Dietary Management of GI Disorders ELENA TEJEDOR RD, CNSC Surgery, GI, ENT

Potential Causes of Vomiting & Diarrhea Healthy Gut Function Potential Causes of Vomiting & Diarrhea Nutrition Concerns Dietary Management Goal

Stomach & Pylorus(1) Digestion Gastric acid - denatures proteins, acts as an Antimicrobial - activates pepsin (optimal pH 1.8 -3.5) - increases bioavailability of calcium, iron, B12 Gastric Lipase (optimal pH 4.5-6) - Digests 10-25% of dietary TG - Secretion ↑ 3x-4x, incompletely compensating for pancreatic lipase deficiency Secretion 2-3L/d Begins with sight, smell,& thought = Cerebral phase ~40% of gastric secretion Gastric fluids=HCl acid, IF, KCl, NaCl, gastric lipase,HCO3, mucin

Stomach & Pylorus(1) Reservoir - Stores (1.5-2L) - Grinds < 2mm Dispenses chyme. Rate determined by: pH, osmolality, consistency, lipid, calorie content ~150kcal/hr, Ileal brake feedback Absorption Niacin, copper, ETOH, drugs

Small Bowel – Duodenum(1) Length ~30cm (12 inch) D1-D4 Digestion Fat digestion – critically dependent on simultaneous release of bile salts + pancreatic lipase + calipase, and pH CHO + Protein digestion – Dependent on combined action of pancreatic enzymes + brush boarder enzymes +pH Absorption Calcium, Copper, Iron (10% of PO Iron is absorbed enterically), Folate, Vit D, Zinc (25% absorbed in duodenum + prox jejunum) B12-heptocorrin complex – cleaved by Trypsin, so B12 can bind to IF and be absorbed in Terminal Ileum

Gallbladder(1) -Bile Secretion D2 500-600 ml/day - 95% re-absorbed in Terminal Ileum by active transport & re-cycled via portal circulation (2x/meal) - Maximum bile synthesis 5-10mmol/d, Use 25-30mmol/d - Hepatic excretion of lipid-soluble xenobiotics, drug metabolites, and heavy metals Digestion Lipid digestion / absorption, and fat-soluble vit. absorption Cholesterol homeostasis Conjugated bile acids have limited permeability to cell membranes improving fat absorption. Bile salts ppt at pH <5

Composition of Bile (1) Components Concentration (mmol/L or otherwise stated) Sodium 140-160 Potassium 3-8 Chloride 70-120 Bicarbonate 20-50 Calcium 1-5 Phosphate 0-1.2 Magnesium 1-3 Iron 2-72 umol/L Copper 12-21 umol/L B12, Vit A, Zinc ? Bile Acids (67% of bile) 5-50 Bilirubin total (0.3% of bile) 1-2 Phospholipid (Lecithin) (22% of bile) 0.5-20 Cholesterol (4% of bile) .5-1 Glutathione 3-5 Glucose 0.2-1 Urea 2.2-6.5 Protein (g/dL) (4.5% of bile) .2-3g/dL

Pancreas(1) Secretion Exocrine: 1.5-2.5 L/day of digestive enzymes, bicarb, water, KCL, NaCl 0.2-0.3ml/minute in rest, 4.0ml/minute post meal Sham Feeding (chew + spit) triggers 50% of normal secretion Effected by location of food entry, if pre-digested, and if enzymes are supplemented Endocrine Hormones –insulin, glucagon, somatostatin, pancreatic polypeptides Digestion Exocrine Amylase (Active pH 6.7-7) & Lipase (Active pH 3.5-6) Trypsinogen -activated to trypsin by Enteropeptidase (Optimal pH 7.5-8.5) Procalipase -activated to calipase by trypsin Bicarb

Small Bowel(1) Jejunum 2-3M, Ileum 3-4M Secretion ~ 1.5LFluids/day secreted, ~6L Absorbed Digestion ~90% all nutrient absorption occurs in the first 1-1.5M of SB. Absorption Jejunal Thiamine, Pantothenic Acid, Folic Acid, B6, Riboflavin, Vit A, Vit K, Niacin, zinc Absorption Ileal Vit C, Vit D, B12, Vit K, selenium B12 absorbed within 60cm terminal Ileum Bile Salts re-absorbed within 100cm terminal ileum Adaptive Ability Best in the Ileum -Significant growth of microvilli size & number, and bowel diameter. Special transit biofeedback mechanisms

Small Bowel Ileocecal region Transit Time Ileal Brake –by way of “Neuro Hormone Mediators” delays gastric emptying & slows intestinal transit when undigested CHO and fat reach the ileocecal region IC valve controls the amount and slows the passage of ileal contents into the colon Adaptive Involvement Prevents bacterial overgrowth - Limiting fluid losses & competition for B12

Large Bowel(1) Length 1.5 Meters Absorption 1-1.5L fluid, K, Na, Oxalates, SCFA/MCT, calcium, Vit K, unconjugated Bile Salts Transit Time Entry into colon at ~50ml/hr. ~20 hr Transit time (8hrs ascending colon, 8 hr transverse colon, 4 hrs descending colon) Role in Adaptation Highly Adaptable(1/2 remaining colon = 50cm SB) Increased fluid (5-6L) and electrolyte absorption Colonic Bacteria ferment undigested CHO/Fibre forming ~500-1200kcals/day of short chain FA. Qualitative and quantitative colonic flora changes increasing capacity to metabolize CHO

Potential Causes of Emesis & Diarrhea The Diseased Gut Healthy Gut Function Dietary Intervention Nutrition Concerns Potential Causes of Emesis & Diarrhea

Nausea & Vomiting Partial Bowel Obstruction Mass Cancer Bezoar Adhesions Bowel Edema Crohn’s UC Surgery Gastric Obstruction Edema Gastroenteritis Crohn’s Surgery Pancreatic Pseudocyst Severe Pancreatitis Gastric Dysmotility Hyperglycemia Uncontrolled DM Vagal Nerve Damage Trauma Surgery Cancer Bowel Dysmotility Medication Opioids Loperamide Ileus Surgery Ischemic Bowel

OBSTRUCTIONS Duct Obstructions, Hernias, Volvulus, Intussusception, Bowel Edema, Diverticulitis, Adhesions, Cancer

Bowel Dysmotility/Obstruction Vagal Nerve Damage (Cranial Nerve X),Bowel Ischemia

Likelihood of Resolution Nausea & Vomiting Things to consider when deciding where and what to feed. Limitations Likelihood of Resolution Location Dietary Intervention Resolution of obstruction Pain / Nausea Medications Vagal nerve damage vs. Ileus Adhesion vs. edema Proximal vs. Distal GIT Small frequent meals Liquids – Blenderized Chew well Low fibre/ Limit poorly digested foods High pro High cal NJ Feeds TPN

Inadequate Pancreatic Enzymes Diarrhea & Bloating Inadequate Pancreatic Enzymes Gastric Hypersecretion Duct obstruction Pancreatitis Pancreatic Resection Maldigestion Gastric Acid Suppression Low Fat Diet Repletion: Fat Soluble Vitamins Calcium, Mg, Zinc Enzyme Replacement Inadequate Bile Salts Duct Obstruction Cholecystitis Minor terminal ileum +IC resection >100cm terminal ileum resection Malabsorption Lower Fat Diet Small Frequent Meals Replete : Fat Soluble Vitamins Calcium, Mg, Zinc +/- Cholestyramine Restrict High Oxolate foods

Maldigestion & Malabsorption Diarrhea & Bloating Dumping Syndrome Gastric Bypass Pyloroplasty Maldigestion & Malabsorption Liquids Between Meals Encourage Soluble Fibre Limit Simple Sugars Multiple Small Meals Chew Well

Vitamins / Mineral Deficiency Risk Review B12 Limited IF or gastric acid, TI disease, Bacterial Overgrowth Folate Proximal SB disease/resection. Drugs Iron Proximal SB resection Loss from Chronic bleed Calcium Proximal SB resection, Limited gastric acid Fat malabsorption (insoluble calcium soaps), Vit D deficiency Sodium & Potassium Increased losses from vomiting & diarrhea (rapid transit or bowel resection) Magnesium Rapid transit, Fat malabsorption (luminal binding of Mg with fat) A,D,E,K Fat malabsorption (limited bile, limited pancreatic enzymes) Zinc Rapid transit, Proximal bowel disease (14mg/L stool)

MVI with Water-Miscible Versions of Fat-Soluble Vitamins(2) SourceCF (Aptalis) www.sourceCF.com 888-419-8357 AquADEK (Aptalis) www.aptalispharma.com 800-950-8085 VITAMAX (Shear/Kershman Laboratories) www.cfservicespharmacy.com 800-541-4959

Pancreatic Enzyme Dosages(2) Start with 500 units lipase/kg/meal Increase to max of 2,500 units lipase/kg/meal Provide ½ meal dose with snacks Start with 500 units lipase/gram fat Increase to max of 4,000 units lipase/gram fat Caution with doses > 2,500 units lipase/kg/meal or > 4,000 units lipase/gram fat

PGSD/Low Fat/Oxalate Foods Resources PGSD/Low Fat/Oxalate Foods Low Fibre Handouts http://www.hhsc.ca Search “The Dumping Syndrome Diet” Search “Low Fat Diet” Http://www.pennutrition.com Search “Eating Guidelines for Kidney stones” Diet Handouts: Visit www.bccancer.bc.ca Search “Low Fibre Food Choices for partial Bowel Obstruction” http://vch.eduhealth.ca Search “Nutrition After Ileostomy Surgery” http://www.hhsc.ca Search “What to eat and drink when you have a High Output ostomy”

References Feldman, Friedman & Bradt (2010). Sleisenger & Fordtrains Gastrointestinal and liver disease: Pathophysiology, diagnosis, management. (9th ed). Philadelphia,PA: Elsevier Rogers. C.L. (2013). Nutrition management of the adult with cystic fibrosis-Part 1 Practical Gastroenterology. (113), 10-24 Recommended Read: Parrish. C.R (2005) The clinician’s guide to short bowel syndrome. Practical Gastroenterology. (31), 67-106.

Feel free to contact me with questions. Elena.tejedor@vch.ca THANK YOU Feel free to contact me with questions. Elena.tejedor@vch.ca