1. Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders
Chapter 30
Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders

2. Common Intestinal Symptoms
Intestinal gas and flatulence
Constipation
Diarrhea
Steatorrhea
Gastrointestinal strictures and obstruction

3. Diarrhea Need to solidify stools Pectin (apples, bananas) is helpful
World Health Organization provides guidance on fluid and electrolyte replacements—set formula works best
Gatorade also useful

4. Steatorrhea Dietary Modification
Increase kcal to meet needs, especially protein and carbohydrate
Control fat level
Give only level tolerated
Use MCT oil to meet kcal needs with caution
Vitamin and mineral supplements
Use fat-soluble vitamins; add extra Ca, Mg, Zn, Fe

5. Steatorrhea MCT Oil 8 to 10 carbons long
Bile not needed for absorption
Delivered to liver via blood
8.3 kcal/g
1 T = 116 kcal
Expensive
Increases osmolality of tube feedings

6. Celiac Disease Gluten-Sensitive Enteropathy
Adverse reaction to gluten—gliadin fraction
Intestinal mucosa damaged
—Malabsorption of nutrients
—Iron deficiency
—Osteomalacia
—Growth failure
—Projectile vomiting

7. Normal Human Duodenal Mucosa (A) and Peroral Small Bowel Biopsy Specimen (B) from a Patient with Gluten Enteropathy
(From Floch MH. Nutrition and Diet Therapy in Gastrointestinal Disease. New York: Menum Medical Book Co., 1981.)

8. Celiac Disease−Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

9. Celiac Disease−Pathophysiology
(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenisis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

10. Celiac Disease−Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

11. Celiac Disease Gluten-Sensitive Enteropathy
Treatment
Remove gluten from the diet:
—Wheat
—Rye
—Buckwheat
—Barley

12. Celiac Disease Gluten-Sensitive Enteropathy—cont’d
Gluten/gliadin-containing foods
Used to thicken many processed foods
See Tables 30-3 and 30-4

13. Tropical Sprue Cause unknown; imitates celiac disease
Results in atrophy and inflammation of villi
Sx: diarrhea, anorexia, abdominal distention
Rx: tetracycline, folate 5 mg/d, B12 IM

14. Intestinal Brush Border Enzyme Deficiencies
Lactose intolerance
Causes: genetic or secondary deficiency of milk sugar enzyme, lactase
—Blacks, Asians, Native Americans
—Aging: damage to GI tract
Dx: lactose tolerance test or breath hydrogen test
Rx: avoid large amounts of lactose
(milk protein allergy requires milk-free diet); take lactase enzyme; processed dairy sometimes OK

15. Inflammatory Bowel Disease
Crohn’s disease or ulcerative colitis
Both involve damage to the intestine
Crohn’s: may damage either small or large intestine
Disease progression varies
Ulcerative colitis: begins at rectum and progresses up the large intestine

16. Inflammatory Bowel Disease−Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

17. Inflammatory Bowel Disease− Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

18. Inflammatory Bowel Disease−Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

19. Inflammatory Bowel Diseases
Rx:
Diet depends on patient’s status
Nutrition assessment
Select route of feeding
Fiber is beneficial except during flareups.

20. Disorders of the Large Intestine
1. Irritable bowel syndrome
—Common syndrome involving altered intestinal motility, increased sensitivity of the GI tract, and increased awareness and responsiveness of the viscera to internal and external stimuli
—Alternating constipation and diarrhea, abdominal pain, and bloating

21. Disorders of the Large Intestine —cont’d
2. Diverticular disease
—Herniations of the colon, chronic diverticulosis, acute diverticulitis
—Diverticulosis
High-fiber diet: fruits, vegetables, whole grains (2 tsp bran daily)
—Diverticulitis
Low-residue or elemental diet Possibly low-fat diet

22. Disorders of the Large Intestine —cont’d
3. Colon cancer and polyps
—Colon cancer is the second most common cancer among US adults
—Polyps are considered precursors of colon cancer.

23. Short Bowel Syndrome
Follows removal of more than two thirds of small intestine
Causes weight loss; diarrhea; decreased transit time; malabsorption; dehydration; loss of electrolytes; hypokalemia

24. Short Bowel Syndrome —cont’d
Removal of ileocecal valve causes more complications.
Fat malabsorption frequent
Steatorrhea
Saponify calcium, zinc, and magnesium
Remove ileum and lose B12 and bile salt absorption

25. Short Bowel Syndrome —cont’d
Factors Affecting Severity of Malabsorption, Number of Complications, and Dependence on Parenteral Nutrition
Length of remaining small intestine
Loss of ileum, especially distal one third
Loss of ileocecal valve
Loss of colon
Disease in remaining segments(s) of gastrointestinal tract
Radiation enteritis
Coexisting malnutrition
Older age surgery

26. Short Bowel Syndrome Nutritional Care
Step 1
Parenteral only for most patients
Step 2
Gradually introduce enteral nutrition.
Glutamine is an important nutrient for the gut.
Narcotic drugs for pain cause GI problems and should be evaluated.

27. Short Bowel Syndrome
Eventually the remaining bowel increases absorptive surface, and problems decrease.
Nutrition support is designed to meet each patient’s needs.

28. Other Bowel Diseases Irritable bowel syndrome
Alternating diarrhea and constipation
Rx:
High-fiber diet: be careful with wheat bran
Elimination of stimulants
Evaluate for food allergies or intolerances

29. Blind Loop Syndrome
Bacterial overgrowth from stasis in intestine, obstruction, radiation enteritis, fistula, or surgical repair
Treatment (Rx):
Appropriate meds for malabsorption
Antibiotics for bacterial overgrowth

30. Diet Modification of Fiber in Diets
Restricted-fiber diet
5 to 10 g/day
High-fiber diet
25 to 35 g/day
Minimal-residue diet or elemental formulas

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

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

33. Fistula Abnormal Opening Between Organs
Causes: birth defects; trauma; inflammatory disease; malignant disease
Rx:
For fluid loss
For electrolyte loss
Aggressive nutritional support

34. Ileostomy or Colostomy Surgical Opening of Intestine to Outside
Causes: ulcerative colitis; Crohn’s disease; colon cancer; trauma
Rx:
Nutrition needs vary with location and individual
Avoid gas- or odor-forming foods
Fluid and electrolyte needs

35. Hemorrhoidectomy Delay stool formation until healing can take place
Rx:
Minimal-residue diet or elemental diet
After recovery
High-fiber diet to prevent

36. Summary Lower GI conditions—important for nutritional consequences
Important to note where obstruction or surgery has taken place to determine impact on specific nutrients
Most dramatic: short bowel syndrome, which may require long-term TPN