Chapter 18 Nutrition and Lower Gastrointestinal Disorders

1818Nutrition and

Lower Gastrointestinal

Disorders

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Common Intestinal Problems

• Constipation– Fewer than three bowel movements per week– Hard stools and excessive straining– More prevalent in women and older adults– Causes of constipation

• Low-fiber diet, low food intake, inadequate fluid intake, or low level of physical activity

• Some medical conditions and medications



Common Intestinal Problems: Constipation (cont’d.)

• Treatment of constipation– Fiber intake: gradual increase to 20-25 g/day

• Foods that increase stool weight: wheat bran, fruits, and vegetables

• Fiber supplements– Adequate fluids: 1.5 to 2 liters per day– Prunes or prune juice– Increase physical activity if inactive



Common Intestinal Problems: Constipation (cont’d.)

• Laxatives– Action: increase stool weight, increase stool

water content, or stimulate peristaltic contractions

– Enemas and suppositories: distend and stimulate the rectum or lubricate the stool

• Medical interventions• What medical interventions may be taken for

patients who do not respond to dietary or laxative treatments?



Common Intestinal Problems (cont’d.)

• Intestinal gas (flatulence)– Nutrition therapy: restrict FODMAPs

• Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols

– Foods associated with flatulence• Corn, carbonated beverages• FODMAPs sources: apples, broccoli, cabbage,

dried beans and peas, fructose-sweetened products, pears, etc.



Common Intestinal Problems (cont’d.)

• Diarrhea– Passage of frequent, watery stools– Severe or persistent: dehydration and

electrolyte imbalances– Chronic cases: weight loss and malnutrition– Causes of diarrhea

• Various GI disorders, infections, medications, or dietary substances



Common Intestinal Problems: Diarrhea (cont’d.)

• Causes of diarrhea– Osmotic diarrhea

• Unabsorbed nutrients or other substances attract water to the colon and increase fecal water content

– Secretory diarrhea • Fluid secreted by the intestines exceeds the

amount that can be reabsorbed by intestinal cells– Motility disorders may result in diarrhea




• Causes of diarrhea– Acute cases

• Start abruptly and may persist for several weeks• What are some typical causes of acute cases of

diarrhea?– Chronic cases

• Persist for about four weeks or longer• Result from malabsorption disorders, inflammatory

diseases, motility disorders, infections, etc.




• Medical treatment of diarrhea– Correct the underlying problem

• Antibiotics for intestinal infections; eliminating responsible foods; prescribing a different medication; etc.

– Bulk-forming agents– Antidiarrheal drugs– Probiotics– Intractable diarrhea: parenteral nutrition




• Oral rehydration therapy– Replace lost fluid and electrolytes– Rehydration solutions: water, salts, glucose

(Box 18-3)– Why are commercial sport drinks not ideal

fluids for rehydration?




• Nutrition therapy for diarrhea– Depends on cause, severity, duration– Initially recommended: low-fiber, low-fat, and

lactose-free diet– Fluid intakes increased to replace fluid losses– Formula-fed infants: apple pectin or banana

flakes added to formulas



Malabsorption

• Causes– Pancreatic disorders leading to enzyme or

bicarbonate deficiencies– Disorders leading to bile deficiency– Inflammatory diseases or medical treatments

damaging intestinal tissue



Malabsorption (cont’d.)

• Fat malabsorption– Fat = nutrient most frequently malabsorbed

• Requires both digestive enzymes and bile for its digestion

– Steatorrhea: excessive fat in the stools• Evidence of fat malabsorption

– Consequences of fat malabsorption• Losses of food energy, essential fatty acids,

fat-soluble vitamins, and some minerals



The Consequences of Fat Malabsorption



Malabsorption: Fat Malabsorption (cont’d.)

• Nutrition therapy for fat malabsorption– Fat-restricted diet (Table 18-5)

• Fat restricted no more than necessary– Medium-chain triglycerides (MCT): alternative

dietary fat source• Lacks essential fatty acids

– Box 18-5 provides tips for adhering to a fat-restricted diet and using MCT oil



Sample Menu—Fat-Restricted Diet




• Bacterial overgrowth– Excessive bacterial colonization of the

stomach and small intestine– May result in fat malabsorption

• Deficiencies of fat-soluble vitamins may develop

– May reduce absorption of vitamin B12

– Causes of bacterial overgrowth• Impaired intestinal motility, reduced gastric

secretions




• Bacterial overgrowth– Treatment for bacterial overgrowth

• Antibiotics• Surgical correction of anatomical defects• Medications to stimulate peristalsis• Discontinuation of acid-suppressing medications• Lactose-restricted diet• Dietary supplements to correct nutrient

deficiencies




• Lactose intolerance– Prevalence: 75% of people worldwide– Primary symptoms:

• Diarrhea • Increased intestinal gas

– What dietary adjustments are recommended for people with lactose intolerance?



Disorders of the Pancreas

• Pancreatitis: an inflammatory disease– Acute pancreatitis

• Digestive enzymes within pancreatic cells become prematurely activated, causing pancreatic tissue destruction and subsequent inflammation

• 70% to 80% of cases are caused by gallstones or alcohol abuse

• What are common symptoms of acute pancreatitis?



Disorders of the Pancreas: Pancreatitis (cont’d.)

• Nutrition therapy for acute pancreatitis– Initial treatment: pain control and intravenous

hydration; oral fluids and food withheld– Usually progress to regular diet

• Fat-restricted diet if malabsorption symptoms occur

• Continuous tube feedings (started within 48 hours) for severe disease

• Protein: 1.2 to 1.5 g/kg/day




• Chronic pancreatitis– Progressive, permanent damage

• Impaired secretion of digestive enzymes and bicarbonate

– 70% to 80% of cases due to excessive alcohol consumption

• Nutrition therapy for chronic pancreatitis– Objectives: reduce malabsorption, correct

malnutrition




• Nutrition therapy for chronic pancreatitis– Pancreatic enzyme replacement for

steatorrhea/malabsorption– Daily needs: 1.0-1.5 g/kg protein, 35 kcal/kg– Dietary supplements to correct nutrient

deficiencies– Avoid alcohol completely; quit smoking



Disorders of the Pancreas (cont’d.)

• Cystic fibrosis– Genetic disorder that alters the ion

concentration and/or viscosity of exocrine secretions

– Consequences of cystic fibrosis• Lung disease: chronic respiratory infections,

progressive inflammation, airway obstruction• Pancreatic disease: obstructed pancreatic ducts



Disorders of the Pancreas: Cystic Fibrosis (cont’d.)

• Consequences of cystic fibrosis– Excessive salt losses in sweat– Others: intestinal obstruction; gallbladder and

liver diseases; abnormalities in genital tissues• Nutrition therapy for cystic fibrosis

– High-kcal, high-protein diet; liberal fat intake– Oral supplements and/or tube feedings– Pancreatic enzyme therapy



Disorders of the Small Intestine

• Celiac disease– Immune disorder; abnormal response to

wheat gluten and related proteins– Causes severe damage to the intestinal

mucosa• Subsequent malabsorption

– Consequences of celiac disease• GI disturbances: diarrhea, steatorrhea, and

flatulence



Disorders of the Small Intestine (cont’d.)

• Celiac disease– Nutrition therapy for celiac disease

• Gluten-free diet (Table 18-6) • Avoid lactose until recovered if lactase deficiency

suspected• Dietary supplements



Sample Menu—Gluten-Free Diet




• Inflammatory bowel diseases– Chronic inflammatory illnesses characterized

by abnormal immune responses to microbes that inhabit the GI tract

– Major forms:• Crohn’s disease• Ulcerative colitis



Disorders of the Small Intestine: Inflammatory Bowel Diseases (cont’d.)

• Complications of Crohn’s disease– Ulcerations, fissures, fistulas, strictures– 40% require surgery within 10 y of diagnosis– Increased risk of intestinal cancer– Malnutrition

• Poor food intake, malabsorption, diarrhea, bleeding, nutrient losses, increased needs

– B12 deficiency, anemia, and anorexia




• Complications of ulcerative colitis– Mucosal atrophy, thin walls, colon dilation– Varying symptoms: diarrhea, constipation,

rectal bleeding, and abdominal pain– Weight loss, fever, and weakness– Severe cases: anemia, dehydration, and

electrolyte imbalances– Colon cancer risk substantially increased




• Drug treatment for inflammatory bowel diseases– Purpose: control symptoms, reduce

inflammation, and minimize complications• Nutrition therapy for Crohn’s disease

– Aggressive dietary management• Specific measures: depend on functional status of

the GI tract; symptoms and complications that develop




• Nutrition therapy for ulcerative colitis– In most cases: few adjustments to diet– Manage symptoms as needed

• Restore fluid and electrolyte balances• Correct deficiencies• Low-fiber diet may reduce irritation

– Severely impaired colon function• NPO, intravenous fluids and electrolytes




• Short bowel syndrome– Malabsorption syndrome following resection

of a major portion of small intestine– Intestinal adaptation

• What changes occur during intestinal adaptation?– Nutrition therapy for short bowel syndrome

• Initially following resection: fluids and electrolytes must be supplied intravenously

• First few weeks: rehydration therapy




• Short bowel syndrome– Nutrition therapy for short bowel syndrome

• Gradual transition: parenteral nutrition to tube feedings and/or oral feedings

• What factors determine the exact diet prescribed for short bowel syndrome?

• Dietary choices tailored according to individual symptoms and tolerances

• Example: Box 18-12 (case study)



Nutrient Absorption and Consequences of Intestinal Surgeries



Disorders of the Large Intestine

• Irritable bowel syndrome– Chronic and recurring intestinal symptoms

• Not explained by specific physical abnormalities– Symptoms

• Disturbed defecation, bloating, abdominal discomfort or pain

– Treatment of irritable bowel syndrome• Dietary adjustments, stress management, and

behavioral therapies; medications



Disorders of the Large Intestine: Irritable Bowel Syndrome (cont’d.)

– Nutrition therapy for irritable bowel syndrome– Responses among patients vary considerably

• Avoid foods that aggravate symptoms: fried or fatty foods, gas-producing foods, milk products, etc.

• Low-FODMAP diet• Small, frequent meals• Psyllium supplementation (for constipation)• Under investigation: peppermint oil, probiotics



Disorders of the Large Intestine (cont’d.)

• Diverticular disease of the colon– Diverticulosis

• Presence of small herniations (diverticula) in the intestinal mucosa

• Usually asymptomatic– Diverticulitis

• Inflammation or infection involving diverticula• Persistent abdominal pain, tenderness in the

affected area, fever, constipation, and diarrhea



Disorders of the Large Intestine: Diverticular Disease (cont’d.)

• Treatment for diverticular disease– Increased fiber intakes often recommended

but not shown to reverse the disease or prevent its progression

– Diverticulitis treatment• May need antibiotics and pain-control drugs• NPO, intravenous fluids in severe cases• Surgical interventions for complications



Disorders the Large Intestine (cont’d.)

• Colostomies and ileostomies– Ostomy: surgically created opening (stoma) in

the abdominal wall• For dietary waste elimination

– Colostomy: stoma formed from a section of the colon

– Ileostomy: stoma formed from a section of the ileum



Colostomy and Ileostomy



Disorders of the Large Intestine: Colostomies and Ileostomies (cont’d.)

• Nutrition care for patients with ostomies– Individualized dietary adjustments

• Depends on surgical procedure and symptoms– Recommendations with ileostomies

• Chew foods thoroughly• Avoid foods high in insoluble fibers• Use salt liberally and drink beverages with added

electrolytes




• Nutrition care for patients with ostomies– Recommendations with colostomies

• Most patients return to a regular diet

• Obstructions– Primary concern of ileostomy patients– What are examples of foods that may cause

difficulty?




• Reducing gas and odors – Foods that may reduce odors: buttermilk,

cranberry juice, parsley, and yogurt• Diarrhea

– Table 18-3: foods that may worsen diarrhea– Foods that may thicken stool: applesauce,

banana, cheese, pasta, potatoes, smooth peanut butter, tapioca, white rice



Nutrition in Practice:Probiotics and Intestinal Health

• Roles of nonpathogenic intestinal bacteria• Probiotics

– Research on uses in medical treatment• Infectious diarrhea• Pouchitis following ileostomy or colostomy

– Dietary sources (mainly fermented foods)• Adverse effects

– Bacterial translocation


Chapter 18 Nutrition and Lower Gastrointestinal Disorders

Education

Transcript of Chapter 18 Nutrition and Lower Gastrointestinal Disorders