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