Transcript Upper GI Disorders MNT

Medical Nutrition Therapy
for Upper 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.
Head and Neck Cancers
 Can affect any part of
the head and neck area
 Surgical treatment can
have profound effect
on ability to take food
orally
 Often feeding tubes
are placed at the time
of surgery
Head and Neck Cancers
MNT in Head and Neck Cancers
 Address nutritional consequences of disease
and treatments (radiation therapy, surgery)
 Radiation therapy can alter taste sensation,
result in dry mouth, loss of appetite,
mucositis and dysphagia
 Malnutrition is reported to affect 30 to 50%
of patients with head and neck cancers.
MNT in Head and Neck Cancers
 Goal is to maintain adequate intake to promote
healing and allow aggressive treatment
 May involve enteral feedings, liquid oral
supplements, dietary changes (liquid, moist, softtextured foods and small, frequent meals
 Artificial saliva solutions, increased fluids, topical
anaesthetics to relieve pain
 Aggressive oral hygiene, fluoride, treatment of
fungal infections
Gastroesophageal Reflux Disease
(GERD)
 Defined as symptoms or mucosal damage
produced by the abnormal reflux of gastric
contents into the esophagus
 Symptoms: Burning sensation after meals;
heartburn, regurgitation or both, especially
after meals
 Symptoms often aggravated by
recumbency or bending over and are
relieved by antacids
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of
Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
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
Complications of GERD
 Esophagitis, stricture or ulcer
 Barrett’s Esophagus (premalignant state)
Diagnosis of GERD
 Empirically, via symptoms (symptoms don’t
always correlate with the degree of damage)
 Endoscopy – to confirm Barrett’s
Esophagus and dysplasia (a negative
endoscopy does not rule out the presence of
GERD)
 Ambulatory reflux monitoring
DeVault KR and Castell DO. Updated guidelines for the diagnosis and
treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol
2005;100:190-200
Ambulatory Reflux Monitoring
Goals of Nutrition Intervention in
GERD
 Increasing lower esophageal sphincter competence
 Decreasing gastric acidity, which results in
decreasing severity of symptoms
 Improving clearance of contents from the
esophagus
 Identification of drug-nutrient interaction
 Prevention of obstruction if esophageal stricture
present
 Improvement of nutritional intake if appropriate
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for GERD
 Initiate weight-reduction program if overweight
 Initiate smoking cessation (lowers LES pressure)
 Improve clearing of materials from esophagus
 Remain upright after eating
 Avoid eating within 3 hours of bedtime
 Wear loose-fitting clothing
 Raise the head of bed for sleeping
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for GERD
Reduce gastric acidity by eliminating the following:
 Black and red pepper
 Coffee (caffeinated and decaffeinated)
 Alcohol
Substitute smaller more frequent meals
Restrict foods that lessen lower esophageal sphincter
pressure by eliminating the following:
 Chocolate
 Mint
 Foods with a high fat content.
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for GERD
 Spicy, acidic foods may be irritating if
esophagitis is present
 Limitation of these foods should be based
on individual tolerance
Nutritional Care for Patients with
Reflux and Esophagitis
 Evidence reflecting the true efficacy of
these maneuvers in patients is almost
completely lacking
– American College of Gastroenterology
Guidelines, 2005
Drugs Commonly Used to Treat
Gastrointestinal Disorders
 Antibiotics: eradicate Helicobacter pylori,
prevent or treat infection after abdominal
wounds or surgery
 Antacids: neutralize gastric acid in acid
reflux, peptic ulcer
 Proton pump inhibitors (omeprazole,
lansoprazole): decrease gastric acid secretion
 Histamine-2 receptor antagonists (cimetidine,
ranitidine): inhibit gastric acid secretion
 Sucralfate (sulfated disaccharide): protects
stomach lining and may increase mucosal
resistance to acid or enzyme damage
Medications Used to Tx GERD
 Antacids: Mylanta, Maalox: neutralize
acids
 Gaviscon: barrier between gastric
contents and esophageal mucosa
 H2 receptor antagonists available over
the counter and by prescription (reduce
acid secretion): cimetadine, ranitidine,
famotidine, nizatidine
Medications Used to Treat GERD
 Proton Pump Inhibitors
(PPIs) Omeprazole
(Prilosec), lansoprazole,
rabeprazole, pantoprazole,
esomeprazole
 Some available over the
counter now
 Decrease gastric acid
secretion
Medications Used to Treat GERD
 Acid suppression is the mainstay of therapy
for GERD. Proton pump inhibitors provide
the most rapid symptomatic relief and heal
esophagitis in the highest percentage of
patients.
 Although less effective than PPIs,
Histamine-2 receptor blockers given in
divided doses may be effective in persons
with less severe GERD
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of
Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Medications Used to Treat GERD
 Promotility agents may be used in selected
patients, especially as an adjunct to acid
suppression. Currently available promotility
agents are not ideal monotherapy for most
patients with GERD
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of
Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
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#
MNT in NAUSEA/VOMITING
Nausea & Vomiting
 Prolonged vomiting = hyperemesis
– Loss of nutrients, fluids, electrolytes
– Dehydration, electrolyte imbalance, wt. loss
 Medications:
– Antinauseants
– Antiemetics
Goals of MNT in Nausea/Vomiting
 Decrease the frequency and severity of
nausea and/or vomiting
 Maintain optimal fluid balance and
nutritional status
 Prevent development of anticipatory nausea,
vomiting, and learned food aversions
ADA Nutrition Care Manual, accessed 4-06
MNT for Nausea/Vomiting
 When vomiting stops, introduce ice chips if older
than 3 years of age. If tolerated, start with
rehydration beverage or clear liquids, 1 tsp every
10 minutes. Increase to 1 Tbsp every 20 minutes.
Double amount of fluid every hour. If diarrhea is
present, use only rehydration beverage.
 Apple juice
 Sports drink
 Warm or cold tea
 Lemonade
ADA Nutrition Care Manual, accessed 4-06
MNT for Nausea/Vomiting
 When there has been no vomiting for at least 8 hours,




initiate oral intake slowly with adding one solid food at a
time in very small increments. Choose the following types
of foods:
Without odor
Low in fat
Low in fiber (see Client Education - Detailed, Foods
Recommended).
Take prescribed antiemetics and other medications on a
regular schedule to assist in prevention of nausea and
vomiting. Take all other medications after eating.
ADA Nutrition Care Manual, accessed 4-06
Nausea/Vomiting: Food and Feeding
Issues
 Keep patient away from strong food odors
 Provide assistance in food preparation so as to
avoid cooking odors
 Eat foods at room temperature
 Keep patient's mouth clean and perform oral
hygiene tasks after each episode of vomiting
 Offer fluids between meals
 Patient should sip liquids throughout the day
 Cold beverages may be more easily tolerated
 Keep low-fat crackers or dry cereal by the bed to
eat before getting out of bed
Nausea/Vomiting: Lifestyle Issues









Relax after meals instead of moving around
Sit up for 1 hour after eating
Wear loose-fitting clothes
Provide fresh air with a fan or open window
Limit sounds, sights, and smells that may trigger nausea
and vomiting
Other complementary and alternative medicine
interventions that have anecdotal evidence (though clinical
trials have not been conducted):
Relaxation techniques
Acupuncture
Hypnosis
ADA Nutrition Care Manual, accessed 4-06
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
Endoscopy
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
MNT for Peptic Ulcer Disease
and Gastritis
 Avoid foods that increase gastric acid
secretion, such as the following:
 Alcohol
 Pepper
 Caffeine
 Tea
 Coffee (including noncaffeinated)
 Chocolate
ADA Nutrition Care Manual, accessed 4-06
MNT for Peptic Ulcer Disease
 Identify foods that directly irritate the
gastric mucosa or are not generally tolerated
 Avoid eating at least 2 hours 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 medical 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.
Carcinoma of the Stomach
 Obstruction and mechanical interference
 Surgical resection or gastrectomy
 Prevention of GI cancers: fruits,
vegetables, and selenium
 Increase risk of GI cancers: alcohol,
overweight, high salted or pickled foods,
inadequate micronutrients
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 vagotomy
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
ADA Nutrition Care Manual, accessed 4-06
Dumping Syndrome Symptoms
 Cramping
 Abdominal pain
 Hypermotility
 Diarrhea
 Dizziness
 Weakness
 Tachycardia within 10-20 minutes after
eating
MNT for Dumping Syndrome
 Prevent onset of early and late dumping syndromes.
 Initially avoid all hypertonic, concentrated sweets. Do not




start clear liquids as first oral feeding.
The first meals should consist of protein, fat, and complex
carbohydrate, but with only 1-2 food items at a time.
Patients may be initially lactose intolerant. Slowly progress
to 5-6 small meals each day.
Consume liquids 30 minutes to 1 hour after consuming
solid food.
Lie down after eating.
Consider addition of functional fibers to delay gastric
emptying and assist with treatment of diarrhea.
MNT for Dumping Syndrome
These foods may exacerbate symptoms:
 Sucrose
 Fructose
 Sugar alcohols:
– Xylitol
– Mannitol
– Sorbitol
Source: ADA Nutrition Care Manual,
accessed 4-06
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
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.