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 GERDPromotility 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.com/ac/adamsurg.nsf/page/100181#

Nausea & Vomiting

Prolonged vomiting = hyperemesis– Loss of nutrients, fluids, electrolytes– Dehydration, electrolyte imbalance, wt. loss

Meds:– Antinauseants– Antiemetics

Nausea & VomitingDietary 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 acid-producing 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 DiseaseTreatment with DietPeptic Ulcer DiseaseTreatment 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

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.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 & Zollinger-

Ellison 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.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 amounts (1/2 to 1 cup)

Dumping SyndromeDietary 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 high-

fat 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.