Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders

Medical Nutrition Therapy for Upper 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.

Head and Neck Cancers ¨ Can affect any part of the head and neck area ¨ Surgical treatment can have profound effect on ability to take food orally ¨ Often feeding tubes are placed at the time of surgery

Head and Neck Cancers

MNT in Head and Neck Cancers ¨ Address nutritional consequences of disease and treatments (radiation therapy, surgery) ¨ Radiation therapy can alter taste sensation, result in dry mouth, loss of appetite, mucositis and dysphagia ¨ Malnutrition is reported to affect 30 to 50% of patients with head and neck cancers.

MNT in Head and Neck Cancers ¨ Goal is to maintain adequate intake to promote healing and allow aggressive treatment ¨ May involve enteral feedings, liquid oral supplements, dietary changes (liquid, moist, softtextured foods and small, frequent meals ¨ Artificial saliva solutions, increased fluids, topical anaesthetics to relieve pain ¨ Aggressive oral hygiene, fluoride, treatment of fungal infections

Gastroesophageal Reflux Disease (GERD) ¨ Defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus ¨ Symptoms: Burning sensation after meals; heartburn, regurgitation or both, especially after meals ¨ Symptoms often aggravated by recumbency or bending over and are relieved by antacids De. Vault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005; 100: 190 -200

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

Complications of GERD ¨ Esophagitis, stricture or ulcer ¨ Barrett’s Esophagus (premalignant state)

Diagnosis of GERD ¨ Empirically, via symptoms (symptoms don’t always correlate with the degree of damage) ¨ Endoscopy – to confirm Barrett’s Esophagus and dysplasia (a negative endoscopy does not rule out the presence of GERD) ¨ Ambulatory reflux monitoring De. Vault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005; 100: 190 -200

Ambulatory Reflux Monitoring

Goals of Nutrition Intervention in GERD ¨ Increasing lower esophageal sphincter competence ¨ Decreasing gastric acidity, which results in decreasing severity of symptoms ¨ Improving clearance of contents from the esophagus ¨ Identification of drug-nutrient interaction ¨ Prevention of obstruction if esophageal stricture present ¨ Improvement of nutritional intake if appropriate ADA Nutrition Care Manual, accessed 4 -06

Nutrition Prescription for GERD ¨ Initiate weight-reduction program if overweight ¨ Initiate smoking cessation (lowers LES pressure) ¨ Improve clearing of materials from esophagus ¨ Remain upright after eating ¨ Avoid eating within 3 hours of bedtime ¨ Wear loose-fitting clothing ¨ Raise the head of bed for sleeping ADA Nutrition Care Manual, accessed 4 -06

Nutrition Prescription for GERD Reduce gastric acidity by eliminating the following: ¨ Black and red pepper ¨ Coffee (caffeinated and decaffeinated) ¨ Alcohol Substitute smaller more frequent meals Restrict foods that lessen lower esophageal sphincter pressure by eliminating the following: ¨ Chocolate ¨ Mint ¨ Foods with a high fat content. ADA Nutrition Care Manual, accessed 4 -06

Nutrition Prescription for GERD ¨ Spicy, acidic foods may be irritating if esophagitis is present ¨ Limitation of these foods should be based on individual tolerance

Nutritional Care for Patients with Reflux and Esophagitis ¨ Evidence reflecting the true efficacy of these maneuvers in patients is almost completely lacking – American College of Gastroenterology Guidelines, 2005

Drugs Commonly Used to Treat Gastrointestinal Disorders ¨ Antibiotics: eradicate Helicobacter pylori, prevent or treat infection after abdominal wounds or surgery ¨ Antacids: neutralize gastric acid in acid reflux, peptic ulcer ¨ Proton pump inhibitors (omeprazole, lansoprazole): decrease gastric acid secretion ¨ Histamine-2 receptor antagonists (cimetidine, ranitidine): inhibit gastric acid secretion ¨ Sucralfate (sulfated disaccharide): protects stomach lining and may increase mucosal

Medications Used to Tx GERD ¨ Antacids: Mylanta, Maalox: neutralize acids ¨ Gaviscon: barrier between gastric contents and esophageal mucosa ¨ H 2 receptor antagonists available over the counter and by prescription (reduce acid secretion): cimetadine, ranitidine, famotidine, nizatidine

Medications Used to Treat GERD ¨ Proton Pump Inhibitors (PPIs) Omeprazole (Prilosec), lansoprazole, rabeprazole, pantoprazole, esomeprazole ¨ Some available over the counter now ¨ Decrease gastric acid secretion

Medications Used to Treat GERD ¨ Acid suppression is the mainstay of therapy for GERD. Proton pump inhibitors provide the most rapid symptomatic relief and heal esophagitis in the highest percentage of patients. ¨ Although less effective than PPIs, Histamine -2 receptor blockers given in divided doses may be effective in persons with less severe GERD De. Vault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005; 100: 190 -200

Medications Used to Treat GERD ¨ Promotility agents may be used in selected patients, especially as an adjunct to acid suppression. Currently available promotility agents are not ideal monotherapy for most patients with GERD De. Vault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005; 100: 190 -200

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#

MNT in NAUSEA/VOMITING

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

Goals of MNT in Nausea/Vomiting ¨ Decrease the frequency and severity of nausea and/or vomiting ¨ Maintain optimal fluid balance and nutritional status ¨ Prevent development of anticipatory nausea, vomiting, and learned food aversions ADA Nutrition Care Manual, accessed 4 -06

MNT for Nausea/Vomiting ¨ When vomiting stops, introduce ice chips if older than 3 years of age. If tolerated, start with rehydration beverage or clear liquids, 1 tsp every 10 minutes. Increase to 1 Tbsp every 20 minutes. Double amount of fluid every hour. If diarrhea is present, use only rehydration beverage. ¨ Apple juice ¨ Sports drink ¨ Warm or cold tea ¨ Lemonade ADA Nutrition Care Manual, accessed 4 -06

MNT for Nausea/Vomiting ¨ When there has been no vomiting for at least 8 hours, ¨ ¨ initiate oral intake slowly with adding one solid food at a time in very small increments. Choose the following types of foods: Without odor Low in fat Low in fiber (see Client Education - Detailed, Foods Recommended). Take prescribed antiemetics and other medications on a regular schedule to assist in prevention of nausea and vomiting. Take all other medications after eating. ADA Nutrition Care Manual, accessed 4 -06

Nausea/Vomiting: Food and Feeding Issues ¨ Keep patient away from strong food odors ¨ Provide assistance in food preparation so as to avoid cooking odors ¨ Eat foods at room temperature ¨ Keep patient's mouth clean and perform oral hygiene tasks after each episode of vomiting ¨ Offer fluids between meals ¨ Patient should sip liquids throughout the day ¨ Cold beverages may be more easily tolerated ¨ Keep low-fat crackers or dry cereal by the bed to eat before getting out of bed

Nausea/Vomiting: Lifestyle Issues ¨ ¨ ¨ ¨ ¨ Relax after meals instead of moving around Sit up for 1 hour after eating Wear loose-fitting clothes Provide fresh air with a fan or open window Limit sounds, sights, and smells that may trigger nausea and vomiting Other complementary and alternative medicine interventions that have anecdotal evidence (though clinical trials have not been conducted): Relaxation techniques Acupuncture Hypnosis ADA Nutrition Care Manual, accessed 4 -06

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

Endoscopy

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

MNT for Peptic Ulcer Disease and Gastritis ¨ Avoid foods that increase gastric acid secretion, such as the following: ¨ Alcohol ¨ Pepper ¨ Caffeine ¨ Tea ¨ Coffee (including noncaffeinated) ¨ Chocolate ADA Nutrition Care Manual, accessed 4 -06

MNT for Peptic Ulcer Disease ¨ Identify foods that directly irritate the gastric mucosa or are not generally tolerated ¨ Avoid eating at least 2 hours 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 medical 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.

Carcinoma of the Stomach ¨ Obstruction and mechanical interference ¨ Surgical resection or gastrectomy ¨ Prevention of GI cancers: fruits, vegetables, and selenium ¨ Increase risk of GI cancers: alcohol, overweight, high salted or pickled foods, inadequate micronutrients

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 vagotomy 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 ADA Nutrition Care Manual, accessed 4 -06

Dumping Syndrome Symptoms ¨ Cramping ¨ Abdominal pain ¨ Hypermotility ¨ Diarrhea ¨ Dizziness ¨ Weakness ¨ Tachycardia within 10 -20 minutes after eating

MNT for Dumping Syndrome ¨ Prevent onset of early and late dumping syndromes. ¨ Initially avoid all hypertonic, concentrated sweets. Do not ¨ ¨ start clear liquids as first oral feeding. The first meals should consist of protein, fat, and complex carbohydrate, but with only 1 -2 food items at a time. Patients may be initially lactose intolerant. Slowly progress to 5 -6 small meals each day. Consume liquids 30 minutes to 1 hour after consuming solid food. Lie down after eating. Consider addition of functional fibers to delay gastric emptying and assist with treatment of diarrhea.

MNT for Dumping Syndrome These foods may exacerbate symptoms: ¨ Sucrose ¨ Fructose ¨ Sugar alcohols: – Xylitol – Mannitol – Sorbitol Source: ADA Nutrition Care Manual, accessed 4 -06

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

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.