral agents n Medications (antibiotics, elixirs) n Overconsumption of sugars n Insufficient or damaged mucosal absorptive surface n Malnutrition n Inflammatory disease n Infections with fungal, bacterial, or viral agents n Medications (antibiotics, elixirs) n Overconsumption of sugars n Insufficient or damaged mucosal absorptive surface n Malnutrition

16. Diarrhea Treatment for Adults n Identify and treat the underlying problem n Manage fluid and electrolyte replacement using oral glucose electrolyte solutions (see WHO guidelines) n Initiate minimum-residue diet n Avoid large amounts of sugars and sugar alcohols n Prebiotics in modest amounts including pectin, oligosaccharides, inulin, oats, banana flakes n Probiotics, cultured foods and supplements that are sources of beneficial gut flora n Identify and treat the underlying problem n Manage fluid and electrolyte replacement using oral glucose electrolyte solutions (see WHO guidelines) n Initiate minimum-residue diet n Avoid large amounts of sugars and sugar alcohols n Prebiotics in modest amounts including pectin, oligosaccharides, inulin, oats, banana flakes n Probiotics, cultured foods and supplements that are sources of beneficial gut flora

17. Low- or Minimum Residue Diet n Foods completely digested, well absorbed n Foods that do not increase GI secretions n Used in: –Maldigestion –Malabsorption –Diarrhea –Temporarily after some surgeries, e.g. hemorrhoidectomy n Foods completely digested, well absorbed n Foods that do not increase GI secretions n Used in: –Maldigestion –Malabsorption –Diarrhea –Temporarily after some surgeries, e.g. hemorrhoidectomy

18. Foods to Limit in a Low- or Minimum Residue Diet n Lactose (in lactose malabsorbers) n Fiber >20 g/day n Resistant starches –Raffinose, stachyose in legumes n Sorbitol, mannitol, xylitol >10g/day n Caffeine n Alcohol, esp. wine, beer n Lactose (in lactose malabsorbers) n Fiber >20 g/day n Resistant starches –Raffinose, stachyose in legumes n Sorbitol, mannitol, xylitol >10g/day n Caffeine n Alcohol, esp. wine, beer

19. Restricted-Fiber Diets n Uses: –When reduced fecal output is necessary –When GI tract is restricted or obstructed –When reduced fecal residue is desired n Uses: –When reduced fecal output is necessary –When GI tract is restricted or obstructed –When reduced fecal residue is desired

20. Restricted-Fiber Diets n Restricts fruits, vegs, coarse grains n <10 g fiber/day n Phytobezoars –Obstructions in stomach resulting from ingestion of plant foods –Common in edentulous pts, poor dentition, with dentures –Potato skins, oranges, grapefruit n Restricts fruits, vegs, coarse grains n <10 g fiber/day n Phytobezoars –Obstructions in stomach resulting from ingestion of plant foods –Common in edentulous pts, poor dentition, with dentures –Potato skins, oranges, grapefruit

21. MNT for Infants and Children n Acute diarrhea most dangerous in infants and children n Aggressive replacement of fluid/ electrolytes n WHO/AAP recommend 2% glucose (20g/L) 45-90 mEq sodium, 20 mEq/L potassium, citrate base n Newer solutions (Pedialyte, Infalyte, Lytren, Equalyte, Rehydralyte) contain less glucose and less salt, available without prescription n Acute diarrhea most dangerous in infants and children n Aggressive replacement of fluid/ electrolytes n WHO/AAP recommend 2% glucose (20g/L) 45-90 mEq sodium, 20 mEq/L potassium, citrate base n Newer solutions (Pedialyte, Infalyte, Lytren, Equalyte, Rehydralyte) contain less glucose and less salt, available without prescription

22. MNT for Infants and Children n Continue a liquid or semisolid diet during bouts of acute diarrhea for children 9 to 20 months n Intestine absorbs up to 60% of food even during diarrhea n Early refeeding helpful; gut rest harmful n Clear liquid diet (hyperosmolar, high in sugar) is inappropriate n Access American Academy of Pediatrics Clinical Guidelines http://aappolicy.aappublications.org/cgi/reprint/ pediatrics;97/3/424.pdf n Continue a liquid or semisolid diet during bouts of acute diarrhea for children 9 to 20 months n Intestine absorbs up to 60% of food even during diarrhea n Early refeeding helpful; gut rest harmful n Clear liquid diet (hyperosmolar, high in sugar) is inappropriate n Access American Academy of Pediatrics Clinical Guidelines http://aappolicy.aappublications.org/cgi/reprint/ pediatrics;97/3/424.pdf

23. Celiac Disease n Also called Gluten-Sensitive Enteropathy and Non-tropical Sprue n Caused by inappropriate autoimmune reaction to gliadin (found in gluten) n Much more common than formerly believed (prevalence 1 in 133 persons in the US) n Frequently goes undiagnosed n Also called Gluten-Sensitive Enteropathy and Non-tropical Sprue n Caused by inappropriate autoimmune reaction to gliadin (found in gluten) n Much more common than formerly believed (prevalence 1 in 133 persons in the US) n Frequently goes undiagnosed

24. Celiac Disease n Results in damage to villi of intestinal mucosa – atrophy, flattening n Potential or actual malabsorption of all nutrients n May be accompanied by dermatitis herpetiformis, anemia, bone loss, muscle weakness, polyneuropathy, follicular hyperkeratosis n Increased risk of Type 1 diabetes, lymphomas and other malignancies n Results in damage to villi of intestinal mucosa – atrophy, flattening n Potential or actual malabsorption of all nutrients n May be accompanied by dermatitis herpetiformis, anemia, bone loss, muscle weakness, polyneuropathy, follicular hyperkeratosis n Increased risk of Type 1 diabetes, lymphomas and other malignancies

25. Celiac Disease Symptoms n Early presentation: diarrhea, steatorrhea, malodorous stools, abdominal bloating, poor weight gain n Later presentation: other autoimmune disorders, failure to maintain weight, fatigue, consequences of nutrient malabsorption (anemias, osteoporosis, coagulopathy) n Often misdiagnosed as irritable bowel disease or other disorders n Early presentation: diarrhea, steatorrhea, malodorous stools, abdominal bloating, poor weight gain n Later presentation: other autoimmune disorders, failure to maintain weight, fatigue, consequences of nutrient malabsorption (anemias, osteoporosis, coagulopathy) n Often misdiagnosed as irritable bowel disease or other disorders

26. Copyright © 2000 by W. B. Saunders Company. All rights reserved. Normal human duodenal mucosa and peroral small bowel biopsy specimen from a patient with gluten enteropathy. Fig. 31-1. p. 673. (From Floch MH. Nutrition and Diet Therapy in Gastrointestinal Disease. New York: Menum Medical Book Co., 1981.) Forward Back MENU

27. IBS: Surgical Treatment n

29. Ileostomy or Colostomy n Sometimes temporary n Output from stoma depends on location –Ileostomy output will be liquid –Colostomy output more solid, more odorous n Sometimes temporary n Output from stoma depends on location –Ileostomy output will be liquid –Colostomy output more solid, more odorous

30. Colostomy Illustration

31. Types of ileostomies

32. Ileoanal Pouch