Transcript No Slide Title

Medical Nutrition Therapy
for Gastrointestinal Tract
Disorders
Esophagus
 Tube from pharynx to stomach
 Upper esophageal sphincter (UES or
cardiac sphincter) closed except when
swallowing
 Lower esophageal sphincter (LES)
closes entrance to stomach; prevents
reflux of stomach contents back into
esophagus
Common Symptoms of
Gastrointestinal Disease
Cancer of the Oral Cavity,
Pharynx, Esophagus



Existing nutritional problems and eating
difficulties caused by the tumor mass,
obstruction, oral infection and ulceration, or
alcoholism
Chewing, swallowing, salivation, and taste
acuity are often affected.
Weight loss is common.
Gastroesophageal Reflux Disease
(GERD)
 Backward flow of the stomach and/or
duodenal contents into the esophagus
 Burning sensation after meals; heartburn
 Possible discomfort during and after
eating, change in eating habits, especially
in the evening
Hiatal Hernia
 An outpouching of a portion of the
stomach into the chest through the
esophageal hiatus of the diaphragm
 Heartburn after heavy meals or with
reclining after meals
 May worsen GERD symptoms
Anatomy of Esophagus and
Hiatal Hernia
Nutritional Care for GERD
 Maintain upright posture during and 45-
60 minutes after eating
 Avoid eating within 2-3 hours before
bedtime
 Avoid clothing that is tight in the
abdominal area
 Stop smoking (lower LES pressure)
 Limit caffeine intake
Source: Am Diet Assoc. Manual of
Clinical Nutr, 6th Edition.
Nutritional Care for GERD
 Avoid chocolate
 Limit/avoid alcohol intake
 Achieve and maintain a healthy weight
 Elevate the head of bed (6-8 inches)
when sleeping
 Try problem foods in small quantities as
part of a meal.
Source: Am Diet Assoc. Manual of
Clinical Nutr, 6th Edition.
Medications Used to Tx GERD
Antacids
 Mylanta, Maalox: neutralize acids
 Gaviscon: barrier between gastric
contents and esophageal mucosa
 H2 receptor antagonists (reduce acid
secretion)
 Cimetadine, ranitidine, famotidine,
nizatidine
 Omeprazole (Prilosec) short term
Medications Used to Tx GERD
Promotility Agents (enhance esophageal
clearing and gastric emptying)
 Cisapride, bethanechol
Surgical Treatment of GERD
 Fundoplication: Fundus of stomach is
wrapped around lower esophagus to limit
reflux
Illustration of Fundoplication
Source:
http://www.medformation.c
om/ac/adamsurg.nsf/page/1
00181#
Nausea & Vomiting
 Prolonged vomiting = hyperemesis
– Loss of nutrients, fluids, electrolytes
– Dehydration, electrolyte imbalance, wt. loss
 Meds:
– Antinauseants
– Antiemetics
Nausea & Vomiting
Dietary Measures
 NPO for several hours
 Clear liquids if tolerated, then progress
as tolerated
 IV fluids if liquids not tolerated
 Parenteral nutrition if severe, though
increasingly enteral nutrition is used for
hyperemesis of pregnancy
Diseases of Stomach
 Indigestion
 Acute gastritis from: H. pylori
tobacco, chronic use of drugs
such as:
—Alcohol
—Aspirin
—Nonsteroidal
antiinflammatory agents
Indigestion (Dyspepsia)
Symptoms





Abdominal pain
Bloating
Nausea
Regurgitation
Belching
Dyspepsia Treatment
 Avoid offending foods
 Eat slowly
 Chew thoroughly
 Do not overindulge
Gastritis
 Normally gastric & duodenal mucosa
protected by:
– Mucus
– Bicarbonate (acid neutralized)
– Rapid removal of excess acid
– Rapid repair of tissue
Gastritis
 Erosion of mucosal layer
 Exposure of cells to gastric secretions,
bacteria
 Inflammation & tissue damage
Gastritis
 Helicobacter Pylori (H. pylori)
– Bacteria, resistant to acid
– Damages mucosa
– Treat with bismuth, antibiotics,
antisecretory agents
– Causes ~92% duodenal ulcers; 70%
gastric ulcers
Atrophic Gastritis
 Loss of parietal cells in stomach
– Hypochloria =  in HCl production
– Achlorhydria = loss of HCl production
– Decrease or loss of intrinsic factor production
• Malabsorption of vitamin B12
• Pernicious anemia
• vitamin B12 injections or nasal spray
Peptic Ulcer Disease (PUD)
 Gastric or duodenal ulcers
 Asymptomatic or sx similar to gastritis
or dyspepsia
 Danger of hemorrhage, perforation,
penetration into adjacent organ or space
– Melena = black, tarry stools from GI
bleeding
Characteristics and Comparisons
Between Gastric and Duodenal Ulcers
 Gastric ulcer formation involves
inflammatory involvement of acidproducing cells but usually occurs with
low acid secretion; duodenal ulcers are
associated with high acid and low
bicarbonate secretion.
 Increased mortality and hemorrhage are
associated with gastric ulcers.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
Gastric and Duodenal Ulcers
Peptic Ulcer Disease (PUD)
Definition and Etiology
 Erosion through mucosa into submucosa
– H. pylori
– Aspirin, NSAIDs
– Stress:
• Severe burns, trauma, surgery, shock, renal
failure, radiation
Peptic Ulcer Disease (PUD)
Medical Management
 Plays a more important role than diet
–  or stop aspirin, NSAIDs
– Use antibiotics, antacids
– Use sucralfate (Carafate) = gastric
mucosa protectant – forms barrier over
ulcer
Peptic Ulcer Disease (PUD)
Behavioral Management
 Avoid tobacco
• Risk factor for ulcer development
•  complications – impairs healing,
increases incidence of recurrence
• Interferes with tx
• Risk of recurrence, degree of
healing inhibition correlate with
number of cigarettes per day
Peptic Ulcer Disease
Treatment with Diet
 Reduce decaffeinated and regular
coffee, cocoa, and tea intake
 Avoid alcohol or pepper
 Avoid low-pH juices if they cause
problems (generally pH in foods is not
an issue)
 Avoid large meals, especially right
before bedtime
Peptic Ulcer Disease
Treatment with Diet
 Meal frequency is controversial: small,
frequent meals may increase comfort but
may also increase acid output
 There is little evidence to support
eliminating specific foods unless they
cause repeated discomfort
 Overall good nutritional status helps 
H. pylori
Gastric Surgery
 Indicated when ulcer complicated by:
– Hemorrhage
– Perforation
– Obstruction
– Intractability (difficult to manage, cure)
– Pt unable to follow medical regimen
 Ulcers may recur after med. or surgical
tx
Gastric Surgery
 Resective surgical procedures
 “anastamosis” – connection of two
tubular structures
 Gastrectomy – surgical removal of part
or all of stomach
– Hemigastrectomy = half
– Partial gastrectomy
– Subtotal gastrectomy = 30-90% resected
Gastric surgical procedures.
Fig. 30-7. p. 661.
Gastric Surgery
 Billroth I = gastroduodenostomy
– Partial gastrectomy – anastomosis to duodenum
– To remove ulcers, other lesions (cancer)
 Billroth II = gastrojejunostomy
– Partial gastrectomy - anastomosis to jejunum
 Allows resection of damaged mucosa
 Reduces number of acid producing cells
 Reduces ulcer recurrence
Gastric Surgery
 Total gastrectomy
– Removal of entire stomach
– Rarely done = negative impact on digestion,
nutritional status
– In extensive gastric cancer & ZollingerEllison syndrome not responding to medical
management
– Anastomosis from esophagus to duodenum
or jejunum
Zollinger-Ellison Syndrome
 PUD caused by “gastrinoma”
– Gastrin producing tumor in pancreas
– Gastrin = hormone stimulates HCl prod
– Causes mucosal ulceration
– 50 – 70% are malignant
– Any part of esoph., stomach, duod., jejun.
– Removal of tumor, gastrectomy
Gastric surgical procedures.
(cont.)
Fig. 30-7. p. 661.
Pyloroplasty
 Surgical enlargement of pylorus or
gastric outlet
 To improve gastric emptying with
obstructions or when vagatomy
interferes with gastric emptying
 May contribute to Dumping Syndrome
 Ulcer recurrence is common
Roux-en-Y
 Gastric partitioning – distal ileum,
proximal jejunum
 Often for “bariatric” purposes (wt. loss)
 Wt loss for 12 – 18 wks with 50 – 60%
excess wt. Loss
Roux-en-Y
 Nutritional Goals:
– Prevent deficiencies
– Promote eating, lifestyle changes to
maintain losses
– Mechanical soft diet ~ 3 mo., then solid
foods
– Small amounts – 1 oz. To 1 cup
– Overeating = N & V, reflux
Vagotomy
 Severing all or part of the vagus nerves
to the stomach
 With partial gastrectomy or pyroplasty
 Significant decrease in acid secretion
 “truncal vagotomy” – no vagal
stimulation to liver, pancreas, other
organs, stomach
 “selective vagotomy” or “parietal cell
vagotomy” – eliminates stimulation to
stomach
Diet Post Gastric Surgery
 Ice chips allowed 24-48 hours after
surgery. Some tolerate warm water better
than ice chips or cold water
 Clear liquids such as broth, bouillon,
unsweetened gelatin, diluted
unsweetened fruit juice
 Initiate postgastrectomy diet and
gradually progress to general diet as
tolerated
 Monitor iron, B12, and folic acid status
Dumping Syndrome
 Complex physiologic response to the rapid
emptying of hypertonic contents into the
duodenum and jejunum
 Dumping syndrome occurs as a result of total
or subtotal gastrectomy and is associated with
mild to severe symptoms including abdominal
distention, systemic systems (bloating,
flatulence, pain, diarrhea), and reactive
hypoglycemia.
Dumping Syndrome
 Rapid movement of hypertonic chyme into
jejunum
 Fluid drawn into bowel by osmosis to dilute
concentrated mass of food
 Volume of circulating blood decreases
•
•
•
•
Tachycardia (rapid heart rate)
Dizziness, flushing
Diaphoresis (profuse sweating)
Orthostatic hypotension
Dumping Syndrome –
Dietary Treatment
 Small meals spread throughout day
 High protein (20%), moderate fat (30 –
40%), complex CHO as tolerated
 Very small amts of concentrated sweets
 Food and drink should be moderate in
temperature
 Use caution with high fiber foods – use
pectin to decrease transit time, glucose
absorption
 Take liquids between meals in small
Dumping Syndrome
Dietary Treatment
 Lactose  transit – poorly tolerated
 Medium-chain triglycerides-steatorrhea
 Eat slowly, chew food thoroughly
 If dumping is a problem, have patient lie
down 20-30 minutes after meals to retard
transit to small bowel
Source: Am Diet Assoc. Manual of
Clinical Nutr, 6th Edition.
Malabsorption, steatorrhea
 Post-surgical complications affecting
nutrition:
• Fat soluble vitamins, calcium
• Folate, B12 (loss of intrinsic factor)
• Iron – better absorbed with  acid
– Supplement may help
Drugs Commonly Used to Treat
Gastrointestinal Disorders
 Antacids: lower acidity
 Cimetidine (Tagamet), ranitidine (Zantac):
block acid secretion by blocking histamine
H2 receptors
 Prostaglandins
 Sucralfate: coats and protects surface
 Colloidal bismuth: coats and protects surface
 Carbenoxolone: strengthens mucosal barrier
 Tinidazole: antibiotic
Diseases of Stomach—cont’d
 Chronic gastritis
Precedes gastric lesion like cancer or
ulcer
H. pylori infection may cause
Sx—Indigestion, loss of appetite, feeling
full, belching, epigastric pain, nausea,
vomiting
Diseases of Stomach—cont’d
Rx: Avoid foods not tolerated; soft consistency;
regular meals; chew foods
—Avoid highly seasoned foods; avoid excess
liquid at meals
 Atrophic gastritis:
—Stomach cells atrophy
—Loss of parietal cells—achlorhydria
—Lose IF for B12 absorption
Disorders of the Stomach—
Nutritional Care
 Lifestyle changes are an important
component of the nutrition care plan.
 Patients with dyspepsia should avoid highfat foods, sugar, caffeine, spices, and
alcohol.
Diabetic Gastroparesis
(Gastroparesis Diabeticorum)
 Delayed stomach emptying of solids
 Etiology—autonomic neuropathy
 Nausea, vomiting, bloating, pain
 Insulin action and absorption of food not
synchronized
 Prescribe small frequent meals (may need
liquid diet)
 Adjust insulin
Summary
 Upper GI disorders—H. pylori plays an
important role
 Maintain individual tolerances as much as
possible.