MdicalNutrTher-GI Disorder '10-'11 (Kuliah GIT S1)

7/30/2019 MdicalNutrTher-GI Disorder '10-'11 (Kuliah GIT S1)

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Victor TambunanJohana Titus

Department of NutritionFaculty of Medicine Universitas Indonesia


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References

Krauses Food & Nutrition Therapy 12th ed.,

2008 ---- L.K. Mahan & S. Escott-Stump

Modern Nutrition in Health and Disease

10th ed., 2006 ---- M.E. Shils et al

Nutrition and Diagnosis-Related Care6th ed., 2008 ---- S. Escott-Stump

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Upper Gastrointestinal (GI) Tract

Esophagus

Stomach

Duodenum

Lower GI Tract

Small intestine

Large intestine

Rectum


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Gastroesophageal Diseases

Gastroesophageal reflux disease (GERD)

Achalasia

Gastritis and peptic ulcer disease

Dumping syndrome

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GERD consists of irritation & inflammation of

the esophagus in response to reflux of

gastric acid into the esophagus

Symptom:

heartburn (pyrosis)

Factors that contribute to GERD:Excessive volume of acidic contents in the stomach

Looseness of lower esophageal sphincter (LES)

Motility disorders in the esophagus

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Medical Nutrition Therapy

Objectives:

1. Prevent esophageal reflux

2. Prevent pain & irritation of theinflamed esophageal mucosa

3. the erosive capacity or acidity ofgastric secretion

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Nutrition Care Guidelines for ReducingGastroesophageal Reflux:

1. Avoid large, high-fat meals

2. Not eating within 34 hours before retiring

3. Avoid tobacco smoking, alcoholic beverages, and

caffeine containing foods & beverages

4. Stay upright & avoid vigorous activity immediatelyafter eating

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Nutrition Care Guidelines (contd)

5. Avoid tight-fitting clothing, especially after a meal

6. Consume a healthy, nutritionally complete diet with

adequate fibre

7. Avoid acidic & highly spiced foods when inflammation

exists

8. Reduce weight if overweight

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Alcohol

Chocolate

Fatty foods

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relaxing the LES & inducing GERD


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Failure of the cardiac sphincter to relax,with obstruction of food passage into thestomach

Nutrition management:

Objective:

Individualized diet according to patient

tolerances & preferences

Monitor chronic dysphagia

Avoid aspiration

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Provide large volumes of fluids with each meal,unless dysphagia prevents appropriate swallowingof liquids. Tube feeding if needed

Emphasize the importance of spacing meals &

achieving relaxation. Recommend intake of food atmoderate temperature only

Elevate head of bed for 3045 minutes after meals& at bedtime

Encourage fluids at mealtimes Avoid foods that aggravate dysphagia

Bland foods are not clearly beneficial & not required

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Gastritis & peptic ulcers may resultwhen

infectious

chemical

neural abnormalities

disrupt mucosal integrity ofthe stomach or duodenum

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The most common cause:

Helicobacter pylori infection

H. pylori infection is responsible for:

Most cases of chronic inflammation of gastricmucosa

Peptic ulcer

Atrophic gastritis

Gastric cancer

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Acute gastritis:refers to rapid onset of inflammation& symptoms

Chronic gastritis:may occur over a period of months

to decades, w/ waxing & waning(increasing & decreasing) of symptoms


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Symptoms

Nausea

Vomiting

Malaise

Anorexia

Hemorrhage

Epigastric pain

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Factors that may also compromise

mucosal integrity and

the chanceof acquiring acute & chronic gastritis

Chronic use of aspirin or other NSAIDs

Steroids

Alcohol

Erosive substances

Tobacco

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Sameas for peptic ulcers

In chronic gastritis: absorption of Fe, Ca, & other nutrients

occurs because gastric acid can their

bioavailability

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Primary causes:

H. pylori infection

Gastritis

Aspirin & other NSAIDsCorticosteroids

Stress-induced ulcer

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Involve two major regions:- Stomach- Duodenum


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Excessive use or high concentration drinks(alcohol) can:

damage gastric mucosa

worsen symptoms of peptic ulcers

interfere w/ ulcer healing

Beers & wines: gastric secretion

Coffee & caffeine:

Stimulate acid secretion

LES pressure19


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Symptoms

Abdominal pain

or

Discomfort

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characteristic ofboth gastric &duodenal ulcers

Anorexia

Weight loss

Nausea & vomitingHeartburn

slightly more often in gastric ulcers


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Avoid alcohol consumption of spices, esp. chili, cayenne, &black peppers.

Turmeric may inhibit adhesion ofH. pylori to the

gastric wallAvoid coffee & caffeine

intake of n-3 & n-6 fatty acids

Use probiotics as complementary therapy

Regular use ofcranberries which contain phenolicantioxidants may have the capacity to help

eradicate H. pylori

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Frequent small meals may:

comfort

the chance for acid reflux

stimulate gastric blood flow

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persons w/ peptic ulcers should avoid

consuming large meals, esp. beforeretiring, to reduce latent increases

in acid secretion


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Dumping syndrome:

a complex physiologic response to the

rapid emptying of hypertonic contents

into the duodenum & jejunum

May occur as a result of:

total or subtotal gastrectomy

manipulation of the pylorus after fundoplication

after some gastric bypass procedures forobesity

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Symptoms

Abdominal distention & pain

Diarrhea

Tachycardia

Symptoms associated w/ hypoglycemia:

Diaphoresis (profuse sweating)

Palpitations

Weakness

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3060 min.after eating

occur later


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Nutrition care:

Frequent small mealsHigh-protein, moderate-fat foods w/ sufficientcalories. Complex CHOs (starches) can beincluded. Simple CHO (lactose, sucrose,

& dextrose) should be limitedSufficient fibres (pectin in fruits, or guar gums)

beneficial because they upper GI transit

time & the rate of glucose absorption

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Prime objective:to restore nutrition status & quality of life


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Nutrition care: .. (contd)

Limit the amount of liquids taken w/ meals, butadequate amounts should be consumed duringthe day, small amounts at a time

Lie down immediately after meals & avoid activityan hour after eating

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Nutrition care: .. (contd)

Very small quantities of hypertonic, concentratedsweets (soft drinks, juices, pies, cakes, cookies,and frozen desserts) can be ingested

Lactose, especially in milk & ice cream, are poorlytolerated, but cheeses & yogurt are better

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Diet for preventing symptoms of dumping syndrome:

Moderate fat (30% of calories intake)

High protein (20% of calories intake)

Low in simple CHO

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helps the patient achieve & maintainoptimal weight & nutritional status

When intake is inadequate vit. D & Ca supplements

may be needed

When steatorrhea (+) give oil or fat which high inmedium-chain triglycerides (MCTs)


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Intestinal gas & flatulence

Constipation

Diarrhea

Steatorrhea

Gastrointestinal stricture & obstruction


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Instestinal Gas & Flatulence

Causes:

Inactivity

GI motility

Aerophagia

Dietary components GI disorders

Medical nutrition therapy:

Reduce intake of CHO that are likely to bemalabsorbed & fermented

e.g. legumes, soluble fibre, resistant starches,& simple CHO such as fructose & alcohol sugars

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Constipation

Most common causes:

Ignoring the urge to defecate

Lack of fibre in the dietInsufficient fluid intake

Inactivity

Chronic use of laxatives

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Consumption of adequate amounts ofboth soluble & insoluble dietary fibre

F i b r e :

colonic fecal fluidmicrobial mass

stool weight & frequency

the rate of colonic transit

softens feces & makes them easier to pass

Adequate water

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Recommended amount of dietary fibre

about 14 g/1000 kcal

Fibre can be provided in the form of:

Whole grainsFruits

Vegetables

LegumesSeeds

Nuts

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Diarrhea

Causes of diarrhea may be related to:

Inflammatory disease

Infections with fungal, bacterial, or viral

agentsMedications

Overconsumption of sugars

Insufficient or damaged mucosal absorptive

surfaceGI resections

Malnutrition

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First step in managing diarrhea:replacement of necessary fluids & electrolytes,

using:

electrolyte solutions

soups & broths vegetable juices

other isotonic liquids

Later:

starchy CHOs (cereals, breads)

low-fat meats added small amounts of vegetables & fruits,

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Probiotics

Modestly successful in:

Antibiotic-related diarrheaTravelers diarrhea

Bacterial overgrowth

Several types of pediatric diarrhea

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Steatorrhea

Steatorrhea:

excessive fat in the stool caused by

disease or surgical resection of organs

involved in the digestion & absorption

oflipid

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Steatorrhea can result in chronic weight loss may require calorie intake, mainly in theform of protein & complex CHOs

MCTs can be given because:able to enter the portal vein for transport to theliver without micelle formation digestion &absoprtion, & resynthesis into triglycerides in

intestinal cell

easier to be absorbed in the abscense of

bile acids

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Food source of MCTs:

coconut oil

Micronutriens supplementation:

Fat-soluble vitamins

Ca

Zn

Mg

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because losses are as a result ofthe formation of insoluble soaps


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Gastrointestinal Strictures &Obstruction

Causes (partially or completely obstruction):

Instestinal tumors

Scarring from GI surgeries

Inflammatory bowel disease (IBD)

Peptic ulcer

Radiation enteritis

If parts of the GI are partially obstructed

obstructions from foods may occur

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The most common foods that may cause

obstructions are fibrous plant foods

Phytobezoars:

obstructions in the stomach that resultfrom the ingestion of plant foods

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Restricted-fibre diet limit fruits, vegetables, &coarse grains

Provide


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Some Diseases and ConditionsAssociated with Malabsorption

Inadequate digestion Pancreatic insufficiency

Gastric resection

Altered bile salt metabolism withimpaired micelle formation Hepatobiliary disease

Bacterial overgrowth

Abnormalities of mucosal cell transport Biochemical or genetic abnormalities

- Disaccharidase deficiency e.g. lactase deficiency

- Celiac disease (gluten-sensitive enteropathy)

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Some Diseases and (contd)

Inflammatory or infiltitative disorders

- Crohns disease

- Ulcerative colitis

- Radiation enteritis

- Short-bowel syndrome

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Abnormalities of intestinal lymphatics

& vascular system Instestinal lymphangiectasia

Chronic congestive heart failure


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Two major forms of IBD:

Crohns disease

Ulcerative colitis

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Clinical characteristics:

Diarrhea Fever

Weight loss

Anemia Food intolerances

Malnutrition

Growth failure Extraintestinal manifestations (arthritic,

dermatologic, & hepatic)

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S f i fl d b l


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Crohns disease Ulcerative colitis

Segments of inflamed bowel


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Abnormal activationof the mucosal

immune response Secondary systemic

response

Unknown irritantViral? Bacterial?Autoimmune?

Geneticpredisposition

Damage to the cells of the small and/or large intestinewith malabsorption, ulceration, or stricture

- Diarrhea- Weight loss- Poor growth

Pathophysiology of inflammatory bowel disease


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IBD patients are at risk ofmalnutrition

Some potential nutrition-related problems

with IBD:

Anemias related to blood loss & poor intake

GI narrowing & strictures leading to bloating,nausea, bacterial overgrowth, & diarrhea

MalabsorptionFood aversion, anxiety, & fear of eating relatedto abdominal pain, bloating, nausea, or diarrhea

Drug-nutrient interactions


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Primary goal of medical nutrition therapy(MNT) to restore & maintain the

nutrition status of patients w/ IBD

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Energy:energy requirements are not greatly

Protein:protein needs may but rarely >50% thannormal needs

Vitamins & minerals supplementation: folic acid, vitamins B6, and B12 Zn, K, and Se


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Small, frequent feedings may be toleratedbetter

Small amounts ofisotonic, liquid, oralsupplements may be valuable

If fat malabsorption (+)

foods made with MCTs

useful to calories intake & for theabsorption of fat-soluble nutrients


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n-3 fatty acids intakeantiinflammatory effect

Probiotics can modify the microbial flora

Prebiotics (such as oligosaccharides): alter the mixture of microorganisms in the

colonic flora favoring lactobacillus & bifidobacteria

suppressing pathogenic or opportunisticmicroflora

production of SCFAs


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Risk factors associated with the onset ofexacerbations of IBD include:

sucrose intakelack of fruits & vegetables

dietary fibre >

alcoholaltered n-6/n-3 fatty acid ratios


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Cirrhosis of liver

a group of chronic liver diseasescharacterized by loss of normal lobulararchitecture with fibrosis, and bydestruction of parenchymal cells andtheir regeneration to form nodules

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56Clinical manifestations external symptoms


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Energy Patients without ascites:

120140% of the resting energy expenditure

(REE)

Patients with ascites, infection, malabsorption,or if nutritional repletion is necessary:

150175% of the REE

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Liver.. (contd)


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Carbohydrate (CHO) Cirrhotic patients are prone to develop diabetes

Insulin resistance seems to be the etiology

Recommendation:

6070% of total calories, preferably as

complex CHO effective in reducing insulinrequirements. Complex CHO intake insoluble fibre >> colonic pH prevent hepatic encephalopathy

Lipid2530% of total calories

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Liver.. (contd)


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Prote in Uncomplicated cirrhosis: 0.81 g/kg dry BW

To promote positive N balance: 1.21.3 g/kg BW

Complicated cirrhosis, including GI bleeding,

severe ascites, infection: 1.5 g/kg BW

Vitamins & Minera ls

Fat-soluble (A, D, E, K) & water-soluble vitamins

(thiamin, B6, B12, niacin, folic acid) Minerals: Fe, Zn, Mg, & Ca

If ascites & edema (+) Na &water restriction

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Liver.. (contd)


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MdicalNutrTher-GI Disorder '10-'11 (Kuliah GIT S1)

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