Medical Nutrition Therapy for Gastrointestinal Tract Disorders Esophagus

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, 6 th 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, 6 th Edition.

Medications Used to Tx GERD Antacids ¨ Mylanta, Maalox: neutralize acids ¨ Gaviscon: barrier between gastric contents and esophageal mucosa ¨ H 2 receptor antagonists (reduce acid secretion) ¨ Cimetadine, ranitidine, famotidine, nizatidine ¨ Omeprazole (Prilosec) short term

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#

Nausea & Vomiting ¨ Prolonged vomiting = hyperemesis – Loss of nutrients, fluids, electrolytes – Dehydration, electrolyte imbalance, wt. loss ¨ Meds: – Antinauseants – Antiemetics

Nausea & Vomiting Dietary 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 B 12 • Pernicious anemia • vitamin B 12 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 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.

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 Disease Treatment with Diet ¨ Reduce decaffeinated and regular coffee, cocoa, and tea intake ¨ Avoid alcohol or pepper ¨ Avoid low-p. H juices if they cause problems (generally p. H 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.

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.

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, B 12, 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

Dumping Syndrome Dietary 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, 6 th Edition.

Malabsorption, steatorrhea ¨ Post-surgical complications affecting nutrition: • Fat soluble vitamins, calcium • Folate, B 12 (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 H 2 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 B 12 absorption

Disorders of the Stomach— Nutritional Care ¨ Lifestyle changes are an important component of the nutrition care plan. ¨ Patients with dyspepsia should avoid highfat 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.