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NUTRITION NUTRITION ANDAND
GASTRO GASTRO ENTEROHEPATOLOGYENTEROHEPATOLOGY DISEASESDISEASES
Nurpudji Astuti TaslimNurpudji Astuti TaslimA. Yasmin SyaukiA. Yasmin Syauki
Nutrition Department School of MedicineNutrition Department School of Medicine
Hasanuddin UniversityHasanuddin University20112011
TopicsTopics Reflux EsophagitisReflux Esophagitis GERDGERD Nausea/vomitingNausea/vomiting Dispepsia Dispepsia GastritisGastritis Peptic ulcerPeptic ulcer Dumping syndromeDumping syndrome ConstipationConstipation DiarrheaDiarrhea Coeliac DiseaseCoeliac Disease Diverticular diseaseDiverticular disease Irritable Bowel SyndromeIrritable Bowel Syndrome Inflammatory Bowel Disease Inflammatory Bowel Disease
Ulcerative colitisUlcerative colitis Crohn’s diseaseCrohn’s disease
Liver diseaseLiver disease Bladder diseaseBladder disease Pancreas diseasePancreas disease
Medical Nutrition Therapy Medical Nutrition Therapy for Upper Gastrointestinal for Upper Gastrointestinal
Tract DisordersTract Disorders
Common Symptoms of Common Symptoms of Gastrointestinal DiseaseGastrointestinal Disease
EsophagusEsophagus Tube from pharynx to stomachTube from pharynx to stomach Upper esophageal sphincter (UES or Upper esophageal sphincter (UES or
cardiac sphincter) closed except cardiac sphincter) closed except when swallowingwhen swallowing
Lower esophageal sphincter (LES) Lower esophageal sphincter (LES) closes entrance to stomach; closes entrance to stomach; prevents reflux of stomach contents prevents reflux of stomach contents back into esophagusback into esophagus
Gastroesophageal Reflux Gastroesophageal Reflux Disease (GERD)Disease (GERD)
Defined as symptoms or mucosal Defined as symptoms or mucosal damage produced by the abnormal damage produced by the abnormal reflux of gastric contents into the reflux of gastric contents into the esophagusesophagus
Symptoms: Burning sensation after Symptoms: Burning sensation after meals; heartburn, regurgitation or meals; heartburn, regurgitation or both, especially after mealsboth, especially after meals
Symptoms often aggravated by Symptoms often aggravated by recumbency or bending over and are recumbency or bending over and are relieved by antacidsrelieved by antacidsDeVault KR and Castell DO. Updated guidelines for the diagnosis and
treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Hiatal HerniaHiatal Hernia An outpouching of a portion of the An outpouching of a portion of the
stomach into the chest through the stomach into the chest through the esophageal hiatus of the diaphragm esophageal hiatus of the diaphragm
Heartburn after heavy meals or with Heartburn after heavy meals or with reclining after mealsreclining after meals
May worsen GERD symptomsMay worsen GERD symptoms
Anatomy of Esophagus and Anatomy of Esophagus and Hiatal HerniaHiatal Hernia
Complications of GERDComplications of GERD Esophagitis, stricture or ulcerEsophagitis, stricture or ulcer Barrett’s Esophagus (premalignant state)Barrett’s Esophagus (premalignant state)
Diagnosis of GERDDiagnosis of GERD
Empirically, via symptoms (symptoms Empirically, via symptoms (symptoms don’t always correlate with the degree of don’t always correlate with the degree of damage)damage)
Endoscopy – to confirm Barrett’s Endoscopy – to confirm Barrett’s Esophagus and dysplasia (a negative Esophagus and dysplasia (a negative endoscopy does not rule out the presence endoscopy does not rule out the presence of GERD)of GERD)
Ambulatory reflux monitoringAmbulatory reflux monitoring
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Ambulatory Reflux Ambulatory Reflux MonitoringMonitoring
Goals of Nutrition Intervention Goals of Nutrition Intervention in GERDin GERD
Increasing lower esophageal sphincter Increasing lower esophageal sphincter competence competence
Decreasing gastric acidity, which results in Decreasing gastric acidity, which results in decreasing severity of symptoms decreasing severity of symptoms
Improving clearance of contents from the Improving clearance of contents from the esophagus esophagus
Identification of drug-nutrient interaction Identification of drug-nutrient interaction Prevention of obstruction if esophageal stricture Prevention of obstruction if esophageal stricture
present present Improvement of nutritional intake if appropriateImprovement of nutritional intake if appropriate
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for Nutrition Prescription for GERDGERD
Initiate weight-reduction program if Initiate weight-reduction program if overweight overweight
Initiate smoking cessation (lowers LES Initiate smoking cessation (lowers LES pressure)pressure)
Improve clearing of materials from Improve clearing of materials from esophagus esophagus
Remain upright after eating Remain upright after eating Avoid eating within 3 hours of bedtime Avoid eating within 3 hours of bedtime Wear loose-fitting clothing Wear loose-fitting clothing Raise the head of bed for sleeping Raise the head of bed for sleeping ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for Nutrition Prescription for GERDGERD
Reduce gastric acidity by eliminating the Reduce gastric acidity by eliminating the following: following:
Black and red pepper Black and red pepper Coffee (caffeinated and decaffeinated) Coffee (caffeinated and decaffeinated) AlcoholAlcoholSubstitute smaller more frequent meals Substitute smaller more frequent meals Restrict foods that lessen lower esophageal Restrict foods that lessen lower esophageal
sphincter pressure by eliminating the following: sphincter pressure by eliminating the following: Chocolate Chocolate Mint Mint Foods with a high fat content. Foods with a high fat content.
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for Nutrition Prescription for GERDGERD
Spicy, acidic foods may be irritating if Spicy, acidic foods may be irritating if esophagitis is presentesophagitis is present
Limitation of these foods should be based Limitation of these foods should be based on individual toleranceon individual tolerance
Nutritional Care for Patients Nutritional Care for Patients with Reflux and Esophagitiswith Reflux and Esophagitis
Evidence reflecting the true Evidence reflecting the true efficacy of these maneuvers in efficacy of these maneuvers in patients is almost completely patients is almost completely lackinglacking American College of Gastroenterology American College of Gastroenterology
Guidelines, 2005Guidelines, 2005
Drugs Commonly Used to Drugs Commonly Used to Treat Gastrointestinal Treat Gastrointestinal
DisordersDisorders Antibiotics: eradicate Antibiotics: eradicate Helicobacter pyloriHelicobacter pylori, ,
prevent or treat infection after abdominal prevent or treat infection after abdominal wounds or surgerywounds or surgery
Antacids: neutralize gastric acid in acid Antacids: neutralize gastric acid in acid reflux, peptic ulcerreflux, peptic ulcer
Proton pump inhibitors (omeprazole, Proton pump inhibitors (omeprazole, lansoprazole): decrease gastric acid lansoprazole): decrease gastric acid secretionsecretion
Histamine-2 receptor antagonists Histamine-2 receptor antagonists (cimetidine, ranitidine): inhibit gastric (cimetidine, ranitidine): inhibit gastric acid secretionacid secretion
Sucralfate (sulfated disaccharide): Sucralfate (sulfated disaccharide): protects stomach lining and may protects stomach lining and may increase mucosal resistance to acid or increase mucosal resistance to acid or enzyme damageenzyme damage
Medications Used to Tx Medications Used to Tx GERDGERD
Antacids: Mylanta, Maalox: neutralize Antacids: Mylanta, Maalox: neutralize acidsacids
Gaviscon: barrier between gastric Gaviscon: barrier between gastric contents and esophageal mucosacontents and esophageal mucosa
H2 receptor antagonists available over H2 receptor antagonists available over the counter and by prescription (reduce the counter and by prescription (reduce acid secretion): cimetacid secretion): cimetiidine, ranitidine, dine, ranitidine, famotidine, nizatidinefamotidine, nizatidine
Medications Used to Treat Medications Used to Treat GERDGERD
Proton Pump Proton Pump Inhibitors (PPIs) Inhibitors (PPIs) Omeprazole (Prilosec), Omeprazole (Prilosec), lansoprazole, lansoprazole, rabeprazole, rabeprazole, pantoprazole, pantoprazole, esomeprazoleesomeprazole
Some available over Some available over the counter nowthe counter now
Decrease gastric acid Decrease gastric acid secretionsecretion
Medications Used to Treat Medications Used to Treat GERDGERD
Acid suppression is the mainstay of Acid suppression is the mainstay of therapy for GERD. Proton pump inhibitors therapy for GERD. Proton pump inhibitors provide the most rapid symptomatic relief provide the most rapid symptomatic relief and heal esophagitis in the highest and heal esophagitis in the highest percentage of patients. percentage of patients.
Although less effective than PPIs, Although less effective than PPIs, Histamine-2 receptor blockers given in Histamine-2 receptor blockers given in divided doses may be effective in persons divided doses may be effective in persons with less severe GERDwith less severe GERD
DeVault 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 Medications Used to Treat GERDGERD
Promotility agents may be used in Promotility agents may be used in selected patients, especially as an selected patients, especially as an adjunct to acid suppression. adjunct to acid suppression. Currently available promotility Currently available promotility agents are not ideal monotherapy for agents are not ideal monotherapy for most patients with GERDmost patients with GERD
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
MNT in NAUSEA/VOMITINGMNT in NAUSEA/VOMITING
Nausea & VomitingNausea & Vomiting Prolonged vomiting = Prolonged vomiting =
hyperemesishyperemesis Loss of nutrients, fluids, electrolytesLoss of nutrients, fluids, electrolytes Dehydration, electrolyte imbalance, Dehydration, electrolyte imbalance,
wt. losswt. loss
Medications:Medications: AntinauseantsAntinauseants Antiemetics Antiemetics
Goals of MNT in Goals of MNT in Nausea/VomitingNausea/Vomiting
Decrease the frequency and severity Decrease the frequency and severity of nausea and/or vomiting of nausea and/or vomiting
Maintain optimal fluid balance and Maintain optimal fluid balance and nutritional status nutritional status
Prevent development of anticipatory Prevent development of anticipatory nausea, vomiting, and learned food nausea, vomiting, and learned food aversionsaversions
ADA Nutrition Care Manual, accessed 4-06
MNT for Nausea/VomitingMNT for Nausea/Vomiting
When vomiting stops, introduce ice chips if older When vomiting stops, introduce ice chips if older than 3 years of age. If tolerated, start with than 3 years of age. If tolerated, start with rehydration beverage or clear liquids, 1 tsp every rehydration beverage or clear liquids, 1 tsp every 10 minutes. Increase to 1 Tbsp every 20 minutes. 10 minutes. Increase to 1 Tbsp every 20 minutes. Double amount of fluid every hour. If diarrhea is Double amount of fluid every hour. If diarrhea is present, use only rehydration beverage. present, use only rehydration beverage.
Apple juice Apple juice Sports drink Sports drink Warm or cold tea Warm or cold tea LemonadeLemonade
ADA Nutrition Care Manual, accessed 4-06
MNT for Nausea/VomitingMNT for Nausea/Vomiting When there has been no vomiting for at least 8 hours, When there has been no vomiting for at least 8 hours,
initiate oral intake slowly with adding one solid food at initiate oral intake slowly with adding one solid food at a time in very small increments. Choose the following a time in very small increments. Choose the following types of foods: types of foods:
Without odor Without odor Low in fat Low in fat Low in fiber (see Client Education - Detailed, Foods Low in fiber (see Client Education - Detailed, Foods
Recommended).Recommended). Take prescribed antiemetics and other medications on Take prescribed antiemetics and other medications on
a regular schedule to assist in prevention of nausea a regular schedule to assist in prevention of nausea and vomiting. Take all other medications after eating. and vomiting. Take all other medications after eating.
ADA Nutrition Care Manual, accessed 4-06
Nausea/Vomiting: Food and Nausea/Vomiting: Food and Feeding IssuesFeeding Issues
Keep patient away from strong food odors Keep patient away from strong food odors Provide assistance in food preparation so as to Provide assistance in food preparation so as to
avoid cooking odors avoid cooking odors Eat foods at room temperature Eat foods at room temperature Keep patient's mouth clean and perform oral Keep patient's mouth clean and perform oral
hygiene tasks after each episode of vomiting hygiene tasks after each episode of vomiting Offer fluids between meals Offer fluids between meals Patient should sip liquids throughout the day Patient should sip liquids throughout the day Cold beverages may be more easily tolerated Cold beverages may be more easily tolerated Keep low-fat crackers or dry cereal by the bed Keep low-fat crackers or dry cereal by the bed
to eat before getting out of bed to eat before getting out of bed
Nausea/Vomiting: Lifestyle Nausea/Vomiting: Lifestyle IssuesIssues
Relax after meals instead of moving around Relax after meals instead of moving around Sit up for 1 hour after eating Sit up for 1 hour after eating Wear loose-fitting clothes Wear loose-fitting clothes Provide fresh air with a fan or open window Provide fresh air with a fan or open window Limit sounds, sights, and smells that may trigger Limit sounds, sights, and smells that may trigger
nausea and vomiting nausea and vomiting Other complementary and alternative medicine Other complementary and alternative medicine
interventions that have anecdotal evidence interventions that have anecdotal evidence (though clinical trials have not been conducted): (though clinical trials have not been conducted):
Relaxation techniques Relaxation techniques Acupuncture Acupuncture HypnosisHypnosis
ADA Nutrition Care Manual, accessed 4-06
Diseases of StomachDiseases of Stomach IndigestionIndigestion Acute gastritis from: Acute gastritis from: H. H.
pylori pylori tobacco, chronic tobacco, chronic use of drugs such as: use of drugs such as:
——AlcoholAlcohol
——AspirinAspirin
——Nonsteroidal Nonsteroidal antiinflammatory antiinflammatory agentsagents
Indigestion (Dyspepsia)Indigestion (Dyspepsia)SymptomsSymptoms
Abdominal painAbdominal pain BloatingBloating NauseaNausea RegurgitationRegurgitation BelchingBelching
Dyspepsia TreatmentDyspepsia Treatment
Avoid Avoid offending foodsoffending foods
Eat slowlyEat slowly Chew Chew
thoroughlythoroughly Do not Do not
overindulgeoverindulge
GastritisGastritis
Normally gastric & duodenal Normally gastric & duodenal mucosa protected by:mucosa protected by: MucusMucus Bicarbonate (acid neutralized)Bicarbonate (acid neutralized) Rapid removal of excess acidRapid removal of excess acid Rapid repair of tissueRapid repair of tissue
GastritisGastritis
Erosion of Erosion of mucosal layermucosal layer
Exposure of Exposure of cells to gastric cells to gastric secretions, secretions, bacteriabacteria
Inflammation & Inflammation & tissue damagetissue damage
GastritisGastritis Helicobacter Pylori (H. pylori)Helicobacter Pylori (H. pylori)
Bacteria, resistant to acidBacteria, resistant to acid Damages mucosaDamages mucosa Treat with bismuth, Treat with bismuth,
antibiotics, antisecretory antibiotics, antisecretory agentsagents
Causes ~92% duodenal Causes ~92% duodenal ulcers; 70% gastric ulcersulcers; 70% gastric ulcers
Atrophic GastritisAtrophic Gastritis
Loss of parietal cells in stomachLoss of parietal cells in stomach Hypochloria = Hypochloria = in HCl production in HCl production Achlorhydria = loss of HCl productionAchlorhydria = loss of HCl production Decrease or loss of intrinsic factor Decrease or loss of intrinsic factor
productionproduction Malabsorption of vitamin BMalabsorption of vitamin B1212 Pernicious anemiaPernicious anemia vitamin Bvitamin B12 12 injections or nasal sprayinjections or nasal spray
EndoscopyEndoscopy
Peptic Ulcer Disease (PUD)Peptic Ulcer Disease (PUD) Gastric or duodenal ulcersGastric or duodenal ulcers Asymptomatic or sx similar to Asymptomatic or sx similar to
gastritis or dyspepsiagastritis or dyspepsia Danger of hemorrhage, Danger of hemorrhage,
perforation, penetration into perforation, penetration into adjacent organ or spaceadjacent organ or space Melena = black, tarry stools from GI Melena = black, tarry stools from GI
bleedingbleeding
Characteristics and Comparisons Characteristics and Comparisons Between Gastric and Duodenal Between Gastric and Duodenal
UlcersUlcers Gastric ulcer formation involves Gastric ulcer formation involves
inflammatory involvement of acid-inflammatory involvement of acid-producing cells but usually occurs with producing cells but usually occurs with low acid secretion; duodenal ulcers are low acid secretion; duodenal ulcers are associated with high acid and low associated with high acid and low bicarbonate secretion. bicarbonate secretion.
Increased mortality and hemorrhage are Increased mortality and hemorrhage are associated with gastric ulcers.associated with gastric ulcers.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
Gastric and Duodenal Gastric and Duodenal UlcersUlcers
Peptic Ulcer Disease (PUD)Peptic Ulcer Disease (PUD)Definition and EtiologyDefinition and Etiology
Erosion through mucosa into Erosion through mucosa into submucosasubmucosa H. pyloriH. pylori Aspirin, NSAIDsAspirin, NSAIDs Stress:Stress:
Severe burns, trauma, surgery, shock, Severe burns, trauma, surgery, shock, renal failure, radiationrenal failure, radiation
Peptic Ulcer Disease (PUD)Peptic Ulcer Disease (PUD)Medical ManagementMedical Management
Plays a more important role than dietPlays a more important role than diet or stop aspirin, NSAIDsor stop aspirin, NSAIDs Use antibiotics, antacidsUse antibiotics, antacids Use sucralfate (Carafate) = gastric Use sucralfate (Carafate) = gastric
mucosa protectant – forms barrier mucosa protectant – forms barrier over ulcerover ulcer
Peptic Ulcer Disease (PUD)Peptic Ulcer Disease (PUD)Behavioral ManagementBehavioral Management
Avoid tobaccoAvoid tobacco Risk factor for ulcer developmentRisk factor for ulcer development complications – impairs healing, complications – impairs healing,
increases incidence of recurrenceincreases incidence of recurrence Interferes with txInterferes with tx Risk of recurrence, degree of Risk of recurrence, degree of
healing inhibition correlate with healing inhibition correlate with number of cigarettes per daynumber of cigarettes per day
MNT for Peptic Ulcer MNT for Peptic Ulcer Disease and GastritisDisease and GastritisMNT for Peptic Ulcer MNT for Peptic Ulcer Disease and GastritisDisease and Gastritis
Avoid foods that increase gastric acid Avoid foods that increase gastric acid secretion, such as the following: secretion, such as the following:
Alcohol Alcohol Pepper Pepper Caffeine Caffeine Tea Tea Coffee (including noncaffeinated) Coffee (including noncaffeinated) ChocolateChocolate
Avoid foods that increase gastric acid Avoid foods that increase gastric acid secretion, such as the following: secretion, such as the following:
Alcohol Alcohol Pepper Pepper Caffeine Caffeine Tea Tea Coffee (including noncaffeinated) Coffee (including noncaffeinated) ChocolateChocolate
ADA Nutrition Care Manual, accessed 4-06
MNT for Peptic Ulcer MNT for Peptic Ulcer DiseaseDisease
Identify foods that directly irritate the Identify foods that directly irritate the gastric mucosa or are not generally gastric mucosa or are not generally tolerated tolerated
Avoid eating at least 2 hours before Avoid eating at least 2 hours before bedtime bedtime
Peptic Ulcer Disease Peptic Ulcer Disease Treatment with DietTreatment with Diet
Meal frequency is controversial: small, Meal frequency is controversial: small, frequent meals may increase comfort but frequent meals may increase comfort but may also increase acid outputmay also increase acid output
There is little evidence to support There is little evidence to support eliminating specific foods unless they eliminating specific foods unless they cause repeated discomfortcause repeated discomfort
Overall good nutritional status helps Overall good nutritional status helps H. H. pyloripylori
Gastric SurgeryGastric Surgery Indicated when ulcer complicated Indicated when ulcer complicated
by:by: HemorrhageHemorrhage PerforationPerforation ObstructionObstruction Intractability (difficult to manage, cure)Intractability (difficult to manage, cure) Pt unable to follow medical regimenPt unable to follow medical regimen
Ulcers may recur after medical or Ulcers may recur after medical or surgical txsurgical tx
Gastric SurgeryGastric Surgery Resective surgical proceduresResective surgical procedures ““anastamosis” – connection of anastamosis” – connection of
two tubular structurestwo tubular structures Gastrectomy – surgical removal Gastrectomy – surgical removal
of part or all of stomachof part or all of stomach Hemigastrectomy = halfHemigastrectomy = half Partial gastrectomyPartial gastrectomy Subtotal gastrectomy = 30-90% Subtotal gastrectomy = 30-90%
resectedresected
Gastric surgical Gastric surgical procedures.procedures.
Fig. 30-7. p. 661.Fig. 30-7. p. 661.
Carcinoma of the StomachCarcinoma of the Stomach Obstruction and mechanical Obstruction and mechanical
interferenceinterference Surgical resection or Surgical resection or
gastrectomygastrectomy Prevention of GI cancers: fruits, Prevention of GI cancers: fruits,
vegetables, and seleniumvegetables, and selenium Increase risk of GI cancers: Increase risk of GI cancers:
alcohol, overweight, high salted alcohol, overweight, high salted or pickled foods, inadequate or pickled foods, inadequate micronutrientsmicronutrients
Gastric SurgeryGastric Surgery Billroth I = gastroduodenostomyBillroth I = gastroduodenostomy
Partial gastrectomy – anastomosis to Partial gastrectomy – anastomosis to duodenumduodenum
To remove ulcers, other lesions (cancer)To remove ulcers, other lesions (cancer) Billroth II = gastrojejunostomyBillroth II = gastrojejunostomy
Partial gastrectomy - anastomosis to Partial gastrectomy - anastomosis to jejunumjejunum
Allows resection of damaged mucosaAllows resection of damaged mucosa Reduces number of acid producing cellsReduces number of acid producing cells Reduces ulcer recurrenceReduces ulcer recurrence
Gastric SurgeryGastric Surgery Total gastrectomyTotal gastrectomy
Removal of entire stomachRemoval of entire stomach Rarely done = negative impact on Rarely done = negative impact on
digestion, nutritional statusdigestion, nutritional status In extensive gastric cancer & In extensive gastric cancer &
Zollinger-Ellison syndrome not Zollinger-Ellison syndrome not responding to medical managementresponding to medical management
Anastomosis from esophagus to Anastomosis from esophagus to duodenum or jejunumduodenum or jejunum
Zollinger-Ellison SyndromeZollinger-Ellison Syndrome PUD caused by “gastrinoma”PUD caused by “gastrinoma”
Gastrin producing tumor in Gastrin producing tumor in pancreaspancreas
Gastrin = hormone stimulates HCl Gastrin = hormone stimulates HCl prodprod
Causes mucosal ulcerationCauses mucosal ulceration 50 – 70% are malignant50 – 70% are malignant Any part of esoph., stomach, Any part of esoph., stomach,
duod., jejun.duod., jejun. Removal of tumor, gastrectomyRemoval of tumor, gastrectomy
Gastric surgical Gastric surgical procedures. (cont.)procedures. (cont.)
Fig. 30-7. p. 661.Fig. 30-7. p. 661.
PyloroplastyPyloroplasty
Surgical enlargement of pylorus or Surgical enlargement of pylorus or gastric outletgastric outlet
To improve gastric emptying with To improve gastric emptying with obstructions or when vagotomy obstructions or when vagotomy interferes with gastric emptyinginterferes with gastric emptying
May contribute to Dumping May contribute to Dumping SyndromeSyndrome
Ulcer recurrence is commonUlcer recurrence is common
Roux-en-YRoux-en-Y
Gastric partitioning Gastric partitioning – distal ileum, – distal ileum, proximal jejunumproximal jejunum
Often for Often for “bariatric” “bariatric” purposes (wt. loss)purposes (wt. loss)
Wt loss for 12 – 18 Wt loss for 12 – 18 wks with 50 – 60% wks with 50 – 60% excess wt. Lossexcess wt. Loss
Roux-en-YRoux-en-Y
Nutritional Goals:Nutritional Goals: Prevent deficienciesPrevent deficiencies Promote eating, lifestyle changes to Promote eating, lifestyle changes to
maintain lossesmaintain losses Mechanical soft diet ~ 3 mo., then solid Mechanical soft diet ~ 3 mo., then solid
foodsfoods Small amounts – 1 oz. To 1 cupSmall amounts – 1 oz. To 1 cup Overeating = N & V, refluxOvereating = N & V, reflux
VagotomyVagotomy
Severing all or part of the vagus nerves Severing all or part of the vagus nerves to the stomachto the stomach
With partial gastrectomy or pyroplastyWith partial gastrectomy or pyroplasty Significant decrease in acid secretionSignificant decrease in acid secretion ““truncal vagotomy” – no vagal truncal vagotomy” – no vagal
stimulation to liver, pancreas, other stimulation to liver, pancreas, other organs, stomachorgans, stomach
““selective vagotomy” or “parietal cell selective vagotomy” or “parietal cell vagotomy” – eliminates stimulation to vagotomy” – eliminates stimulation to stomachstomach
Diet Post Gastric SurgeryDiet Post Gastric Surgery
Ice chips allowed 24-48 hours after Ice chips allowed 24-48 hours after surgery. Some tolerate warm water surgery. Some tolerate warm water better than ice chips or cold waterbetter than ice chips or cold water
Clear liquids such as broth, bouillon, Clear liquids such as broth, bouillon, unsweetened gelatin, diluted unsweetened gelatin, diluted unsweetened fruit juiceunsweetened fruit juice
Initiate postgastrectomy diet and Initiate postgastrectomy diet and gradually progress to general diet as gradually progress to general diet as toleratedtolerated
Monitor iron, B12, and folic acid statusMonitor iron, B12, and folic acid status
Dumping syndromeDumping syndrome
Is a complex physiologic response to presence Is a complex physiologic response to presence of undigested food in the jejunumof undigested food in the jejunum
Following gastric surgery– 2/3 of the stomach Following gastric surgery– 2/3 of the stomach removedremoved
Symptom; abdominal fullness, nausea crampy Symptom; abdominal fullness, nausea crampy abdominal pain, following by diarrhea, 15 abdominal pain, following by diarrhea, 15 minutes after ingestion.minutes after ingestion.
Lying down immediately after eating reduces Lying down immediately after eating reduces these symptoms because food remains longer these symptoms because food remains longer in the stomach pouchin the stomach pouch
Alimentary hypoglycemia—occurs 1-2 hours Alimentary hypoglycemia—occurs 1-2 hours after eating-caused by the rapid digestion and after eating-caused by the rapid digestion and absorption of food especially of sugarabsorption of food especially of sugar
Dumping SyndromeDumping Syndrome Complex physiologic response to the Complex physiologic response to the
rapid emptying of hypertonic contents rapid emptying of hypertonic contents into the duodenum and jejunuminto the duodenum and jejunum
Dumping syndrome occurs as a result of Dumping syndrome occurs as a result of total or subtotal gastrectomy and is total or subtotal gastrectomy and is associated with mild to severe symptoms associated with mild to severe symptoms including abdominal distention, systemic including abdominal distention, systemic systems (bloating, flatulence, pain, systems (bloating, flatulence, pain, diarrhea), and reactive hypoglycemia. diarrhea), and reactive hypoglycemia.
Dumping SyndromeDumping Syndrome RapidRapid movement of hypertonic chyme movement of hypertonic chyme
into jejunuminto jejunum Fluid drawn into bowel by osmosis to Fluid drawn into bowel by osmosis to
dilute concentrated mass of fooddilute concentrated mass of food Volume of circulating blood decreasesVolume of circulating blood decreases
ADA Nutrition Care Manual, accessed 4-06
Dumping Syndrome Dumping Syndrome SymptomsSymptoms
Cramping Cramping Abdominal pain Abdominal pain Hypermotility Hypermotility Diarrhea Diarrhea Dizziness Dizziness Weakness Weakness Tachycardia within 10-20 minutes after Tachycardia within 10-20 minutes after
eatingeating
MNT for Dumping SyndromeMNT for Dumping Syndrome Prevent onset of early and late dumping syndromes. Prevent onset of early and late dumping syndromes. Initially avoid all hypertonic, concentrated sweets. Do not Initially avoid all hypertonic, concentrated sweets. Do not
start clear liquids as first oral feeding. start clear liquids as first oral feeding. The first meals should consist of protein, fat, and complex The first meals should consist of protein, fat, and complex
carbohydrate, but with only 1-2 food items at a time. carbohydrate, but with only 1-2 food items at a time. Patients may be initially lactose intolerant. Slowly progress Patients may be initially lactose intolerant. Slowly progress to 5-6 small meals each day. to 5-6 small meals each day.
Consume liquids 30 minutes to 1 hour after consuming Consume liquids 30 minutes to 1 hour after consuming solid food. solid food.
Lie down after eating. Lie down after eating. Consider addition of functional fibers to delay gastric Consider addition of functional fibers to delay gastric
emptying and assist with treatment of diarrhea.emptying and assist with treatment of diarrhea.
MNT for Dumping SyndromeMNT for Dumping Syndrome
These foods may exacerbate These foods may exacerbate symptoms:symptoms:
Sucrose Sucrose Fructose Fructose Sugar alcohols: Sugar alcohols:
Xylitol Xylitol Mannitol Mannitol SorbitolSorbitol
Source: ADA Nutrition Care Manual, accessed 4-06
Malabsorption, Malabsorption, steatorrheasteatorrhea
Post-surgical complications Post-surgical complications affecting nutrition:affecting nutrition:
Fat soluble vitamins, calciumFat soluble vitamins, calcium Folate, BFolate, B1212 (loss of intrinsic factor) (loss of intrinsic factor) Iron – better absorbed with Iron – better absorbed with acid acid
Supplement may helpSupplement may help
Drugs Commonly Used to Drugs Commonly Used to Treat Gastrointestinal Treat Gastrointestinal
DisordersDisorders Antacids: lower acidityAntacids: lower acidity Cimetidine (Tagamet), ranitidine (Zantac): Cimetidine (Tagamet), ranitidine (Zantac):
block acid secretion by blocking block acid secretion by blocking histamine histamine HH22 receptors receptors
ProstaglandinsProstaglandins Sucralfate: coats and protects surfaceSucralfate: coats and protects surface Colloidal bismuth: coats and protects surfaceColloidal bismuth: coats and protects surface Carbenoxolone: strengthens mucosal barrierCarbenoxolone: strengthens mucosal barrier Tinidazole: antibioticTinidazole: antibiotic
Diabetic Gastroparesis Diabetic Gastroparesis (Gastroparesis (Gastroparesis Diabeticorum)Diabeticorum) Delayed stomach emptying of Delayed stomach emptying of
solidssolids Etiology—autonomic neuropathyEtiology—autonomic neuropathy Nausea, vomiting, bloating, painNausea, vomiting, bloating, pain Insulin action and absorption of Insulin action and absorption of
food not synchronizedfood not synchronized Prescribe small frequent meals Prescribe small frequent meals
(may need liquid diet) (may need liquid diet) Adjust insulinAdjust insulin
SummarySummary
Upper GI disorders—H. pylori plays Upper GI disorders—H. pylori plays an important rolean important role
Maintain individual tolerances as Maintain individual tolerances as much as possible.much as possible.
Medical Nutrition Therapy Medical Nutrition Therapy for for Lowe Lowe Gastrointestinal Gastrointestinal
Tract DisordersTract Disorders
Normal Function of Normal Function of Lower GILower GI
DigestionDigestion AbsorptionAbsorption Excretion Excretion
Normal Function of Normal Function of Lower GILower GI
DigestionDigestion Begins in mouth & stomachBegins in mouth & stomach Continues in duodenum & jejunumContinues in duodenum & jejunum Secretions:Secretions:
LiverLiver PancreasPancreas Small intestineSmall intestine
Normal Function of Normal Function of Lower GILower GI
AbsorptionAbsorption Most nutrients absorbed in jejunumMost nutrients absorbed in jejunum Small amounts of nutrients absorbed Small amounts of nutrients absorbed
in ileumin ileum Bile salts & BBile salts & B12 12 absorbed in terminal absorbed in terminal
ileumileum Residual water absorbed in colonResidual water absorbed in colon
Principles of Nutritional Principles of Nutritional CareCare
Intestinal disorders & symptoms:Intestinal disorders & symptoms: Motility Motility Secretion Secretion AbsorptionAbsorption ExcretionExcretion
Principles of Nutritional Principles of Nutritional CareCare
Dietary modifications Dietary modifications To alleviate symptomsTo alleviate symptoms Correct nutritional deficienciesCorrect nutritional deficiencies Address primary problemAddress primary problem Must be individualizedMust be individualized
Common Intestinal Common Intestinal ProblemsProblems
Intestinal gas or flatulenceIntestinal gas or flatulence ConstipationConstipation DiarrheaDiarrhea SteatorrheaSteatorrhea
Photo courtesy http://www.drnatura.com/
ConstipationConstipation
Defined as hard stools, straining Defined as hard stools, straining with defecation, infrequent bowel with defecation, infrequent bowel movementsmovements
Normal frequency ranges from one Normal frequency ranges from one stool q 3 days to 3 times a daystool q 3 days to 3 times a day
Occurs in 5% to more than 25% of Occurs in 5% to more than 25% of the population, depending on how the population, depending on how defineddefined
Causes of Constipation - Causes of Constipation - SystemicSystemic
Side effect of medication, esp narcoticsSide effect of medication, esp narcotics Metabolic Endocrine abnormalities, such as Metabolic Endocrine abnormalities, such as
hypothyroidism, uremia and hypercalcemiahypothyroidism, uremia and hypercalcemia Lack of exerciseLack of exercise Ignoring the urge to defecateIgnoring the urge to defecate Vascular disease of the large bowelVascular disease of the large bowel Systemic neuromuscular disease leading to Systemic neuromuscular disease leading to
deficiency of voluntary musclesdeficiency of voluntary muscles Poor diet, low in fiberPoor diet, low in fiber PregnancyPregnancy
Causes of Constipation - Causes of Constipation - GastrointestinalGastrointestinal
Diseases of the upper gastrointestinal tractDiseases of the upper gastrointestinal tract Celiac DiseaseCeliac Disease Duodenal ulcerDuodenal ulcer
Diseases of the large bowel resulting in: Diseases of the large bowel resulting in: Failure of propulsion along the colon Failure of propulsion along the colon
(colonic inertia)(colonic inertia) Failure of passage though anorectal structures Failure of passage though anorectal structures
(outlet obstruction)(outlet obstruction) Irritable bowel syndromeIrritable bowel syndrome Anal fissures or hemorrhoidsAnal fissures or hemorrhoids Laxative abuseLaxative abuse
– Gastric cancer
– Cystic fibrosis
– Gastric cancer
– Cystic fibrosis
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
Treatment of Treatment of ConstipationConstipation
Encourage physical activity as possibleEncourage physical activity as possible Bowel training: encourage patient to Bowel training: encourage patient to
respond to urge to defecaterespond to urge to defecate Change drug regimen if possible if it is Change drug regimen if possible if it is
contributorycontributory Use laxatives and stool softeners Use laxatives and stool softeners
judiciouslyjudiciously Use stool bulking agents such as psyllium Use stool bulking agents such as psyllium
(metamucil) and pectin(metamucil) and pectin
MNT for ConstipationMNT for Constipation
Depends on causeDepends on cause Use high fiber or high residue Use high fiber or high residue
diet as appropriatediet as appropriate If caused by medication, may be If caused by medication, may be
refractory to diet treatmentrefractory to diet treatment
Fiber, roughage, and Fiber, roughage, and residueresidue
FiberFiber or roughage or roughage From plant foodsFrom plant foods Not digestible by human enzymesNot digestible by human enzymes
ResidueResidue Fecal contents, including bacteria and Fecal contents, including bacteria and
the net remains after ingestion of the net remains after ingestion of food, secretions into the GI tract, and food, secretions into the GI tract, and absorptionabsorption
High-Fiber DietsHigh-Fiber Diets
Most Americans = 10 – 15 g/dayMost Americans = 10 – 15 g/day Recommended = 25 g/dayRecommended = 25 g/day More than 50g/day = no added More than 50g/day = no added
benefit, may cause problemsbenefit, may cause problems
High-Fiber DietHigh-Fiber Diet Increase consumption of whole-grain Increase consumption of whole-grain
breads, cereals, flours, other whole-breads, cereals, flours, other whole-grain productsgrain products
Increase consumption of vegetables, Increase consumption of vegetables, especially legumes, and fruits, edible especially legumes, and fruits, edible skins, seeds, hullsskins, seeds, hulls
Consume high-fiber cereals, granolas, Consume high-fiber cereals, granolas, legumes to increase fiber to 25 g/daylegumes to increase fiber to 25 g/day
Increase consumption of water to at Increase consumption of water to at least 2 qts (eight 8 oz cups)least 2 qts (eight 8 oz cups)
High-Fiber Diets: High-Fiber Diets: cautionscautions
Gastric obstruction, fecal impaction Gastric obstruction, fecal impaction may occur when insufficient fluid may occur when insufficient fluid consumedconsumed
With GI strictures, motility problems, With GI strictures, motility problems, increase fiber slowly (~1mo.)increase fiber slowly (~1mo.)
Unpleasant side effectsUnpleasant side effects Increased flatulenceIncreased flatulence BorborygmusBorborygmus Cramps, diarrheaCramps, diarrhea
Physiologic effect of dietary fiberPhysiologic effect of dietary fiber stimulating chewing, saliva flow, gastric stimulating chewing, saliva flow, gastric juice juice
secretionsecretion fills the stomach and provides a sense of fills the stomach and provides a sense of
satietysatiety Increase fecal bulkIncrease fecal bulk Normalizes intestinal transit timeNormalizes intestinal transit time Become a substrat for colonic fermentationBecome a substrat for colonic fermentation Delay gastric emptyngDelay gastric emptyng Slows the rate of digestion and absorptionSlows the rate of digestion and absorption Lower serum cholesterolLower serum cholesterol
DiarrheaDiarrhea
Characterized by frequent evacuation of Characterized by frequent evacuation of liquid stoolsliquid stools
Accompanied by loss of fluid and Accompanied by loss of fluid and electrolytes, especially sodium and electrolytes, especially sodium and potassiumpotassium
Occurs when there is excessively rapid Occurs when there is excessively rapid transit of intestinal contents through the transit of intestinal contents through the small intestine, decreased absorption of small intestine, decreased absorption of fluids, increased secretion of fluids into fluids, increased secretion of fluids into the GI tractthe GI tract
Diarrhea EtiologyDiarrhea Etiology
Inflammatory diseaseInflammatory disease Infections with fungal, bacterial, Infections with fungal, bacterial,
or viral agentsor viral agents Medications (antibiotics, elixirs)Medications (antibiotics, elixirs) Overconsumption of sugarsOverconsumption of sugars Insufficient or damaged mucosal Insufficient or damaged mucosal
absorptive surfaceabsorptive surface MalnutritionMalnutrition
Diarrhea Treatment for Diarrhea Treatment for AdultsAdults
Identify and treat the underlying problemIdentify and treat the underlying problem Manage fluid and electrolyte replacement Manage fluid and electrolyte replacement
using oral glucose electrolyte solutions (see using oral glucose electrolyte solutions (see WHO guidelines) WHO guidelines)
Initiate minimum-residue dietInitiate minimum-residue diet Avoid large amounts of sugars and sugar Avoid large amounts of sugars and sugar
alcoholsalcohols Prebiotics in modest amounts including Prebiotics in modest amounts including
pectin, oligosaccharides, inulin, oats, banana pectin, oligosaccharides, inulin, oats, banana flakesflakes
Probiotics, cultured foods and supplements Probiotics, cultured foods and supplements that are sources of beneficial gut florathat are sources of beneficial gut flora
Low- or Minimum Low- or Minimum Residue DietResidue Diet
Foods completely digested, well Foods completely digested, well absorbedabsorbed
Foods that do not increase GI secretionsFoods that do not increase GI secretions Used in:Used in:
MaldigestionMaldigestion MalabsorptionMalabsorption DiarrheaDiarrhea Temporarily after some surgeries, e.g. Temporarily after some surgeries, e.g.
hemorrhoidectomyhemorrhoidectomy
Foods to Limit in a Low- or Foods to Limit in a Low- or Minimum Residue DietMinimum Residue Diet
Lactose (in lactose malabsorbers)Lactose (in lactose malabsorbers) Fiber >20 g/dayFiber >20 g/day Resistant starchesResistant starches
Raffinose, stachyose in legumesRaffinose, stachyose in legumes Sorbitol, mannitol, xylitol >10g/daySorbitol, mannitol, xylitol >10g/day CaffeineCaffeine Alcohol, esp. wine, beerAlcohol, esp. wine, beer
Restricted-Fiber DietsRestricted-Fiber Diets Uses:Uses:
When reduced fecal output is necessaryWhen reduced fecal output is necessary When GI tract is restricted or obstructedWhen GI tract is restricted or obstructed When reduced fecal residue is desiredWhen reduced fecal residue is desired
Restricted-Fiber DietsRestricted-Fiber Diets
Restricts fruits, vegs, coarse Restricts fruits, vegs, coarse grainsgrains
<10 g fiber/day<10 g fiber/day PhytobezoarsPhytobezoars
Obstructions in stomach resulting Obstructions in stomach resulting from ingestion of plant foodsfrom ingestion of plant foods
Common in edentulous pts, poor Common in edentulous pts, poor dentition, with denturesdentition, with dentures
Potato skins, oranges, grapefruitPotato skins, oranges, grapefruit
MNT for Infants and MNT for Infants and ChildrenChildren
Acute diarrhea most dangerous in infants Acute diarrhea most dangerous in infants and childrenand children
Aggressive replacement of fluid/ Aggressive replacement of fluid/ electrolyteselectrolytes
WHO/AAP recommend 2% glucose (20g/L) WHO/AAP recommend 2% glucose (20g/L) 45-90 mEq sodium, 20 mEq/L potassium, 45-90 mEq sodium, 20 mEq/L potassium, citrate basecitrate base
Newer solutions (Pedialyte, Infalyte, Lytren, Newer solutions (Pedialyte, Infalyte, Lytren, Equalyte, Rehydralyte) contain less glucose Equalyte, Rehydralyte) contain less glucose and less salt, available without prescriptionand less salt, available without prescription
MNT for Infants and MNT for Infants and ChildrenChildren
Continue a liquid or semisolid diet Continue a liquid or semisolid diet during bouts of acute diarrhea for during bouts of acute diarrhea for children 9 to 20 monthschildren 9 to 20 months
Intestine absorbs up to 60% of food Intestine absorbs up to 60% of food even during diarrheaeven during diarrhea
Early refeeding helpful; gut rest Early refeeding helpful; gut rest harmfulharmful
Clear liquid diet (hyperosmolar, high Clear liquid diet (hyperosmolar, high in sugar) is inappropriatein sugar) is inappropriate
Access American Academy of Access American Academy of Pediatrics Clinical Guidelines Pediatrics Clinical Guidelines http://aappolicy.aappublications.org/http://aappolicy.aappublications.org/cgi/reprint/pediatrics;97/3/424.pdfcgi/reprint/pediatrics;97/3/424.pdf
Diseases of Small Diseases of Small IntestineIntestine
Celiac diseaseCeliac disease Brush border enzyme deficienciesBrush border enzyme deficiencies Crohn’s diseaseCrohn’s disease
Celiac DiseaseCeliac Disease
Also called Gluten-Sensitive Also called Gluten-Sensitive Enteropathy and Non-tropical Enteropathy and Non-tropical SprueSprue
Caused by inappropriate Caused by inappropriate autoimmune reaction to gliadin autoimmune reaction to gliadin (found in gluten)(found in gluten)
Much more common than Much more common than formerly believed (prevalence 1 formerly believed (prevalence 1 in 133 persons in the US)in 133 persons in the US)
Frequently goes undiagnosedFrequently goes undiagnosed
Celiac Disease Celiac Disease SymptomsSymptoms
Early presentation: diarrhea, Early presentation: diarrhea, steatorrhea, malodorous stools, steatorrhea, malodorous stools, abdominal bloating, poor weight gainabdominal bloating, poor weight gain
Later presentation: other autoimmune Later presentation: other autoimmune disorders, failure to maintain weight, disorders, failure to maintain weight, fatigue, consequences of nutrient fatigue, consequences of nutrient malabsorption (anemias, osteoporosis, malabsorption (anemias, osteoporosis, coagulopathy)coagulopathy)
Often misdiagnosed as irritable bowel Often misdiagnosed as irritable bowel disease or other disordersdisease or other disorders
Celiac Disease DiagnosisCeliac Disease Diagnosis Positive family historyPositive family history Pattern of symptomsPattern of symptoms Serologic tests: antiendomysial Serologic tests: antiendomysial
antibodies (AEAs), antibodies (AEAs), immunoglobulin A (IgA), immunoglobulin A (IgA), antigliadin antibodies (AgG-AGA) antigliadin antibodies (AgG-AGA) or IgA tissue transglutaminaseor IgA tissue transglutaminase
Gold standard is intestinal Gold standard is intestinal mucosal biopsymucosal biopsy
Evaluation should be done Evaluation should be done before gluten-containing foods before gluten-containing foods are withdrawnare withdrawn
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
Normal human duodenal mucosa and peroral small bowel Normal human duodenal mucosa and peroral small bowel biopsy specimen from a patient with gluten enteropathy.biopsy specimen from a patient with gluten enteropathy.Normal human duodenal mucosa and peroral small bowel Normal human duodenal mucosa and peroral small bowel biopsy specimen from a patient with gluten enteropathy.biopsy specimen from a patient with gluten enteropathy.
Fig. 31-1. p. 673.Fig. 31-1. p. 673.
(From Floch MH. Nutrition and Diet Therapy in Gastrointestinal Disease. New York: Menum Medical Book Co., 1981.)
Forward Forward BackBack MENUMENU
Celiac DiseaseCeliac Disease Results in damage to villi of Results in damage to villi of
intestinal mucosa – atrophy, intestinal mucosa – atrophy, flatteningflattening
Potential or actual malabsorption Potential or actual malabsorption of all nutrientsof all nutrients
May be accompanied by dermatitis May be accompanied by dermatitis herpetiformis, anemia, bone loss, herpetiformis, anemia, bone loss, muscle weakness, polyneuropathy, muscle weakness, polyneuropathy, follicular hyperkeratosisfollicular hyperkeratosis
Increased risk of Type 1 diabetes, Increased risk of Type 1 diabetes, lymphomas and other lymphomas and other malignanciesmalignancies
Celiac Disease: Diet IS Celiac Disease: Diet IS the Therapythe Therapy
Electrolyte and fluid replacement (acute Electrolyte and fluid replacement (acute phase)phase)
Vitamin and mineral supplementation as Vitamin and mineral supplementation as needed (calcium, vitamin D, vitamin K, iron, needed (calcium, vitamin D, vitamin K, iron, folate, B12, A & E)folate, B12, A & E)
Delete gluten sources from diet (wheat, rye, Delete gluten sources from diet (wheat, rye, barley, oats)barley, oats)
Substitute corn, potato, rice, soybean, tapioca, Substitute corn, potato, rice, soybean, tapioca, and arrowrootand arrowroot
Patients should see a dietitian who is familiar Patients should see a dietitian who is familiar with this disease and its treatmentwith this disease and its treatment
Celiac DiseaseCeliac Disease
Read labels carefully for problem Read labels carefully for problem ingredientsingredients
Even trace amounts of gliadin are Even trace amounts of gliadin are problematicproblematic
Common problem additives include Common problem additives include fillers, thickeners, seasonings, fillers, thickeners, seasonings, sauces, gravies, coatings, vegetable sauces, gravies, coatings, vegetable proteinprotein
Tropical SprueTropical Sprue Cause unknown; possible infectious Cause unknown; possible infectious
processprocess Imitates celiac diseaseImitates celiac disease Results in atrophy and inflammation of villiResults in atrophy and inflammation of villi Sx: diarrhea, anorexia, abdominal Sx: diarrhea, anorexia, abdominal
distentiondistention Rx: tetracycline, folate 5 mg/d, BRx: tetracycline, folate 5 mg/d, B1212 IM IM
Intestinal Brush Border Intestinal Brush Border Enzyme DeficienciesEnzyme Deficiencies Deficiency of brush border Deficiency of brush border
disaccharidases disaccharidases Disaccharides not hydrolyzed at Disaccharides not hydrolyzed at
mucosal cell membranemucosal cell membrane
Intestinal Brush Border Intestinal Brush Border Enzyme DeficienciesEnzyme Deficiencies May occur asMay occur as
Rare congenital defectsRare congenital defects Lack of sucrase, isomaltase, lactase in Lack of sucrase, isomaltase, lactase in
newbornsnewborns Secondary to diseases that Secondary to diseases that
damage intestinal epitheliumdamage intestinal epithelium Crohn’s disease, celiac diseaseCrohn’s disease, celiac disease
Genetic formGenetic form Lactase deficiency Lactase deficiency
Lactase “Deficiency”Lactase “Deficiency” 70% of adults worldwide are lactase 70% of adults worldwide are lactase
deficient, especially Africans, South deficient, especially Africans, South Americans, and AsiansAmericans, and Asians
Maintenance of lactase into adulthood is Maintenance of lactase into adulthood is probably the result of a genetic probably the result of a genetic mutationmutation
Lactase “deficiency)Lactase “deficiency)
Diagnosed based on history of GI Diagnosed based on history of GI intolerance to dairy productsintolerance to dairy products
Hydrogen breath testHydrogen breath test Abnormal lactose tolerance test Abnormal lactose tolerance test
(failure of blood glucose response to (failure of blood glucose response to lactose load, along with GI lactose load, along with GI symptoms) symptoms)
MNT for Lactase MNT for Lactase DeficiencyDeficiency
Most lactase deficient individuals can Most lactase deficient individuals can tolerate small amounts of lactose tolerate small amounts of lactose without symptoms, particularly with without symptoms, particularly with meals or as cultured products meals or as cultured products (yogurt or cheese)(yogurt or cheese)
Can use lactase enzyme or lactase Can use lactase enzyme or lactase treated foods, e.g. Lactaid milktreated foods, e.g. Lactaid milk
Distinct from milk protein allergy; Distinct from milk protein allergy; allergy requires milk free dietallergy requires milk free diet
Inflammatory Bowel Inflammatory Bowel DiseaseDisease
Crohn’s Disease and Ulcerative ColitisCrohn’s Disease and Ulcerative Colitis Autoimmune diseases of unknown Autoimmune diseases of unknown
originorigin Genetic component and Genetic component and
environmental factorsenvironmental factors Onset usually between 15 to 30 years Onset usually between 15 to 30 years
of ageof age
IBS: Nutritional CareIBS: Nutritional Care
ID individual food intolerancesID individual food intolerances Keep food record, include symptoms, Keep food record, include symptoms,
time they occur in relation to mealstime they occur in relation to meals
Avoid offending foods, Avoid offending foods, substancessubstances
Milk, milk products (lactose) only in Milk, milk products (lactose) only in presence of lactose deficiencypresence of lactose deficiency
Fatty foodsFatty foods Gas-forming foods, beveragesGas-forming foods, beverages Caffeine, alcoholCaffeine, alcohol Foods w/ Foods w/ fructose or sorbitol fructose or sorbitol
IBS: Nutritional CareIBS: Nutritional Care
Eat small frequent meals at Eat small frequent meals at relaxed pace, regular timesrelaxed pace, regular times
Gradually add dietary fiber to dietGradually add dietary fiber to diet 20 – 30 g20 – 30 g Fiber supplements may help Fiber supplements may help
(psyllium)(psyllium) Fluids – 2 – 3 qts w/ fiber supp.Fluids – 2 – 3 qts w/ fiber supp. Regular physical activity to reduce Regular physical activity to reduce
stressstress
DiverticulosisDiverticulosis
Sac-like herniations or Sac-like herniations or outpouches of the colon walloutpouches of the colon wall
Caused by long-term increased Caused by long-term increased colonic pressurescolonic pressures
Believed to result from low fiber Believed to result from low fiber diet, constipationdiet, constipation
DiverticulitisDiverticulitis Caused when bacteria or other Caused when bacteria or other
irritants are trapped in irritants are trapped in diverticular pouchesdiverticular pouches
InflammationInflammation Abscess formationAbscess formation Acute perforationAcute perforation Acute bleedingAcute bleeding ObstructionObstruction Sepsis Sepsis
Diverticulitis: MNT for Diverticulitis: MNT for acute diseaseacute disease
Use elemental diet if patient is acutely Use elemental diet if patient is acutely ill. Progress to clear liquidsill. Progress to clear liquids
Initiate soft diet with no excess spices Initiate soft diet with no excess spices or fiber. Avoid nuts, seeds, popcorn, or fiber. Avoid nuts, seeds, popcorn, fibrous vegetablesfibrous vegetables
Ensure adequate intake of protein and Ensure adequate intake of protein and ironiron
Progress to normal fiber intake as Progress to normal fiber intake as inflammation decreasesinflammation decreases
Low fat diet may also be beneficialLow fat diet may also be beneficial
Diverticulosis: MNT for Diverticulosis: MNT for chronic diseasechronic disease
High fiber diet (increase gradually)High fiber diet (increase gradually) Supplement with psyllium, Supplement with psyllium,
methylcellulose may be helpfulmethylcellulose may be helpful 2 – 3 qt water daily with high fiber 2 – 3 qt water daily with high fiber
intakeintake Low fat diet may be helpfulLow fat diet may be helpful ? Avoid seeds, nuts, skins of plants? Avoid seeds, nuts, skins of plants
Colon Cancer Colon Cancer
Second most common cancer in adultsSecond most common cancer in adults Second most common cause of deathSecond most common cause of death Factors that increase risk:Factors that increase risk:
Family historyFamily history Occurrence of IBD – Crohn’s, Occurrence of IBD – Crohn’s,
ulcerative colitisulcerative colitis PolypsPolyps DietDiet
Colon Cancer/Polyps: Colon Cancer/Polyps: dietary risk factorsdietary risk factors
Increased meat intake, esp. red meatsIncreased meat intake, esp. red meats Increased fat intakeIncreased fat intake Low intakes of vegetables, high fiber Low intakes of vegetables, high fiber
grains, carotenoidsgrains, carotenoids Low intakes of vits D, E, folateLow intakes of vits D, E, folate Low intakes of calcium, zinc, seleniumLow intakes of calcium, zinc, selenium Some food preparation methods Some food preparation methods
(chargrilling)(chargrilling)
Colon Cancer/Polyps: Colon Cancer/Polyps: possible dietary protective possible dietary protective
factorsfactors Omega-3 fatty acids –fish oils, Omega-3 fatty acids –fish oils,
flaxseed, etcflaxseed, etc Wheat branWheat bran Legumes Legumes Some phytochemicals (plants)Some phytochemicals (plants) Butyric acid – dairy fats, bacterial Butyric acid – dairy fats, bacterial
fermentation of fiber in colonfermentation of fiber in colon Calcium Calcium
Short-bowel syndrome Short-bowel syndrome (SBS)(SBS)
Consequence of significant Consequence of significant resections of small intestineresections of small intestine
Jejunal resectionsJejunal resections Ileal resectionsIleal resections
40 – 50% small bowel resected40 – 50% small bowel resected Crohn’s, radiation enteritis, Crohn’s, radiation enteritis,
mesenteric infarct, malignant mesenteric infarct, malignant disease, volvulusdisease, volvulus
SBS ComplicationsSBS Complications
Malabsorption of micronutrients, Malabsorption of micronutrients, macronutrientsmacronutrients
Fluid, electrolyte imbalancesFluid, electrolyte imbalances Wt lossWt loss Growth failure in childrenGrowth failure in children Gastric hypersecretionGastric hypersecretion Kidney stones, gallstonesKidney stones, gallstones
SBS: Predictors of SBS: Predictors of Malabsorption, Malabsorption, Complications, Need for PNComplications, Need for PN
Length of remaining small intestineLength of remaining small intestine Loss of ileum, especially distal one thirdLoss of ileum, especially distal one third Loss of ileocecal valveLoss of ileocecal valve Loss of colonLoss of colon Disease in remaining segments(s) of Disease in remaining segments(s) of
gastrointestinal tractgastrointestinal tract Radiation enteritisRadiation enteritis Coexisting malnutritionCoexisting malnutrition Older age surgeryOlder age surgery
Jejunal ResectionJejunal Resection
Most digestion, absorption in Most digestion, absorption in first 100 cm of small intestinefirst 100 cm of small intestine
After period of adaptation, ileum After period of adaptation, ileum can perform functions of jejunumcan perform functions of jejunum
With loss of jejunum, less With loss of jejunum, less digestive, absorptive surfacedigestive, absorptive surface
Ileal ResectionsIleal Resections
May produce major nutritional, May produce major nutritional, medical problemsmedical problems
Distal ileum:Distal ileum: Site for absorption of vit BSite for absorption of vit B1212/intrinsic /intrinsic
factor complex, bile salts, fluidfactor complex, bile salts, fluid Impaired bile salt absorption results Impaired bile salt absorption results
in malabsorption of fats, fat-sol vits, in malabsorption of fats, fat-sol vits, minerals (“soaps”)minerals (“soaps”)
Increased absorption of oxalates = Increased absorption of oxalates = renal stonesrenal stones
Small Bowel Surgery – Small Bowel Surgery – Nutritional CareNutritional Care
Initially may require TPNInitially may require TPN 2 general principles for resuming enteral 2 general principles for resuming enteral
nutrition:nutrition: Start enteral feedings earlyStart enteral feedings early Increase feeding concentration, Increase feeding concentration,
volume gradually volume gradually
Small Bowel Surgery – Small Bowel Surgery – Nutritional CareNutritional Care
Small frequent mini-meals (6 – 10)Small frequent mini-meals (6 – 10) Transition to more normal foods, Transition to more normal foods,
meals may take weeks to monthsmeals may take weeks to months Some pts never tolerate normal Some pts never tolerate normal
concentrations or volumes of foodconcentrations or volumes of food Maximal adaptation of GI tract may Maximal adaptation of GI tract may
take up to 1 yr after surgerytake up to 1 yr after surgery
Ileostomy or ColostomyIleostomy or Colostomy
Surgical creation of an opening from the Surgical creation of an opening from the body surface to the intestinal tract = body surface to the intestinal tract = “stoma”“stoma”
Permits defecation from intact portion of Permits defecation from intact portion of intestineintestine
““ileostomy” = removal of entire colon, ileostomy” = removal of entire colon, rectum, anus with stoma into ileumrectum, anus with stoma into ileum
““colostomy” = removal of rectum, anus colostomy” = removal of rectum, anus with stoma into colonwith stoma into colon
Ileostomy or ColostomyIleostomy or Colostomy Sometimes temporarySometimes temporary Output from stoma depends on Output from stoma depends on
locationlocation Ileostomy output will Ileostomy output will
be liquidbe liquid Colostomy output moreColostomy output more
solid, more odorous solid, more odorous
Colostomy IllustrationColostomy Illustration
Types of ileostomiesTypes of ileostomies
Ileoanal PouchIleoanal Pouch
Ileostomy or Colostomy – Ileostomy or Colostomy – Nutr. CareNutr. Care
Increase water, salt with ileostomiesIncrease water, salt with ileostomies Pt w/ normal, well-functioning Pt w/ normal, well-functioning
ileostomy usually does not become ileostomy usually does not become nutritionally depleted –no higher nutritionally depleted –no higher energy intake neededenergy intake needed
W/ resection of terminal ileum need W/ resection of terminal ileum need BB1212 supplement supplement
Ileostomy or Colostomy – Ileostomy or Colostomy – Nutr. CareNutr. Care
May restrict fruits & vegetables so may May restrict fruits & vegetables so may need vit Cneed vit C
May need to avoid very fibrous vegs, May need to avoid very fibrous vegs, chew wellchew well
Individual tolerances: address issues such Individual tolerances: address issues such as odor or gas individuallyas odor or gas individually
For high output ileostomy may need to For high output ileostomy may need to follow dumping recommendations; use follow dumping recommendations; use soluble fiber (oatmeal, applesauce, soluble fiber (oatmeal, applesauce, banana, rice); monitor fat soluble vitsbanana, rice); monitor fat soluble vits
Rectal SurgeryRectal Surgery Low residue to allow wound repair, Low residue to allow wound repair,
prevent infectionprevent infection Chemically defined diets may be used Chemically defined diets may be used
to reduce stool volume and frequencyto reduce stool volume and frequency
Lower GI Disorders Lower GI Disorders SummarySummary
Food intolerances should be dealt with Food intolerances should be dealt with individuallyindividually
Patients should be encouraged to Patients should be encouraged to follow the least restrictive diet possiblefollow the least restrictive diet possible
Patients should be re-evaluated Patients should be re-evaluated frequently and the diet advanced as frequently and the diet advanced as appropriateappropriate
LIVER DISEASELIVER DISEASE
HEPATITISHEPATITISCIRRHOSIS HEPATISCIRRHOSIS HEPATISCOMA HEPATICCOMA HEPATIC
SymptomsSymptoms
IcterusIcterus AnorexiaAnorexia Nausea in the afternoonNausea in the afternoon Sub-febrilSub-febril
Functions of the Liver:Functions of the Liver:A Brief OverviewA Brief Overview
Largest organ in body, integral to most Largest organ in body, integral to most metabolic functions of body, performing over metabolic functions of body, performing over 500 tasks500 tasks
Only 10-20% of functioning liver is required to Only 10-20% of functioning liver is required to sustain lifesustain life
Removal of liver will result in death within 24 Removal of liver will result in death within 24 hourshours
Functions of the LiverFunctions of the Liver Main functions include:Main functions include:
Metabolism of CHO, protein, fatMetabolism of CHO, protein, fat Storage/activation vitamins and mineralsStorage/activation vitamins and minerals Formation/excretion of bileFormation/excretion of bile Steroid metabolism, detoxifier of drugs/alcoholSteroid metabolism, detoxifier of drugs/alcohol Action as (bacteria) filter and fluid chamberAction as (bacteria) filter and fluid chamber Conversion of ammonia to ureaConversion of ammonia to urea
Gastrointestinal tract significant source of ammoniaGastrointestinal tract significant source of ammonia Generated from ingested protein substances that are Generated from ingested protein substances that are
deaminated by colonic bacteriadeaminated by colonic bacteria Ammonia enters circulation via portal veinAmmonia enters circulation via portal vein Converted to urea by liver for excretionConverted to urea by liver for excretion
Alanine Transaminase (ALT)
Aspartate Transaminase(AST) The Urea Cycle
Progression of Liver Diseases
Normal LiverNormal Liver
Alcoholic Fatty LiverAlcoholic Fatty Liver
Cirrhotic Liver
Malnutrition In Liver DiseaseMalnutrition In Liver Disease Malnutrition is an early and typical aspect of Malnutrition is an early and typical aspect of
hepatic cirrhosishepatic cirrhosis Contributes to poor prognosis and complicationsContributes to poor prognosis and complications
Degree of malnutrition related to severity of liver Degree of malnutrition related to severity of liver dysfunction and disease etiology (higher in dysfunction and disease etiology (higher in alcoholics)alcoholics) Mortality doubled in cirrhotic patients with malnutrition Mortality doubled in cirrhotic patients with malnutrition
(35% vs 16%)(35% vs 16%) Complications more frequent than in well-nourished Complications more frequent than in well-nourished
(44% vs 24%)(44% vs 24%) Usually more of a clinical problem than hepatic Usually more of a clinical problem than hepatic
encephalopathy itselfencephalopathy itself
Cirrhosis is common end result of many chronic liver disorders Severe damage to structure &
function of normal cells
Inhibits normal blood flow
Decrease in # functional hepatocytes
Results in portal hypertension & ascites
Portal systemic shuntingBlood bypasses the liver via shunt, thus bypassing detoxification
Toxins remain in circulating blood
Neurtoxic substances can precipitate hepatic encephalopathy
Amino acids of importance Amino acids of importance in Liver Diseasein Liver Disease
Aromatic AA ( AAA)Aromatic AA ( AAA) Tyrosine, phenyl alanineTyrosine, phenyl alanine**, free trypthopan, free trypthopan**
Branched chain amino acids (BCAA)Branched chain amino acids (BCAA) ValineValine**, leucine, leucine**, isoleucine, isoleucine**
Ammoniogenic amino acidsAmmoniogenic amino acids Glutamin, histidineGlutamin, histidine**, lysine, asparagine, , lysine, asparagine,
lycinelycine**, serine, threonin, serine, threonin**,,
** indispensable AAindispensable AA
““Vitamin/Mineral Deficits in Vitamin/Mineral Deficits in Hepatic Failure”Hepatic Failure”
Vitamin SIGN
A
D
E
K
BG
B12
Niacin
Folate
B1
Zn
Mg
Fe
Dermatitis, night blindness
Osteomalacia
Edema, Peripheral neuropathy
Bleeding
Mucous membr lesions, dermatitis
Megaloblastic an, glossitis, CNS dysfunction
Megaloblastic an, glossitis, irritability
Dermatitis, dementia, diarrhea
Neuropathy, ascites, edema, CNS dysfunction
Imunodef, impaired taste, wound healing, prot synthesa
Neyronyscular irritability, hypokalemia, hypocalcemi
Stomatitis, microcytic anemia, malaise
NUTRITION MANAGEMENTNUTRITION MANAGEMENT
35-45 35-45 CCalorialorieses -- -- endogen endogen protein protein CCatabolismatabolism
Fat --MCTFat --MCT-------- <100 gr lemak/day<100 gr lemak/day CHOCHO------small portionsmall portion, , prevent prevent
hhyypoglikemiapoglikemia
CIRROHIS HEPATIS
Final stage of liver injury & degeneration & occurs 15% of heavy drinkers
Normal liver tissue destroyed replaced by inactive fibrous connective tissue (scar tissue)
Nutrition ManagementNutrition Management
Decreased lDecreased liver function 30%iver function 30%
Maintain ratio of Maintain ratio of BCAA : AAA 3 : 1BCAA : AAA 3 : 1 --- --- prevent prevent hepatic encephalopathy (HE) hepatic encephalopathy (HE) --------false neurotransmittersfalse neurotransmitters
Increased Increased aminobatyric acid aminobatyric acid inhibitory neurotransmitter inhibitory neurotransmitter HE HE
Pathogenesis TheoriesPathogenesis Theories of of Hepatic EncephalopatyHepatic Encephalopaty
Endogenous NeurotoxinsEndogenous Neurotoxins AmmoniaAmmonia MercaptansMercaptans PhenolsPhenols Short-medium fatty acidsShort-medium fatty acids
Increased Permeability of Blood-Brain BarrierIncreased Permeability of Blood-Brain Barrier Change in Neurotransmitters and ReceptorsChange in Neurotransmitters and Receptors
GABAGABA Altered BCAA/AAA ratioAltered BCAA/AAA ratio
OtherOther Zinc defficiencyZinc defficiency Manganese depositsManganese deposits
Treatment of Hepatic Treatment of Hepatic EncephalopathyEncephalopathy
Various measures in current treatment of HEVarious measures in current treatment of HE Strategies to lower ammonia Strategies to lower ammonia
production/absorptionproduction/absorption Nutritional managementNutritional management
Protein restrictionProtein restriction BCAA supplementationBCAA supplementation
Medical managementMedical management Medications to counteract ammonia’s effect on Medications to counteract ammonia’s effect on
brain cell functionbrain cell function LactuloseLactulose AntibioticsAntibiotics
Devices to compensate for liver dysfunctionDevices to compensate for liver dysfunction Liver transplantationLiver transplantation
GALL BLADDER DISEASEGALL BLADDER DISEASE
Function : gall bladder saltFunction : gall bladder salt fatfat metab & metab & ddiigestgest
Enz : cholecystkinine Enz : cholecystkinine
Term of Disease Term of Disease :: 1.1. Biliary dyskinesia (spasme sp. Oddi)Biliary dyskinesia (spasme sp. Oddi)
2.2. Cholelithiasis (batu empedu)Cholelithiasis (batu empedu)
3.3. CholecystiCholecystittis (imflamasi GB)is (imflamasi GB)
4.4. CholedocholithiasiCholedocholithiasiss (batu pada sp. Oddi) (batu pada sp. Oddi)
5.5. cholecystectomcholecystectomii. .
Nutrition care in Gallbladder diseaseNutrition care in Gallbladder disease
AAdequate Fooddequate Food
LowLow fat fat decreaseddecreased contractioncontraction
Moderate intake of Moderate intake of EEnergienergie, prot, proteinein,,
carbohidrate carbohidrate
High intake of FluidHigh intake of Fluid
Small portionSmall portion
not irritatednot irritated
Acute Acute – related to obstruction:
◊ stop oral◊ low fat diet (<50gr)
Chronic--Chronic-- cholecystiasis ◊ Low fat ◊ Decreased Body Weight
◊ Limitation high food content gas
◊ Supl. Vitamin ADEK
PancreatitisPancreatitis
Inflammation characterized by; Inflammation characterized by; edema,cellular exudate,and fat necrosisedema,cellular exudate,and fat necrosis
It can be mild and self limiting or severe It can be mild and self limiting or severe with necrosis of pancraetic tissuewith necrosis of pancraetic tissue
Can be acute or chronic---pancreatic Can be acute or chronic---pancreatic destruction–decreased endocrine and destruction–decreased endocrine and exocrine pancreatic function, steatorrhea exocrine pancreatic function, steatorrhea or diabetes resultsor diabetes results
Nutrition care in PancreatitisNutrition care in Pancreatitis diseasedisease
Acute and severe attacks– oral feeding is Acute and severe attacks– oral feeding is withheld and hydration is maintained withheld and hydration is maintained intravenousintravenous
After 24-48 hours – clear liquid diet as toleranceAfter 24-48 hours – clear liquid diet as tolerance Formula diet consisting of amino acid, glucose, Formula diet consisting of amino acid, glucose,
and small amount of fat will not stimulate and small amount of fat will not stimulate pancreatic secretions.pancreatic secretions.
Prolonged severe Prolonged severe pancreatitis—TPNpancreatitis—TPN Fat emulsion can be used as long as –acute Fat emulsion can be used as long as –acute
pancreatittis is not the basis for pancreatittis is not the basis for hypertriglyceridemiahypertriglyceridemia
SummarySummary GI disease ------ poor healthGI disease ------ poor health Low gas Food content ---- gastritis Low gas Food content ---- gastritis
and ulcus pepticumand ulcus pepticum Fiber diet can prevent of colon Fiber diet can prevent of colon
diseasedisease Low fat diet ---- liver and gall bladderLow fat diet ---- liver and gall bladder Supplementation of vitamin– ADEK Supplementation of vitamin– ADEK
for liver diseasefor liver disease