NMDC221 Session 2: Gastrointestinal & Alimentary Disease ......Drug Action Side Effects Interaction...
Transcript of NMDC221 Session 2: Gastrointestinal & Alimentary Disease ......Drug Action Side Effects Interaction...
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NMDC221 Session 2:
Gastrointestinal & Alimentary
Disease Part II
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Topic Overview
Recommended Reading
Mahan, L.K., & Raymond, J.L. (2016). Krause’s food & the nutrition
care process (14th ed.). St. Louis, MO: Elsevier.
P518-520; 525-557. (prescribed text).
Gastrointestinal & Alimentary Disease: Part II
o Nutritional management & consideration of drug-nutrient
interactions
• Hypochlorhydria
• Gastritis
• Peptic ulcer disease
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Hypochlorhydria
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Hypochlorhydriao A deficient level of hydrochloric acid (HCL) from the parietal cells of
the stomach resulting in poor dietary protein breakdown (HCL &
pepsin) and reduced liberation of protein bound nutrients (e.g. B12
and iron). HCl also activates important enzymes and hormones, and
can help protect against bacterial overgrowth in the gut.
o Ongoing hypochlorhydria increases the risk of gastric ulcerations,
malabsorption, infections, gastritis, gastric cancers, GORD, and
gastric bacterial overgrowth (Prousky J 2001)
o Can be associated with Sjogren’s syndrome, Addison's disease,
asthma, SLE, osteoporosis, gastritis (Prousky J 2001)
o Results in the malabsorption of protein, vitamin B12, folic acid,
calcium, iron and trace minerals.
o Predisposes a person to malnutrition which increases risk of
degenerative disease
o Leads to amino acid deficiencies
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Risk factors1. Age
o hydrochloric acid secretion declines with advancing age
o In one study US researchers found that over 30 percent of men and
women past the age of 60 suffer from atrophic gastritis, a condition
marked by little or no acid secretion. A second study found that up
to 40% of post-menopausal women have no basal gastric acid
secretions (Krasinski SD et al 1986)
2. Lifestyle
o Drinking water with meals; vegetarian diets (or diets low in protein)
can reduce HCL production.
3. Nutrient deficiencies
4. Food allergies and /or sensitivities (although they may be they are a
result of the condition itself).
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Risk Factors Cont.
5. Stress
o Sympathetic nervous system dominance (high stress) decreases
parasympathetic vagal nerve innervation of stomach (Pizzorno &
Murray, 2006, p168)
6. Helibacter pylori.
o Can cause atrophic changes to the gastric mucosa (Carter RE
1992)
7. Drugs - can be induced through the repeated administration of acid-
reducing agents, such as proton-pump inhibitors (PPIs); H2-receptor
antagonists (H2-RAs)
8. Others – early weaning onto refined and processed foods; genetics
(Pro-inflammatory IL-1 polymorphisms are associated with
hypochlorhydria) (Furuta T et al 2002)
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Signs and Symptoms
o Bloating after eating
o Sense of fullness
o Nausea when taking supplements
o Burping and feeling of ‘upset
stomach’
o Dyspeptic symptoms
o Burning sensations, especially of
the mouth
(English J 2013)
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Nutritional treatment
Initial Nutritional Considerations:
o Assess current diet and make necessary modifications
o Consider :- meal size, adequate protein at each meal, small frequent
meals, fluids away from meal times. Suggest - apple cider vinegar
in water before meals or 100ml lemon juice, 15 minutes before main
meals (increases saliva output & stimulation of exocrine secretion of
the pancreas) (Benny 2010)
o Assess microbiome status and support with fermented foods,
probiotics
o Design aims around – providing mucosal repair to tissue (treartment
pplan would then suggest nutrients such as Mucosal– Zinc, Vitamin
A, Glutamine, Vitamin E would be beneifical)
o Assess if there’s any contributing factors – drugs/medications, food
allergies/sensitivities that may need attention.
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HypochlorhydriaFurther Nutritional Considerations:
o Provide adequate dietary support
o Consider referring on for H pylori infection (HPSA) testing; assess if
there’s any underlying pathology
o Assess patients digestive secretions – apple cider vinegar, lemon
juice water, fermented foods
o Consider supplementations – Betaine hydrochloride, B complex,
Vitamin C, Probiotics
o Support digestive tissue repair – mucosal repair nutrients, anti-
inflammatory nutrients (see slides 15,16)
o Assess patient’s lifestyle – reduce stress and consumption of acid
reducing agents, avoid smoking, alcohol and poor food choices
(refined, processed). Support physical activity (PA) especially in
those with advancing age to support digestive ,motility
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Key Nutrients to Consider
o Betaine hydrochloride
o Vitamin B3
o Enzymes – Bromelain, Papain
o Zinc
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Betaine Hydrochloride
Mechanism of
action
• The chloride component is directly used to increase stomach acid
production. (Eklund et. al. 2005)
• Substrate for HCL production.
Evidence of
clinical
application
• “If low stomach acid is the cause of reflux symptoms, betaine hydrochloride
may be useful.” (Hechtman, 2012)
• “Betaine hydrochloride was successful in lowering gastric pH.”
(Yago MR et al 2013)
Dosage• There is no typical dosage for betaine hydrochloride. Practitioners should
follow manufacturers guidelines. However, a general guide is 100-400mg
before or with a protein rich meal.
Other
considerations
• “Betaine hydrochloride dose should be built up slowly”. (Hechtman, 2012)
• Patients may feel a warming sensation in their abdomen.
• “Consider the following before prescribing :- B3 deficiency, Malabsorption,
Age, drugs (proton pump inhibitors, H2 receptor antagonists H2-RAs)”
(Prousky J, 2001)
• Often combined with pepsin
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Vitamin B3
Mechanism of
action
• Adequate B3 is required for healthy release of PGD2 that leads to the
binding of the prostaglandin to receptors on parietal cells stimulating the
release of HCL
(Prousky J 2001)
Evidence of
clinical
application
• Hypochlorhydria is an early sign of increased metabolic need for vitamin
B3. There will often be other disturbances in mood (anxiety, depression,
fatigue) evident.
(Prousky J 2001)
Dosage• 100-200mg (up to 3,000mg can be used with caution)
Other
considerations
• Best taken in a B complex
• Niacin flush at high doses
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Enzymes and other nutrients
Pepsin 10-100mg / Meal Cleaves peptide bonds
Bromelain 150-400mg / Meal Protein Digestion
Papain 10-100mg / Meal Protein Digestion
Glutamic Acid 500-3,000mg Raises stomach acid,
Substrate for HCl
Zinc 10-100mg Cofactor required for HCl
production
Iron
Vitamin C (ascorbic acid)
EFA’s
15-50mg
500-5,000mg
Up to 6,000mg
Impaired absorption
Anti-inflammatory, supports
acid production
Anti-inflammatory
(Osiecki 7thed, p.16, 26, 47,
139, 162, 170-1, 266;
Rodwell-Williams &
Schlenker, 2003, p 90)
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Gastritis
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Gastritis
Gastritis = inflammation, irritation, or erosion of the lining of the
stomach. It can occur suddenly (acute) or gradually (chronic).
Types:
1. Acute
o Sudden onset of inflammation and symptoms usually caused by
severe stress, viral infections, alcohol abuse or the use of iron
supplementation, aspirin or NSAID’s
2. Chronic
o Helicobacter pylori infection is the main aetiological factor for
chronic gastritis worldwide (Varbanova M et al. 2014)
o Bile reflux following gastric surgery
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Signs and symptomsMay be asymptomatic or present with symptoms such as :-
o abdominal pain and bloating
o indigestion
o loss of appetite
o nausea
o Vomiting +-blood
(Padmavathi et al 2013)
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Risk factorso Smoking
o Diet - spicy food, caffeinated beverages, alcohol (Ethanol exposure
alters motility and inflames the mucosa leading to potential for
nutrient deficiencies, particularly folate
(Shils et al 2006, p1525).
o Medications/drugs
o Stress
(Padmavathi GV et al 2013)
o Helibacter pylori -It is thought that all individuals with H. pylori
infection will develop some degree of gastritis. This will depend on
the degree of interplay of bacterial virulence factors, host
susceptibility, genes and environmental factors.
(Varbanova M et al 2014).
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Nutritional Treatment
Nutritional Considerations:-
Ask yourself:-
o Are there potential lifestyle factors compromising the patients and lifestyle factors – consider alcohol excess, smoking, caffeine, spicy foods, drugs/med’s, excessive stress etc.
o Are there enough nutrients to support GIT lining?
o Is there effective digestive breakdown of foods? Look at Cofactors for HCL production
o Is a referral required - Consider Helibacter pylori infection (HPSA test)
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Gastritis – nutrients
Garlic 0.4 -
1gm(dried) or
2-5g (fresh)
H. pylori overgrowth (implicated in gastritis) (Cardelle-Cobas et al 2010)
Antibacterial against H. pylori
The antibacterial properties of allicin from garlic have been found to reduce the
risk of stomach cancer, lower gastric nitrite (nitrosamine precursor) & inhibit H.
pylori.
Vitamin C 500-5,000mg Ascorbic acid deficiency is found in those with gastritis
Diets high in ascorbic acid are associated with protection from gastric atrophy
and a ‘reduction in the incidence of gastric cancer (possibly through the ability
of ascorbic acid to reduce oxidative damage to the gastric mucosa by
scavenging carcinogenic N-nitroso compounds) thereby attenuating the H.
pylori-induced inflammatory cascade’ (Aditi A et al 2012)
Pharmacologic doses of ascorbic acid also may improve the effectiveness of
H. pylori-eradication therapy significant in gastritis (Aditi A et al 2012)
Glutamine 500-3,000mg
Repairs epithelial cells
Anti-inflammatory protection.
Supports glutathione production and therefore antioxidant
Folate 400mcg Alcohol or sodium bicarbonate consumption for gastritis depletes folate
absorption
Vitamin B12 300-800mcg Deficient in H Pylori patients. Decreases with age, intrinsic factor, anti-
inflammatory
(Shils et al. 2006, p. 1633; Braun & Cohen 2010, p.469)
(Plessas et al, 2012)
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Gastritis – nutrients
Probiotics 10-40 billion
organisms
p/day
Antibiotic association (L. Acidophilus & B. Brevi)
Zinc 10-100mg HCl production, immune, healing
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GastritisDrug Action Side Effects Interaction
Antacids Neutralizes acid by
increasing
bicarbonate and
mucous .
Inactivates pepsin.
Binds bile salts
Diarrhoea (Mg),
constipation (Al),
hypophosphataemia,
hypercalcaemia
Vitamin C increases aluminium
absorption. Separate doses by 2
hrs.
Folate & Iron – reduces
absorption of both. Separate
doses by 2 hours
‘Raft’
Antacids
(Alginic Acid,
Sucralfate)
When combined
with stomach acid
it forms a slimy
jelly ‘raft’
Sucralfate – nausea,
headache, rash,
dizziness and
indigestion.
Constipation (rare)
Vitamin E & Calcium – reduces
absorption of both
(Braun & Cohen, 2010, p. 1096; Bryant & Knights, 2011, p. 538)
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GastritisDrug Action Side effects Interaction
H2-Antagonists Blocks H2 receptors on
parietal cells (Bryant et
al 2007,p541)
Diarrhoea, nausea,
constipation, headache,
dizziness, skin rash
Folate, B12 & Iron –
reduces absorption of
both. Separate doses
by 2 hrs
Proton Pump
Inhibitors (PPI’s)
Reduces gastric output
via non-competitive
bonds
Diarrhoea, nausea,
abdominal pain,
headache
Folate B12 & Iron –
reduces absorption of
both. Separate doses
by 2 hrs
Dopamine 2
Antagonists
(Metoclopramide,
Domperidone)
Enhanced effect on gut
motility. Increases
gastric emptying.
Increases sphincter
tone. Reduces nausea
and vomiting
Metaclopramide –
drowsiness, fatigue,
nervousness, anxiety,
diarrhoea, insomnia.
Domperidone- less side
effects (minimal BBB
crossover)
None known
(Braun & Cohen 2010, p1097; Bryant et al 2011,p541)
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Helicobacter Pylori
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Helicobacter Pylori
Features:o 50% of the worlds population is thought to be infected. More
common in underdeveloped countries. The prevalence of H. pylori
infection varies widely by geographic area, age, race, ethnicity, and
SES (Brown L 2000)
• Currently there is no biomarker that can reliably predict the outcome
of the infection (Varbanova M et al 2014)
• H. pylori infection leads to chronic gastritis, peptic ulceration, gastric
adenocarcinoma, and gastric mucosa-associated lymphoid tissue
lymphoma (Brown L 2000)
• May also be asymptomatic or present as gastritis, ulcer, or another
GIT pathology (Gastric adenocarcinoma, lymphoma)
• Ulcer recurrence is dramatically reduced following the eradication of
H. pylori
• Treatment protocol is usually Triple therapy (Proton pump inhibitor,
antibiotic & antiprotozoal medication).
(Kumar & Clark 2005)
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The exact routes of H. pylori transmission
remain unclear. However, epidemiologic studies
have shown that exposure of food to
contaminated water or soil may increase the
risk of H. pylori infection, suggesting that
person-to-person transmission by oral-oral,
faecal-oral, or gastro-oral exposure is the most
likely path for H. pylori infection
(Brown LM 2000)
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Nutritional Treatment
Treatment plans must be in line with your treatment
goals. Consider the following as an example:-
- Provide antimicrobial support to reduce h.pylori infection
and further colonisation. Treatment plan may then
include prescribing nutrients such as Vitamin C, Zinc,
Garlic etc.
- Support healthy digestive function – therefore your plan
may include modifying the diet to small frequent meals,
no water with foods and nutrients to support breakdown.
- Ensuring healthy microorganism populations – you may
consider prescribing probiotics to help establish healthy
GIT flora.
. (Jamison 2003, p385; Shils et al, 2006, p1638)
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Helicobacter pylori – Vitamin C
Mechanism of
action
Appears to inhibit H. pylori growth (interferes with its colonisation) and
is a free radical scavenger and antioxidant (Zhang HM et al 1997)
Evidence of
clinical
application
High doses of vitamin C inhibits the growth of H. pylori in vitro as well
as in vivo in animal studies (Zhang HM et al 1997)
Appears there’s a causal association between H. pylori infection and
low ascorbic acid levels in gastric juice due to increased oxidation and
decreased secretion of ascorbic acid (Pal J et al 2011)
H. Pylori impairs the bioavailability of Vitamin C (Woodard M et al
2001)
Dosage 500-5,000mg (ascorbic acid)
Other
considerations
Studies have been mixed on the type of Vitamin C exhibiting benefits -
ascorbic acid and sodium ascorbate.
Japan has one of the highest incidences of H. pylori infection rates
(estimated at 70% of the population), the US one of the lowest (but
coincidently a high vitamin C supplement rate exists in the US?)
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Helibacter pylori – further nutrients to consider
Probiotics 10-50 billion
org/day
Lactobacillus acidophilus has antibacterial properties that reduces H.
pylori colonization and growth
(Vitor JM, Vale FF 2011)
Garlic
Zinc
50-100mg
10-40mg
Cardelle-Cobas et al 2010 found that the antibacterial properties of
Garlic (allicin) inhibited H. pylori growth.
Aqueous garlic extract effectively inhibited 16 clinical isolates and 3
reference strains of Helicobacter pylori
Concentrated ethanol garlic extract (5mg/ml) was responsible for a 90%
inhibition of the microbes
Long term ethanol garlic extract treatment would be an effective therapy
against H. pylori bacteria (Vitor JM, Vale FF 2011)
Mucosal membrane support, immune support, HCl production
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Helicobacter PyloriDrug Action Side effects Interaction
Omeprazole /
Esomeprazole
Proton Pump
Inhibitor
Abdominal pain, dizziness,
headache, GIT symptoms,
diarrhoea, flatulence, skin
rash
Iron, zinc, Vitamin B12:
increasing gastric pH
reduces absorption
Nitroimidazole:
Metronidazole
Antiprotozoal Dizziness, headache, GIT
symptoms, discoloured urine,
vaginal candidiasis, peripheral
neuropathy, leukopenia
Alcohol must be avoided.
Macrolide:
Clarithromycin
Bacteriostatic
– inhibits RNA
synthesis in
bacteria
Anorexia, headache, GIT
symptoms, lethargy, severe
anaemia, fever, rash,
abnormal taste
CYP450 metabolism
Vitamin B12: loss of bowel
flora reduces bacterial
production
Probiotics reduces GIT &
UT side effects of drugs
(Bryant & Knights, 2011,p770)
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Helicobacter Pylori
Drug Action Side effects Interaction
Beta-lactam:
Amoxycillin
Medium spectrum
antibiotic (Penicillin
family)
Diarrhoea, GIT
symptoms, headache,
oral & vaginal
candidiasis, hives
Vitamin B12: loss of
bowel flora reduces
bacterial production
Probiotics reduces GIT
& UT side effects of
drugs
Misoprostal
(Cytotec ®)
Prostaglandin synthetic
analogue (PGE1) –
protects the stomach by
decreasing gastric acid
secretions thus helping
to heal the ulcerations
Infrequent –
constipation, flatulence,
headache, GIT
symptoms, diarrhoea.
Can lower blood
pressure.
Dose dependant
diarrhoea.
Contra-indicated in
pregnancy
(Katzung 2001, p1068; Bryant & Knights, 2011, p770)
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Peptic Ulcer
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Peptic ulcer disease (PUD) = mucosa is eroded due to exposure of
acid and pepsin leading to ulceration.
o Can be either seen as gastric or duodenal ulcers (or both
gastroduodenal).
o Helicobactor pylori seen as the primary causal agent (H. pylori is
present in 95% of patients with duodenal ulcers and in 70% of those
with gastric ulcers).
(Ford AC et al 2006)
o Ulcerations are at risk of serious complications of haemorrhage or
intestinal stricture.
(Davidson & Haslett 2002, p784;
Jamison 2003,p.383;
Shils et al,2006,p1185).
Peptic Ulcer
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Risk factors
o Helibacter pylori
o Drugs – NSAID’s
o Smoking
o Stress (Psychosocial factors can be estimated to contribute to 30%
to 65% of ulcers. Heightened stress response -> increases duodenal
acid load results in HPA axis activation altering healing & mucosal
blood flow & Impairment of gastro-duodenal mucosal defences
(Levenstein 2000)
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Treatment plans around diet and lifestyle should emphasis the
importance of :
o Ceasing cigarettes.
o Avoiding alcohol, coffee, tea and sugar
o Avoiding NSAIDs and aspirin
o Eating 5/6 small meals daily
o Drinking 2-3 litres of water daily
o Avoiding spicy/hot/ fatty foods
o Consuming cabbage juice
o Further testing – H.pylori infection.
Nutritional Treatment
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Peptic Ulcers
Nutrients with possible benefits:
Cabbage juice
o Vitamin U (S-methyl methionine sulfonium or MMSC)
has a cytoprotective mechanism on the surface mucosal
mucin of the stomach.
o MMSC was found to increase activity of S-adenosyl-L-
homocysteine that in turn stimulates the methylation
process.
o Trials have found efficacy in treating gastric and
duodenal inflammation and ulceration.
o Cabbage juice has a role in preventive therapy.
(Patel & Prajapati 2012).
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Therapeutic Actions
Soluble Fibre
o Reduces disease risk. Inverse relationship with duodenal ulcer rates (Aldoori et al, 1997)
Phosphatidylcholine
o Protection by strengthening mucous-phospholipid layer
Vitamin E
o Anti-ulcer activity, and effective in preventing aspirin
induced gastric lesions
Peptic Ulcer
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Peptic Ulcer
Nutrient Dosage Therapeutic Actions
Turmeric 300mg caps x 5/day
30-60 minutes
before food
Antioxidant, anti-inflammatory, positively compared to
liquid antacid therapy, efficacy with ulcer eradication
Glutamine 500-3000mg/day GIT support, mucous membrane trophorestorative,
improves gut immunity and IgA levels, maintains acid
base balance
Cabbage Juice
(Glutamine)
1 litre/day fresh juice
in divided doses
Mucin synthesis stimulation
Probiotics 10-40 billion org/day Recolonization of beneficial gut bacteria.
Saccharomyces spp., Lactobacillus spp.,
Bifidobacterium spp.
Mahan, Raymond 2017; Prucksunand et al 2001; Shils et al,2006,p1638; Braun & Cohen
2010, p902
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Peptic Ulcer
Nutrient Dosage Therapeutic Actions
Soluble Fibre 30-60g Cancer prevention, optimizes gut bacteria
Phosphatidyl-
choline
3-6g Cell signalling, structural element in membranes
Omega 3 1000-
6,000mg
Increases the adhesion of gut bacteria, regulates inflammation
Vitamin A 5000iu Promotes mucosal healing. Short term use of 50,000IU/day
improves ulcer healing
Vitamin C 500 –
5000mg
Gastric mucosal healing after eradication of H pylori, protective
effect against aspirin induced duodenal injury
Vitamin E 100-1000iu Antioxidant and anti-ulcer activity (used with caution)
Zinc 10-100mg Healing and repair of lesions
(Osiecki 7thed,p47, 59, 185; McAlindon et al 1996; Prucksunand et al 2001; Jamison
2003,p385; Shils et al,2006,p533)
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Key Nutrients to Consider: Gastritis, H. pylori, Peptic Ulceration
o Vitamin C
o Glutamine
o Zinc
o Vitamin B12
o Garlic
o Probiotics
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Glutamine in Gastritis, H. pylori, Peptic Ulceration
Mechanism
of action
• “The underlying mechanism of action of glutamine-induced gastric
protection is still unclear.” (Hagen, 2009)
Evidence
of clinical
application
• Mostly animal studies – found to protect gastric mucosal cells from
ammonia induced cell death (Hagen 2009)
Dosage1000 – 1500mg twice to three times per day, depending on the level of
severity.
Other
considerations
• None known
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Case Study Discussion
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Case Study
27 year old female.
Presenting Symptoms
o Gastric Ulcer diagnosed at 16 years old treated but
symptoms still mildly apparent.
o These include: mild ‘warm’ gnawing pain worse for
eating.
o GIT: bloating within 15 minutes of eating, lasts for a
couple of hours or until she eats again, burping
constantly. Heartburn after eating (5/7 days per week)
better for antacids. Loose bowel motions if really anxious
(at least 1 every second day). Undigested food in stool,
odorous.
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Case Study
Medications / Supplements
o OCP- Yasmin (Endometriosis)
o Efexor
o Lamictal
o Antacids
o Antibiotics if a UTI is present
Allergies
o Wheat (intolerance)
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Case Study
Family History
o Mother: Depression, Bi-polar disorder
o Father: High blood pressure, cholesterol
Past Medical History
o Infant: Vaginal delivery, breast fed. Cradle cap eczema
as a baby.
o Childhood: frequent stomach aches, bouts of
constipation,
o Adolescence: gastric ulcer diagnosed at 16, wisdom
teeth removed at 17.
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Case Study
System Presentation
o Nervous system & Endocrine: Depression diagnosed
2003 and hospitalized for two weeks. Tried various drugs
but feels stable on the Efexor & Lamictal. Ongoing anxiety
– presents all of the time. Can’t remember a time when she
did not feel anxious. Insomnia: trouble getting to sleep &
when asleep will wake between 3-5am. Dreams frequently
& wakes unrefreshed.
o Urinary: gets 1 UTI per year, doesn’t clear without
antibiotics
o Circulatory: cold hands & feet
o Reproductive: NAD
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Case Study
Physical Examination Results
o Nails: pale, no moons, poor capillary return, white spots
on 5 fingers, vertical ridging, peeling
o Skin: pale, bluish tint
o Appearance: dark circles under eyes, thin, gaunt
o Height: 170cm Weight: 52kg Waist: Hip 0.70
(Female>0.85)
o Tongue: pointed, quivering, thick white coat, pale
o Zinc tally: tastes like ‘water’
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Case Study
Time Daily Dietary Intake
8 am Gluten free muesli (1 cup), almonds (handful), Greek low-fat
yoghurt (pot set)
1 cup green tea
12.30
pm
Left overs – last night’s left-overs, sushi
5.30 pm Meat & vegetables (potatoes, corn, beans), stir-fry
Snacks Chocolate
Water – 1.5 litre per day
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Group Discussion/tutorial
o Break off into small groups
o Using this case, form a schematic understanding of the
case. Be sure to consider body systems involved in the
presentation, link contributing factors.
o Suggest 3 suitable treatment aims for this client with a
treatment plan on how this may be accomplished.
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Constipation
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o Infrequent passage of hard stools accompanied by
straining, peri-anal or abdominal discomfort with a
feeling of incomplete evacuation.
o Can be related to food intake, as a result of medical
(neurological/metabolic/endocrine), GIT disorders or
lifestyle factors (mobility) or past laxative abuse.
o Certain drug classes, age & depression can be factors.
(Mahan & Escott-Stump, 2012, p.611)
Constipation
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Constipation
Consider:
o Investigate possible cause (food intolerances/drugs)
o adequate water intake (2-3 litres/day)
o caffeine & alcohol intake
o Increase insoluble fibre (fruits & vegetables)
o Flaxseed oil or olive oil
o Probiotic therapy
(Osiecki 2006,p.628; Sarris & Wardle 2010, p55; Sygo &
Oh 2010; Mahan & Escott-Stump, 2012, p.612 & 617;
Toner & Claros 2012)
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Constipation
Consider the effect and significance of :-
Probiotics
o The addition of Lactobacillus rhamnosus &
Propionibacterium freudenreichii into the diet has been
shown to increase stool frequency by 24%
(Ouwehand et al, 2002)
Fibre
o A higher intake of dietary fibre was shown to be
associated with a decreased risk of constipation in
women & children
(Roma et al, 1999; Dukas, Willet & Giovannucci, 2003;
Anderson et al 2009).
© Endeavour College of Natural Health endeavour.edu.au 53
Constipation
Nutrient Dosage Therapeutic Actions
Probiotics 10-40billion
org/day
Gut bacteria stability
Omega 3 1-10gm Lipotropic – supports bile synthesis and hepatic
function
Magnesium 300-1,000mg Muscle relaxant
Vitamin C 500-5,000mg Laxative effect, digestive function & healthy gut
microflora,
Betaine HCl 500-650mg Increases digestive function
Insoluble
Fibre
30-60gm Insoluble : increase moisture and content of faecal
matter for transit
(Osiecki 7thedn, p. 47 & 170; Shils et al, 2006, p533; Sarris & Wardle 2010, p 55; Braun
& Cohen 2010, p689; Asif 2011; Skinner et al 2011; Mahan et al 2012, p612)
© Endeavour College of Natural Health endeavour.edu.au 54
ConstipationDrug Action Side Effects Interaction
Bulk forming
laxatives:
Psyllium
Absorbs water to
increase bulk
Flatulence
& bulky
stools
Calcium, Vitamin B12:
decreases absorption. Separate
doses by 2 hours for all
medications.
Hypoglycaemic agents :
additive effects.
Faecal
Softening
Agents:
Docusate &
Poloxamer
Softens stool,
stimulant, detergent-
like & maintains
water & fats in the
stool.
Detergent like action increases
drug absorption in GIT if taken
concurrently.
Liquid Paraffin Coat stool & reduces
water absorption.
Impairs absorption of fat soluble
vitamins
(Bullock et al, 2007 ; Braun & Cohen 2010,p769; Bryant et al, 2011,p548)
© Endeavour College of Natural Health endeavour.edu.au 55
Constipation
Drug Action Side Effects Interaction
Stimulant
Laxatives:
Bisacodyl and
Sodium
Picosulphate
Reduces water
absorption & increases
excretion into lumen.
Directly stimulate
nerves in wall lining to
increase peristalsis
Cramping, water and
electrolyte
imbalances, rebound
constipation
Increased
peristalsis and
reduced water
absorption reduces
vitamin & mineral
absorption.
Osmotic
Laxative
Lactulose,
Glycerol,
Sorbitol
Not absorbed & create
osmotic gradient
drawing water into the
lumen = bulk which
stimulates peristalsis
Flatulence, abdominal
discomfort may occur
with lactulose.
Electrolyte
disturbances with
long term daily use.
(Bullock et al, 2007, Bryant et al 2011,p 548)
© Endeavour College of Natural Health endeavour.edu.au 56
Constipation
Drug Action Side Effects Interaction
Saline Laxatives:
Magnesium salts,
Sodium salts,
Polythylene glycol
electrolyte solution
Not absorbed & =
osmotic gradient
drawing water into
the lumen.
This creates bulk
stimulating
peristalsis
Long term use of
saline laxatives
linked with
electrolyte
disturbances.
Electrolyte
disturbances with
long term daily use.
Sodium salts should
be avoided in
patients with
congestive cardiac
failure.
(Bullock et al 2007, Bryant et al 2011, p549)
© Endeavour College of Natural Health endeavour.edu.au 57
Constipation
Liver Function
o Bile acids have a role in intestinal transport
o A specific bile acid, CDCA, is used medically in the
treatment of functional constipation
o There is a hypothesis that bacterial overgrowth in the
colon leads to deconjugation of CDCA, and therefore
reduces its laxative effect
(Hofmann & Hagey, 2008, p. 2461)
© Endeavour College of Natural Health endeavour.edu.au 58
Diarrhoea
© Endeavour College of Natural Health endeavour.edu.au 59
Diarrhoea
o Frequent evacuation of liquid stools with subsequent
loss of fluid & electrolytes (particularly sodium,
potassium & magnesium). There may be decreased
enzymatic digestion.
o May be due to infection, drugs, food reaction, over
consumption of sugars, inflammatory diseases,
abnormalities of mucosal cell transport (coeliac).
(Shils et al 2006 p1204, Mahan & Escott-Stump, 2012 p613)
© Endeavour College of Natural Health endeavour.edu.au 60
Diarrhoea
• Osmotic: un-absorbable, water-soluble solutes remain in
the bowel, where they attract water
• Secretory: when the small and large bowel secrete more
electrolytes and water than they absorb.
• Exudative: occurs with several mucosal diseases that
cause mucosal inflammation and ulceration.
• Decreased absorption time: chyme is not in contact with
an adequate absorptive surface of the GI tract for a long
enough time so that too much water remains in the
faeces
• Malabsorption: osmotic or secretory causes of diarrhoea
due to malabsorption of various substances
© Endeavour College of Natural Health endeavour.edu.au 61
Diarrhoea
Nutritional Considerations
o Diarrhoea related fluid loss leads to dehydration &
electrolyte loss; even vascular collapse may occur
o Hypokalemia may occur in severe or chronic diarrhoea,
or if the stools contain excess mucus.
o Hypomagnesemia after prolonged diarrhoea may cause
tetany.
© Endeavour College of Natural Health endeavour.edu.au 62
DiarrhoeaFurther considerations:-
o Avoidance of foods that contribute to colonic residue –
high fibre, resistant starch, fructose and sugar alcohols –
these retain fluids in the colon and contribute to osmotic
diarrhoea.
o Milk and dairy products may worsen diarrhoea if lactose
tolerance is an issue.
o Fatty meals can aggravate diarrhoea.
o Poorly digested or absorbed carbohydrates can increase
stomach distension and cause discomfort.
o Caffeine should be avoided as this will reduce water
reabsorption (Rolfes, Pinna & Whitney 2012, p732)
© Endeavour College of Natural Health endeavour.edu.au 63
Diarrhoea
Prebiotics & Probiotics
o Probiotics & prebiotics was shown to reduce diarrhoea
from various causes (infections, HIV, antibiotics & IBS).
Probiotic strains should be present at 109 to be effective
o Prophylactic prebiotics have been found to result in less
severe diarrhoea in travellers. Dose 10-15g/day.
(Braun & Cohen, 2010, 751, 1046)
o Inulin, oligofructose with L. plantarum & B. bifidum was
found inhibit pathogenic strains that cause diarrhoea
(de Vrese & Marteau 2007)
© Endeavour College of Natural Health endeavour.edu.au 64
Diarrhoea
Bovine Colostrum
o Benefits infectious diarrhoea caused by rotavirus,
shingella & HIV (300mg - 10g/day)
Zinc
o A systematic review of zinc supplementation
demonstrated consistent decreases in acute or
persistent pediatric diarrhoea (dose 10mg/day).
(Braun & Cohen, 2010. p. 360, 1046)
© Endeavour College of Natural Health endeavour.edu.au 65
Diarrhoea
Nutrient Dosage Therapeutic Actions
Bifidobacterium
bifidus
10-40
bill org
Recolonise bacteria. Anaerobic pleomorphic rods
(club shaped organisms) that have the role in
breaking down dietary CH2O & interact directly with
the host metabolism.
Glucosamine 1500-
3,000mg
Precursor to the ground substance/gap junctions for
epithelial cells
Soluble fibre 1tsp/bd Mucosal support/repair, Bulking agent.
Mucopolysaccharide
Glutamine 500-
3,000mg
Tissue repair, Restores gut wall integrity & normal
intestinal flora colonisation (great with probiotics &
zinc)
Bromelain 150-
400mg
Anti-inflammatory, Proteolytic enzyme, COX – 2
(Osiecki 7th ed, p. 91, 171, 187, 196; Osiecki 2000, p 273)
© Endeavour College of Natural Health endeavour.edu.au 66
Diarrhoea
Nutrient Dosage Therapeutic Actions
Amylase Carbohydrate Digestion
Lipase Fat Digestion
Betaine
Hydrochloride
100-400mg /
Meal
Raises stomach acid, Substrate for HCL
production
Glutamic Acid 500-3000mg Raises stomach acid, Substrate for HCL
production
(Gropper, Smith & Groff 4th ed, Osiecki 7th ed, p91, 170; Mahan & Escott-Stump 2012, p2)
© Endeavour College of Natural Health endeavour.edu.au 67
Diarrhoea
Drug Action Side effects Interaction
Adsorbents:
Kaolin &
Pectin
Coats the mucous
membranes, binds to the
toxins and excretes via
the stool
Constipation Interfere with the
absorption of other
drugs.
Can alter water and
electrolyte levels
Adsorbents:
Aluminium
hydroxide
As above Increased risk of
aluminium toxicity –
renal failure
Can alter water and
electrolyte levels
Opioid Anti-
diarrhoeals:
Loperamide,
Diphenoxylate
Codeine
Narcotic analgesics
activate opioid receptors
in GIT lining reducing
peristalsis and increasing
the mixing action
Constipation.
Loperamide =
nausea, vomiting
and abdominal
cramping
Adverse reactions
with alcohol
(Katzung 8thed, p1071Bryant et al 2007, p766)
© Endeavour College of Natural Health endeavour.edu.au 68
Haemorrhoids
© Endeavour College of Natural Health endeavour.edu.au 69
Haemorrhoids
o Arise from congestion of the venous plexuses (internal & external)
around the anal canal
o Can be classified as external, internal or internal-external
hemorrhoids; also as first, second and third degree
o Factors increasing venous congestion in perianal region can induce
hemorrhoid formation
• increasing intra-abdominal pressure (inducing straining on
defecation)
• low fibre diet
• Pregnancy – there’s generally slower return of blood from the
lower half of your body, which increases the pressure on the
veins below your uterus and causes them to become more
dilated or swollen. Constipation also a contributing factor.
(Boon, Colledge & Walker, 2006, p. 933)
© Endeavour College of Natural Health endeavour.edu.au 70
Haemorrhoids
Nutritional Considerations:
1. Assess fibre intake
o A high fibre diet and fibre supplements are the
cornerstone of nutritional management
o Fibre attracts water and forms a gelatinous mass to
ensure stools are soft and pass without straining
o Psyllium (Plantago ovata) is less irritating than other
fibres, and has been shown in trials to reduce
haemorrhoid symptoms
(Pizzorno & Murray, 2006, p. 2070-2071)
© Endeavour College of Natural Health endeavour.edu.au 71
Haemorrhoids
2. Maintain regular eating patterns.
Breakfast
o Skipping breakfast leads to a 7.5 fold increased risk of
haemorrhoids
3. Ensure adequate bioflavonoids
o The strengthening effect of flavonoids on venous tissues
makes them useful in both presentation and treatment
(Pizzorno & Murray, 2006, p. 2070-2071)
© Endeavour College of Natural Health endeavour.edu.au 72
Haemorrhoids
Nutrient Dosage Therapeutic Actions
Vitamin A 10000–
50000IU
Assist in the maintenance of the gut integrity + Antioxidant.
Mucous Membrane, Assist in the maintenance of the
epithelial integrity, ability to stimulate specific and non-
specific immune functions, Antioxidant.
Vitamin C 250-
10000mg
Collagen Synthesis + Immune system + Antioxidant.
Facilitates & regulates immune function including increasing
levels of macrophage activity, lymphocyte production &
antibodies (IgA, IgG, IgM). Modulates prostaglandin
synthesis. Heals & rebuilds damaged tissue.
Vitamin E 100-
1000iu
Antioxidant - Enhances Cell Membrane Stability
(Osiecki 7thedn, p4, 44-54)
© Endeavour College of Natural Health endeavour.edu.au 73
Haemorrhoids
Nutrient Dosage Therapeutic Actions
Bioflavonoids 600mg – 3
gm
Collagen synthesis, antioxidant functions & ascorbic
acid can protect flavonoids from oxidative
degradation.
Zinc 10-100mg Collagen Synthesis (Ulcer) + Immune system.
Protein, fats & cholesterol synthesis.
Dietary Fibre
Fruit and
vegetable
12-20gm Bulking agent. Fuel source for bacteria, provides
structure and form, protective barrier for mucous
membranes, Provides an aqueous matrix for diffusion
of nutrients and electrolytes
(Osiecki 7thed, p34, 162,185)
© Endeavour College of Natural Health endeavour.edu.au 74
Haemorrhoids
Drug Action Side effects Interaction
Rectinol
Ointment
Local aesthetic - relieve pain.
Steroids - reduce
inflammation, swelling and
itching.
Antiseptic agents – infection.
Astringents – tighten tissue
and reduce swelling.
Vasoconstrictors – reduce
venous swelling (Bullock et
al 2007)
Local aesthetic –
sensitise the anus.
Steroids – can
irritate infections
and cause skin
thinning
None listed
(Bullock et al 2007)
© Endeavour College of Natural Health endeavour.edu.au 75
Helpful links
o Royal Australian College of General Practitioners 2014.
Helicobacter pylori eradication – an update on the latest
therapies, available at:
http://www.racgp.org.au/afp/2014/may/helicobacter-
pylori-eradication/
o National Prescribing Service (NPS) information on drugs
and drug interactions for health professionals, available
at: http://www.nps.org.au/
o Therapeutic Goods Administration (TGA). Adverse event
reporting, available at: https://www.tga.gov.au/
© Endeavour College of Natural Health endeavour.edu.au 76
Patient Reported Outcome
Measures (PROMs)
o In your own time, you may find this clip a useful resource
on PROM’s to asssit with your tutorial activities and case
study assignments.
o https://www.youtube.com/watch?v=KlBXLVd25gQ&featur
e=youtu.be [13.53 minutes]
© Endeavour College of Natural Health endeavour.edu.au 77
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Ben-Arye, E., Scharf, M., & Frenkel, M. (2007). How should complementary practitioners
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Benny, P. (2010). A review on the Medicinal Significance of Common Fruits. International
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Boon, N., Colledge, N., & Walker, B. (Eds.). (2006). Davidson’s principles and practice of
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Braun, L., & Cohen, M. (2015). Herbs & natural supplements: An evidence-based guide
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Brown, L. M. (2000). Helicobacter pylori: epidemiology and routes of
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Communication & Referral
Networks
© Endeavour College of Natural Health endeavour.edu.au 86
Communication & Referral
Networks
o Optimal care = effective communication between different
practitioners managing the same patient.
o This potentially reduces side effects or unsafe outcomes
o Research has suggested that around 70% of medical practitioners
are interested in collaborative teamwork with CAM practitioners
o The referral process between medical practitioners and CAM
practitioners can be made effective with the use of formalised
referral letters
(Ben-Arye, et al. 2007; Braun & Cohen, 2010, p.76)
© Endeavour College of Natural Health endeavour.edu.au 87
Interaction Reporting
© Endeavour College of Natural Health endeavour.edu.au 88
Interaction Reporting
Interaction Reporting
o Two types of adverse drug reactions
Type A – predictable
Type B – idiosyncratic
o Reporting of any negative or suspected interaction is
vital for patient safety and is required from a professional
stand point.
o Reporting is to the Therapeutic Goods Administration.
(Braun & Cohen, 2010, p. 81-92)