Transcript Malabsorption Disorders (cont`d)

Nutrition for Patients with
Disorders of the Lower GI Tract
and Accessory Organs
Chapter 18
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Nutrition for Patients With Disorders of
the Lower GI Tract
• Ninety to 95% of nutrient absorption occurs in the first
half of the small intestine
• Large intestine absorbs water and electrolytes and
promotes the elimination of solid wastes
• Accessory organs—liver, gallbladder, and pancreas—play
vital roles in nutrient digestion
• Nutrition therapy is used:
– To improve or control symptoms
– Replenish losses
– Promote healing
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Altered Bowel Elimination
• Constipation
– Difficult or infrequent passage of stools that are
hard and dry
– Can occur secondary to irregular bowel habits,
psychogenic factors, lack of activity, chronic
laxative use, inadequate intake of fluid and fiber,
metabolic and endocrine disorders, and bowel
abnormalities (e.g., tumors, hernias, strictures)
– Certain medications cause constipation
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Altered Bowel Elimination (cont’d)
• Constipation (cont’d)
– Nutrition therapy
o Constipation is treated by treating the
underlying cause
o Increasing fiber and fluid intake effectively
relieves and prevents constipation
o High-fiber diet
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Altered Bowel Elimination (cont’d)
• Constipation (cont’d)
– Nutrition therapy (cont’d)
o Adequate intake set for fiber is 25 g/day for
women and 38 g/day for men
o Common practice is to recommend fiber intake be
gradually increased
o Fiber intake should be spread throughout the day
o Lifestyle changes to promote bowel regularity
include drinking more fluid and increasing
exercise
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Altered Bowel Elimination (cont’d)
• Diarrhea
– Characterized by more than 3 bowel
movements a day of large amounts of liquid
or semi-liquid stool
– Potential for dehydration, hyponatremia,
hypokalemia, acid–base imbalance, and
metabolic acidosis
– Chronic diarrhea can lead to malnutrition
related to impaired digestion, absorption, and
intake
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Altered Bowel Elimination (cont’d)
• Diarrhea (cont’d)
– Osmotic diarrhea occurs when there is an
increase in particles in the intestine, which draws
water in to dilute the high concentration
o Causes include maldigestion of nutrients (e.g.,
lactose intolerance), excessive intake of
sorbitol or fructose, dumping syndrome, tube
feedings, and some laxatives
o Cured by treating the underlying cause
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Altered Bowel Elimination (cont’d)
• Diarrhea (cont’d)
– Secretory diarrhea
o Related to an excessive secretion of fluid and
electrolytes into the intestines
o Caused by infections, some medications, some GI
disorders, and an excessive amount of bile acids
or unabsorbed fatty acids in the colon
o Treatment
 Antibiotics if cause is infectious
 Symptoms may be treated with medications
that decrease GI motility or thicken the
consistency of stools
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Altered Bowel Elimination (cont’d)
• Nutrition therapy
– Primary nutritional concern with diarrhea is
maintaining or restoring fluid and electrolyte balance
– Mild diarrhea lasting 24 to 48 hours:
o Usually requires no nutrition intervention other
than encouraging a liberal fluid intake to replace
losses
o High-potassium foods are encouraged; clear
liquids are avoided because they have high
osmolality related to their high sugar content,
which may promote osmotic diarrhea
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Altered Bowel Elimination (cont’d)
• Nutrition therapy (cont’d)
– For more serious cases, commercial (e.g.,
Pedialyte, Rehydralyte) or homemade oral
rehydration solutions, or IV therapy, is used to
replace fluid and electrolytes
– May improve by avoiding foods that stimulate GI
motility
– A low-fiber diet that is also low in fat and lactose
may help decrease bowel stimulation
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Question
• One cause of osmotic diarrhea is:
a. Antibiotics
b. Maldigestion
c. Some GI disorders
d. Unabsorbed fatty acids
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Answer
b. Maldigestion
Rationale: The causes of osmotic diarrhea
include maldigestion of nutrients (e.g., lactose
intolerance), excessive intake of sorbitol or
fructose, dumping syndrome, tube feedings,
and some laxatives. It is cured by treating the
underlying cause.
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Malabsorption Disorders
• Occurs secondary to nutrient maldigestion or from
alterations to the absorptive surface of the intestinal
mucosa
• Malabsorption related to maldigestion involves one
or few nutrients
• Malabsorption that stems from an altered mucosa is
more generalized, resulting in multiple nutrient
deficiencies and weight loss
• Symptoms vary with the underlying disorder
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Malabsorption Disorders (cont’d)
• Excretion of fat in the stool means that
essential fatty acids, fat-soluble vitamins,
calcium, and magnesium are also lost
through the stool
• Can cause metabolic complications
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Malabsorption Disorders (cont’d)
• Goal of nutrition therapy for malabsorption
syndromes is to:
– Control steatorrhea
– Promote normal bowel elimination
– Restore optimal nutritional status
– Promote healing, when applicable
• Individualized according to symptoms and
complications
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Malabsorption Disorders (cont’d)
• Lactose intolerance
– Occurs when the level of lactase is absent
or deficient
– Lactose digestion is impaired
– Undigested lactose increase the osmolality
of the intestinal contents
– May lead to osmotic diarrhea
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Malabsorption Disorders (cont’d)
• Lactose intolerance (cont’d)
– Lactose is fermented in the colon
– Produces bloating, cramping, and flatulence
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Malabsorption Disorders (cont’d)
• Primary lactose intolerance occurs in “well” people
who simply do not secrete adequate lactase
– Least common in people of northern European
descent
– May be asymptomatic when doses less than 4 to
12 g of lactose are consumed (e.g., ⅓ to 1 cup of
milk) or when lactose is consumed as part of a
meal
– Chocolate milk is usually better tolerated than
plain milkCopyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Malabsorption Disorders (cont’d)
• Primary lactose intolerance (cont’d)
– Know individual limits
– Lactose-reduced milk and lactase enzyme
tablets or liquid may be used
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Malabsorption Disorders (cont’d)
• Lactose intolerance secondary to gastrointestinal
disorders that alter the integrity and function of
intestinal villi cells, where lactase is secreted
– Loss of lactase may also develop secondary to
malnutrition because the rapidly growing
intestinal cells that produce lactase are reduced
in number and function
– Tends to be more severe than primary lactose
intolerance
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Malabsorption Disorders (cont’d)
• Nutrition therapy
– Nutrition therapy for lactose intolerance is
to reduce lactose to the maximum amount
tolerated by the individual
– A lactose-free diet is not realistic
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Question
• In lactose intolerance, undigested lactose
increases the __________ of the intestinal
contents.
a. Secretions
b. Osmolality
c. Acidity
d. Liquidity
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Answer
b. Osmolality
Rationale: Particles of undigested lactose
increase the osmolality of the intestinal
contents, which may lead to osmotic diarrhea.
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Malabsorption Disorders (cont’d)
• Inflammatory bowel disease (IBD)
– Primarily refers to 2 chronic inflammatory GI
diseases
o Crohn’s disease
o Ulcerative colitis
– IBD is believed to be caused by an abnormal
immune response to a complex interaction
between environmental and genetic factors
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Malabsorption Disorders (cont’d)
• Inflammatory bowel disease (IBD) (cont’d)
– Characterized by periods of exacerbation
and remission
– Share symptoms and treatment
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Malabsorption Disorders (cont’d)
• Inflammatory bowel disease (IBD) (cont’d)
– Nutrition therapy
o Depends on the presence and severity of
symptoms, the presence of complications, and
the nutritional status of the patient
o Diet restrictions kept to a minimum
o Patients are often reluctant to eat
o Crohn’s disease is more likely to cause nutritional
complications
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Malabsorption Disorders (cont’d)
• Inflammatory bowel disease (IBD) (cont’d)
– Nutrition therapy (cont’d)
o Focus of therapy for acute exacerbation of IBD is
to correct deficiencies by providing nutrients in a
form the patient can tolerate
o For patients consuming an oral diet, low fiber is
recommended to minimize bowel stimulation
o Protein and calorie needs are elevated to facilitate
healing
o Diet modifications are made according to
symptoms
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Malabsorption Disorders (cont’d)
• Celiac disease
– A genetic autoimmune disorder characterized by
chronic inflammation of the proximal small
intestine mucosa
– Related to a permanent intolerance to certain
proteins found in wheat, barley, and rye
– Malabsorption of carbohydrates, protein, fat,
vitamins, and minerals may occur, resulting in
diarrhea, flatulence, weight loss, and vitamin
and mineral deficiencies
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Malabsorption Disorders (cont’d)
• Celiac disease (cont’d)
– Symptoms and their severity vary depending on
the patient’s age and the duration and extent of
the disease
– Classic symptoms in children are diarrhea,
abdominal distention, and failure to thrive
– Adults present with diarrhea, constipation,
weight loss, weakness, flatus, abdominal pain,
and vomiting
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Malabsorption Disorders (cont’d)
• Celiac disease (cont’d)
– Atypical presentations
– In 0% to 20% of people with celiac disease,
dermatitis herpetiformis is the presenting
symptom
– Symptoms of dermatitis herpetiformis
respond to a gluten-free diet
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Malabsorption Disorders (cont’d)
• Celiac disease (cont’d)
– People who have a first-degree relative with
celiac disease, people with Down syndrome,
and those with an autoimmune disease are at
risk for celiac disease
– Untreated celiac disease is associated with an
increased incidence of small-bowel cancers
and enteropathy-associated T-cell lymphoma
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Malabsorption Disorders (cont’d)
• Celiac disease (cont’d)
– Nutrition therapy
o Only scientifically proven treatment for
celiac disease is to completely and
permanently eliminate gluten from the diet
o Lactose intolerance secondary to celiac
disease may be temporary or permanent
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Malabsorption Disorders (cont’d)
• Celiac disease (cont’d)
– Nutrition therapy (cont’d)
o A gluten-free diet requires a major lifestyle change
o Expensive
• Short-bowel syndrome (SBS)
– Occurs when the bowel is surgically shortened to the
extent that the remaining bowel is unable to absorb
adequate levels of nutrients to meet the individual’s
needs
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Question
• Who is at risk for celiac disease?
a. People with a second-degree relative who has
celiac disease
b. People who have lactose intolerance
c. People who have congenital diseases
d. People who have an autoimmune disease
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Answer
d. People who have an autoimmune disease
Rationale: People who have a first-degree
relative with celiac disease, people with Down
syndrome, and those with an autoimmune
disease are at risk for celiac disease.
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Malabsorption Disorders (cont’d)
• Short-bowel syndrome (SBS) (cont’d)
– Most common reasons for extensive intestinal
resections that result in SBS
o Crohn’s disease
o Traumatic abdominal injuries
o Malignant tumors
o Mesenteric infarction
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Malabsorption Disorders (cont’d)
• Short-bowel syndrome (SBS) (cont’d)
– Nutrition complications experienced by people
with short-bowel syndrome depend on the
amount and location of resected and remaining
bowel
o Patients who have 150 cm or more of
remaining small bowel without a colon, or 60
to 90 cm of small bowel with a colon, initially
require TPN and may progress to an oral diet
over a 1- to 2-year period
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Malabsorption Disorders (cont’d)
• Short-bowel syndrome (SBS) (cont’d)
– Factors that influence adaptation
o Length of remaining jejunum and/or ileum and
whether the colon is present
o Patient’s age
o Whether the ileocecal value remains
o Health of the remaining bowel
o Health of the stomach, liver, and pancreas
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Malabsorption Disorders (cont’d)
• Short-bowel syndrome (SBS) (cont’d)
– Nutrition therapy
o In the early months after bowel surgery,
TPN is the major source of nutrition and
hydration
o Consuming intact nutrients promotes
bowel adaptation because they stimulate
blood flow to the intestine and the
secretion of pancreatic enzymes and bile
acids
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Malabsorption Disorders (cont’d)
• Short-bowel syndrome (SBS) (cont’d)
– Nutrition therapy (cont’d)
o 6 to 8 small meals/day
o If the patient’s colon is intact, fat intake
is restricted to avoid steatorrhea and
increased fluid losses
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Conditions of the Large Intestine
• Irritable bowel syndrome (IBS)
– Most frequently diagnosed digestive disorder in
the U.S.
– Many factors involved in its etiology
– Symptoms include lower abdominal pain,
constipation, diarrhea, alternating periods of
constipation and diarrhea, bloating, and mucus
in the stools
– Can significantly impair quality of life
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Conditions of the Large Intestine (cont’d)
• Irritable bowel syndrome (IBS) (cont’d)
– Nutrition therapy
o Inconclusive evidence for any of the current
treatments used for IBS
o Pharmacologic treatment options
 Meet with limited success
o Complementary therapies
o Elimination diet
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Conditions of the Large Intestine (cont’d)
• Irritable bowel syndrome (IBS) (cont’d)
– Nutrition therapy (cont’d)
o Prebiotics
o Grade A level evidence exists for the use
of 5 g of guar gum daily
 Guar gum is a soluble, non-gelling fiber
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Conditions of the Large Intestine (cont’d)
• Diverticular disease
– Diverticula are caused by increased pressure
within the intestinal lumen
– Usually asymptomatic
– Diverticulitis occurs when diverticula become
inflamed
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Conditions of the Large Intestine (cont’d)
• Diverticular disease (cont’d)
– Symptoms of diverticulitis
o Cramping
o Alternating periods of diarrhea and
constipation
o Flatus
o Abdominal distention
o Low-grade fever
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Conditions of the Large Intestine (cont’d)
• Diverticular disease (cont’d)
– Potential complications
o Occult blood loss and acute rectal bleeding
leading to iron-deficiency anemia
o Abscesses and bowel perforation leading to
peritonitis
o Fistula formation causing bowel obstruction
o Bacterial overgrowth (in small-bowel
diverticula) that leads to malabsorption of fat
and vitamin B12
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Conditions of the Large Intestine (cont’d)
• Diverticular disease (cont’d)
– Nutrition therapy
o High-fiber intake may prevent and improve
symptoms of diverticulosis and prevent
diverticulitis
o Avoid nuts, seeds, and popcorn
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Conditions of the Large Intestine (cont’d)
• Diverticular disease (cont’d)
– Nutrition therapy (cont’d)
o During an acute phase of diverticulitis:
 Patients are NPO until bleeding and
diarrhea subside
 Oral intake resumes with clear liquids and
progresses to a low-fiber diet until
inflammation and bleeding are no longer a
risk
 A high-fiber diet is recommended unless
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Health | Lippincott Williams & recur
Wilkins
symptoms
ofKluwer
diverticulitis
Question
• Is the following statement true or false?
Pharmacologic treatment options meet with
limited success in diverticular disease.
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Answer
False.
Rationale: Antidiarrheals, antispasmodics, and
antidepressants are pharmacologic treatment
options that meet with limited success in
irritable bowel syndrome.
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Conditions of the Large Intestine (cont’d)
• Ileostomies and colostomies
– Performed after part or all the colon, anus, and
rectum are removed
– Potential nutritional problems
– The smaller the length of remaining colon, the
greater the potential for nutritional problems
– Ileostomies cause a decrease in fat, bile acid,
and vitamin B12 absorption
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Conditions of the Large Intestine (cont’d)
• Ileostomies and colostomies (cont’d)
– Effluent from an ileostomy is liquidy, and fluid
and electrolyte losses are considerable
– Effluent through a colostomy varies from liquid
to formed stools
– Nutrition therapy
o Goals of nutrition therapy for ileostomies and
colostomies are to minimize symptoms and
replenish losses
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Conditions of the Large Intestine (cont’d)
• Ileostomies and colostomies (cont’d)
– Nutrition therapy (cont’d)
o Initially only clear liquids that are low in simple
sugars
o Advanced slowly based on individual tolerance
o Fear of eating is common
o A near-regular diet resumes 6 to 8 weeks post-op
o Obtaining adequate fluid and electrolytes is a
major concern
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Disorders of the Accessory GI Organs
• Liver disease
– After absorption, almost all nutrients are
transported to the liver
– Vital for detoxifying drugs, alcohol, ammonia,
and other poisonous substances
– Liver damage can have profound and
devastating effects on the metabolism of
almost all nutrients
– Failure can occur from chronic liver disease
or secondary to critical illnesses
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Disorders of the Accessory GI Organs
(cont’d)
• Liver disease (cont’d)
– Early symptoms of hepatitis
o Anorexia, nausea and vomiting, fever, fatigue,
headache, and weight loss
– Later
o Dark-colored urine, jaundice, liver tenderness,
and possibly liver enlargement may develop
– Cell damage reversible with proper rest and
nutrition
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Disorders of the Accessory GI Organs
(cont’d)
• Liver disease (cont’d)
– Acute hepatitis advances to chronic hepatitis,
which may lead to cirrhosis, liver cancer, and
liver failure
– Glucose intolerance is common
– Cirrhosis can progress to hepatic
encephalopathy and hepatic coma
– Liver “fails” when liver cell loss is extensive
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Disorders of the Accessory GI Organs
(cont’d)
• Liver disease (cont’d)
– Nutrition therapy
o Objectives of nutrition therapy for liver disease are
to avoid or minimize permanent liver damage,
promote liver cell regeneration, restore optimal
nutritional status, alleviate symptoms, and avoid
complications
o Regeneration may not be possible
o Patients with acute hepatitis have difficulty
consuming an adequate diet
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Disorders of the Accessory GI Organs
(cont’d)
• Liver disease (cont’d)
– Nutrition therapy (cont’d)
o Malnutrition is common among patients
with cirrhosis
o Meeting nutrient and calorie needs is
difficult
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Disorders of the Accessory GI Organs
• Nutrition therapy for liver transplantation
– Treatment option for patients with severe
and irreversible liver failure
– Moderate to severe malnutrition increases
the risk of complications and death after
transplantation
– Not one specific post-transplant diet
– Small frequent meals and commercial
supplements may help maximize intake
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Disorders of the Accessory GI Organs
(cont’d)
• Nutrition therapy for liver transplantation
(cont’d)
– Long-term complications associated with
immunosuppressive therapy, such as excessive
weight gain, hypertension, hyperlipidemia,
osteopenic bone disease, and diabetes, may
require nutrition therapy
– Use of immunosuppressant drugs elevates the
importance of safe food handling practices to
avoid foodborne illness
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Disorders of the Accessory GI Organs
(cont’d)
• Pancreatitis
– Inflammation of the pancreas
– People with pancreatitis may also develop
hyperglycemia related to insufficient insulin secretion
– Alcohol abuse and gallstones account for 75% to
85% of cases of acute pancreatitis
– Acute pancreatitis that is not resolved or recurs
frequently can lead to chronic pancreatitis
o Characterized by scarring, fibrosis, and loss of
organ function
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Disorders of the Accessory GI Organs
(cont’d)
• Pancreatitis (cont’d)
– Seventy percent of cases are caused by alcohol
abuse; 20% are idiopathic
– Characterized by intermittent pain that is made
worse by eating
– Malabsorption does not occur until pancreatic
enzyme secretion is less than 10% of normal
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Disorders of the Accessory GI Organs
(cont’d)
• Pancreatitis (cont’d)
– Nutrition therapy
o Acute pancreatitis is treated by reducing
pancreatic stimulation
o In mild cases, the patient is given pain
medications, IV therapy, and nothing by
mouth (NPO)
o Small, frequent meals may be better tolerated
initially because they help to reduce the
amount of pancreatic stimulation at each meal
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Disorders of the Accessory GI Organs
(cont’d)
• Pancreatitis (cont’d)
– Nutrition therapy (cont’d)
o In moderate to severe acute
pancreatitis, patients are ordered NPO
and a nasogastric tube is inserted to
suction gastric contents
 Preferred route of delivering
nutritional enteral feeding
 Jejunal feedings
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Disorders of the Accessory GI Organs
(cont’d)
• Pancreatitis (cont’d)
– Nutrition therapy (cont’d)
o Goals of nutrition therapy for chronic
pancreatitis are to maintain weight, reduce
steatorrhea, minimize pain, avoid acute
attacks while meeting the patient’s nutrient
needs
o A mildly low-fat diet that is high in protein is
recommended
o Pancreatic enzyme replacement pills
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Disorders of the Accessory GI Organs
(cont’d)
• Gallbladder disease
– Gallstones
– Cholelithiasis
– Cholecystitis
– Dietary limitations
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