Diseases of the GI
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Questions and Answers

What is the recommended protein intake for patients in a flare state of inflammatory bowel disease?

  • 0.8-1.0g/kg
  • 1.5-2.0g/kg
  • 2-2.5g/kg
  • 1-1.5g/kg (correct)

    • Which class of medications is primarily used for their anti-inflammatory effects in inflammatory bowel disease?

  • Aminosalicylic acid (correct)
  • Anti-diarrheal medications
  • Immunosuppressives
  • Biologics

    • What dietary approach is recommended during a flare state of inflammatory bowel disease?

  • High protein, high calorie, low fiber diet (correct)
  • Low protein, low calorie diet
  • High protein, low calorie diet
  • High fiber, low protein diet

    • Which surgical intervention is most common for patients with Ulcerative Colitis?

    <p>Total colectomy</p> Signup and view all the answers

    In patients with Crohn’s Disease, what percentage may require surgical intervention?

    <p>50-70%</p> Signup and view all the answers

    What is a common complication of both gastric and duodenal ulcers?

    <p>Perforation</p> Signup and view all the answers

    Which of the following factors is NOT a cause of peptic ulcers?

    <p>Overuse of antacids</p> Signup and view all the answers

    Which treatment is typically recommended for managing gastritis?

    <p>Antibiotics</p> Signup and view all the answers

    What symptom is commonly associated with gastroparesis?

    <p>Early satiety</p> Signup and view all the answers

    Which of the following dietary changes is recommended for managing gastroparesis?

    <p>Limit high-fat foods</p> Signup and view all the answers

    Which vitamin deficiency is likely associated with Crohn’s disease due to loss of intrinsic factor?

    <p>Vitamin B12</p> Signup and view all the answers

    What is a key characteristic of Crohn's disease compared to ulcerative colitis?

    <p>Can affect any part of the GI tract</p> Signup and view all the answers

    What is the primary goal of nutritional management in inflammatory bowel disease?

    <p>To address nutrient deficiencies and manage symptoms</p> Signup and view all the answers

    What is a typical symptom of a gastric ulcer?

    <p>Upper abdominal pain</p> Signup and view all the answers

    In nutritional management of duodenal ulcers, what substance is advised to limit?

    <p>Alcohol</p> Signup and view all the answers

    What is the effect of NSAIDs on gastric mucosa?

    <p>Damage to the gastric lining</p> Signup and view all the answers

    Which macronutrient should be monitored closely in patients with Crohn’s disease?

    <p>Protein</p> Signup and view all the answers

    What is the typical recommended meal frequency for patients with gastroparesis?

    <p>Four to six small meals per day</p> Signup and view all the answers

    What is the primary cause of Gastroesophageal Reflux Disease (GERD)?

    <p>Incompetence of the lower esophageal sphincter (LES)</p> Signup and view all the answers

    Which of the following is a possible complication of untreated GERD?

    <p>Esophageal strictures</p> Signup and view all the answers

    Which factor is NOT associated with lower lower esophageal sphincter pressure?

    <p>High protein intake</p> Signup and view all the answers

    What type of medication is a proton pump inhibitor?

    <p>Protonix</p> Signup and view all the answers

    What lifestyle change is recommended for individuals with GERD?

    <p>Raise the head of the bed</p> Signup and view all the answers

    What surgical procedure is performed for severe GERD?

    <p>Nissen Fundoplication</p> Signup and view all the answers

    Which of the following foods should be avoided by individuals with GERD?

    <p>Peppermint</p> Signup and view all the answers

    What is the primary symptom of acute gastritis?

    <p>Nausea and vomiting</p> Signup and view all the answers

    Which medication class is known to cause gastric irritation and potentially contribute to gastritis?

    <p>Non-steroidal anti-inflammatory drugs (NSAIDs)</p> Signup and view all the answers

    What is a common symptom indicating a complication of GERD?

    <p>Dysphagia</p> Signup and view all the answers

    Which of the following reflects a possible nutritional concern for patients with GERD?

    <p>Iron deficiency</p> Signup and view all the answers

    What influence does obesity have on GERD?

    <p>It increases abdominal pressure.</p> Signup and view all the answers

    What factor is primarily responsible for changing the epithelial cells in Barrett's esophagus?

    <p>Acid regurgitation</p> Signup and view all the answers

    What type of foods should individuals with gastritis typically limit?

    <p>Spicy foods and alcohol</p> Signup and view all the answers

    Study Notes

    Gastroesophageal Reflux Disease (GERD)

    • Affects more than 20 million Americans daily and over 100 million occasionally.
    • Symptoms arise from reflux of gastric contents into the esophagus or beyond.
    • Common symptoms include heartburn, increased salivation, belching, and pain.
    • Pain can be severe and is often worse when lying down.
    • Multifactorial etiology involving both physical and lifestyle factors.

    Lower Esophageal Sphincter (LES)

    • Acts as a barrier between the esophagus and stomach.
    • Normally maintains higher pressure in the esophagus than in the stomach to prevent reflux.
    • Transient LES relaxations are normal but become problematic when LES incompetence develops.

    Factors Contributing to LES Incompetence

    • Increased secretion of hormones like gastrin, estrogen, and progesterone.
    • Obesity.
    • Presence of medical conditions like hiatal hernia.
    • Cigarette smoking.
    • Medications like morphine and theophylline.
    • Specific foods including:
      • High-fat foods.
      • Chocolate.
      • Spearmint.
      • Peppermint.
      • Alcohol.
      • Caffeine.

    Hiatal Hernia

    • Out-pouching of the stomach into the chest through the esophageal hiatus of the diaphragm.
    • The esophageal hiatus is an opening in the diaphragm through which the esophagus passes.

    Complications of Untreated GERD

    • Dysphagia (difficulty swallowing) and odynophagia (painful swallowing).
    • Aspiration of gastric contents into the lungs leading to pneumonia.
    • Esophagitis (inflammation of the esophagus).
    • Esophageal erosion, ulceration, and perforation.
    • Esophageal strictures and scarring.
    • Dental corrosion and tooth surface loss.
    • Barrett's esophagus (5-15%) - a change in esophageal mucosa cells that increases the risk of esophageal adenocarcinoma.

    GERD Treatment: Medications

    • Antacids - buffer gastric acid (e.g., Pepto-Bismol, Maalox, Mylanta).
    • H2 antagonists - block histamine action on parietal cells, decreasing acid production (e.g., Pepcid, Zantac, Tagamet).
    • Proton pump inhibitors (PPI) - inhibit acid secretion (e.g., Protonix, Prilosec, Nexium).
    • Prokinetics - increase gastric emptying speed (e.g., Reglan, Erythromycin).
    • Mucosal protectants.

    GERD Treatment: Nissen Fundoplication

    • Surgical procedure for severe GERD where the LES is tightened by wrapping the top of the stomach around the esophagus.

    GERD: Potential Outcomes and Nutrition Considerations

    • Inadequate nutritional intake due to appetite changes, abdominal pain, and food intolerances.
    • Electrolyte imbalances secondary to vomiting.
    • Iron deficiency from blood loss due to ulceration.
    • Reduced iron, vitamin B-12, and calcium absorption associated with long-term use of acid-reducing medications.
    • Difficulty swallowing.

    GERD: Medical Nutrition Therapy (MNT)

    • Avoidance of specific foods:
      • Peppermint or spearmint.
      • Chocolate.
      • Alcohol.
      • Caffeinated beverages.
      • High-fat foods (e.g., whole milk, cream, high-fat cheeses, fried foods, pastries).
      • Acidic foods (e.g., tomatoes).
      • Garlic, onions, black pepper, spicy foods.
      • Other foods that may cause individual intolerance.

    GERD: Lifestyle Suggestions

    • Weight loss for overweight or obese individuals.
    • Avoid tight clothing.
    • No smoking.
    • Raise the head of the bed by 6-9 inches.
    • Eat the last meal at least 3 hours before bedtime.
    • Sit upright after eating and avoid lying down directly after meals.
    • Limit the volume of food consumed at one time.
    • Monitor for potential nutrient deficiencies due to long-term medication use.

    Gastritis

    • Inflammation of the stomach.
    • Symptoms include nausea, vomiting, malaise, anorexia, hemorrhage, and pain.
    • Can be acute or chronic:
      • Acute gastritis - rapid onset of inflammation.
      • Chronic gastritis - occurs over long periods, recurring symptoms.
    • Causes include:
      • Viral, fungal, or bacterial infection.
      • Food poisoning.
      • Excessive/chronic alcohol ingestion.
      • Tobacco use.
      • Medications (NSAIDs - Aspirin, Naproxen, Ibuprofen).
      • Helicobacter pylori infection.
      • Most common causes are NSAIDs and H. pylori.

    Gastritis

    • Disruption of mucosal integrity can be caused by infections, chemicals or neural abnormalities.
    • Gastritis can lead to atrophy, loss of parietal cells, loss of intrinsic factor and pernicious anemia, from decreased B12 absorption.
    • Treatment includes antibiotics and acid-suppressing medications.

    Gastritis: MNT

    • Monitor tolerances and avoid poorly tolerated foods.
    • Avoid highly seasoned or spicy foods.
    • Small frequent meals may be helpful.
    • Soft texture foods may be helpful.
    • Chew foods thoroughly.
    • Restricting fat intake may be helpful.
    • Monitor for nutrient deficiencies:
      • B12, iron (non-heme), calcium (gastric acid needed for bioavailability)
      • Anemia (iron, B12, bleeding, acid-suppressing meds)

    Duodenal and Gastric Ulcers

    • The gastric and duodenal mucosa is protected from the digestive action of acid and pepsin by:
      • secretion of mucus
      • production of bicarbonate
      • removal of excess acid by normal blood flow
      • rapid renewal and repair of epithelial cell injury.
    • Ulcers result from the breakdown of the normal defense and repair mechanisms.
    • Ulcers typically exhibit chronic inflammation and repair processes.
    • Four major complications:
      • Bleeding
      • Perforation
      • Penetration
      • Obstruction

    Duodenal Ulcers

    • Typically within the first few centimeters of the duodenal bulb.
    • Characterized by increased acid secretion throughout the day, decreased bicarbonate.

    Gastric/Peptic Ulcers

    • Usually occur along the lesser curvature.
    • Breakdown of the gastric mucosa; primary causes are Heliobacter pylori (>75% peptic ulcers), aspirin and other NSAIDs, corticosteroids, gastritis.

    Stress Ulcers

    • Can occur anywhere: fundus, antrum, duodenum, distal esophagus.
    • Complication of metabolic stress (inflammation) caused by surgery, trauma (including burns), shock, renal failure, radiation therapy.
    • Acute bleeding is a concern.

    Duodenal and Gastric Ulcers: Medical Management

    • Antibiotics (H pylori infection).
    • Reduce or withdraw use of NSAIDs.
    • Antacids.
    • Histamine-2 antagonists, proton pump inhibitors.
    • Avoid tobacco.

    Duodenal and Gastric Ulcers: Nutritional Management

    • Limit or avoid:
      • Alcohol.
      • Coffee, caffeine.
      • Spices (red and black pepper in particular, when inflamed).
      • Garlic.
    • “Liberal bland” diet.
    • Monitor for anemia.
    • Treat complications accordingly.

    Gastroparesis

    • Delayed gastric emptying in the absence of mechanical obstruction.
    • Also known as gastric stasis, diabetic gastropathy.
    • Common symptoms include:
      • Early satiety.
      • Fullness.
      • Decreased appetite, anorexia.
      • Nausea and vomiting.
      • Abdominal bloating.
      • Halitosis, bad breath.
      • Upper abdominal pain.
    • Diabetes, viral infection, or post-surgical complications are the most common causes, but >30% are idiopathic (without known cause).
    • Intervention: Medical (motility agents)
      • metoclopramide (Reglan)
      • erythromycin

    Gastroparesis: MNT

    • Avoid large portions.
    • Small frequent meals (4-6 per day).
    • Avoid foods high in fat, may delay gastric emptying.
    • Limit fiber intake, may delay gastric emptying.
    • Chew foods thoroughly.
    • Shifting food to pureed, or liquefied food can help:
      • Liquids empty in part by gravity, don't require antral contraction.
      • Liquids with fat better tolerated than solids with fat.
      • Don't restrict in patients struggling to meet needs.
    • For enteral nutrition, would need to feed into small bowel (J-tube).

    Inflammatory Bowel Disease

    • Chronic inflammatory condition of the gastrointestinal tract.
    • Ultimately damages the intestinal mucosa.
    • Etiology unknown: thought to be an interaction of both environmental and clinical factors, causing a response in genetically predisposed individuals.
      • Smoking, infectious agents, intestinal flora, western diet, physiological changes in the small intestine triggering an abnormal inflammatory response.
    • Two major forms: Crohn's and Ulcerative Colitis.
    • Differ based on symptoms, gastrointestinal involvement, type of inflammation, biopsy, and antibody testing.
      • Crohn's can affect any portion of the GI tract, mouth to anus:
        • 50-60% of cases involve the distal ileum and colon.
        • ~75% involve the small intestine; involvement of the small intestine places individuals at higher nutritional risk than disease involving only the colon.
    • Ulcerative Colitis involves the colon/rectum.
      • 40-50% have disease involving the rectum only.
      • Can be cured by removing the colon.
      • Always begins in the rectum and proceeds proximally.

    Inflammatory Bowel Disease: Clinical Phenotypes

    • Crohn's Disease: mouth to anus.
      • 5% gastroduodenal.
      • 5% small intestine alone.
      • 35% distal ileum.
      • 20% colon alone.
      • 35% right colon.
    • Ulcerative Colitis: involves the colon/rectum.
      • 40-50% have disease involving the rectum only.
      • Can cure by removing the colon.
      • Always begins in the rectum and proceeds proximally.

    Inflammatory Bowel Disease: Crohn's Disease vs. Ulcerative Colitis

    • Crohn's Disease:
      • Can affect any portion of the GI tract (50-60% involve distal ileum & colon).
      • Rectum may not be involved.
      • Not continuous; often with skipped areas of GI tract; healthy segments.
      • Symptoms: abdominal pain, diarrhea, fever, extra-intestinal manifestations (oral apthous ulcers).
      • Transmural inflammation; affects all layers of bowel wall.
      • Submucosal thickening, narrowed segments of bowel; obstruction.
      • Strictures and fistulas more common.
      • Malabsorption; disease involving the small intestine has higher nutritional risk.
    • Ulcerative Colitis:
      • Disease activity limited to the large intestine & rectum.
      • Rectum always involved.
      • Always continuous, proximally from rectum; no “skip lesions”.
      • Symptoms: bloody diarrhea, abdominal pain/cramping, fever.
      • Diffuse ulceration; deep ulcers.
      • Limited to mucosa, epithelial lining.
      • Strictures and fistulas are rare.

    Inflammatory Bowel Disease: Nutritional Considerations

    • Inadequate nutrient intake:
      • Decreased appetite.
      • Increased nutrient needs.
      • Desire to limit post prandial diarrhea.
      • Numerous food intolerances.
      • Abdominal pain.
      • Dietary restrictions (actual & self-taught).
    • Peristalsis from food intake causes cramping pain.
    • Severe diarrhea leading to malabsorption.
    • Drug-nutrient interactions; medication side effects.
    • Self-taught information obtained from the internet à many restrictions.

    Common Nutrient Deficiencies Seen With Crohn's Disease

    • Problem/Deficiency | Probable Cause
    • --- | ---
    • Energy/Protein | Insufficient intake, anorexia, fear of abdominal pain/diarrhea, ↑ protein needs, catabolism, healing from surgery.
    • Fluid and electrolytes | Short bowel syndrome; high volume diarrhea.
    • Iron | Blood loss; inadequate intake; malabsorption.
    • Magnesium, Zinc | Intestinal losses; especially from SBS, high volume diarrhea.
    • Calcium, Vitamin D | Long-term steroid use, ↓ intake of dairy foods due to lactose intolerance or lactose restricted diets.
    • Vitamin B12 | Surgical resections: loss of intrinsic factor (stomach) or absorption (ileal resection).
    • Folate | Medications used to treat IBD.
    • Water soluble vitamins | Surgical resections; loss of terminal ileum.
    • Fat soluble vitamins | Steatorrhea; fat malabsorption.

    Inflammatory Bowel Disease: Medications

    • Anti-diarrheal medications, (immodium, lomotil, bismuth subsalicylate).
    • Immunosuppressives, (6-mercaptopurine, Imuran, cyclosporine).
    • Biologics, anti-TNF, cytokine directed inflammatory activity; (Remicade).
    • Steroids, anti-inflammatory (prednisone, prednisolone).
    • Aminosalicylic acid, (5-ASA), anti-inflammatory (Sulfasalazine, Azulfadine).
    • Antibiotics, (cipro, flagyl).

    Inflammatory Bowel Disease: Surgical Interventions

    • Required in ~50-70% of patients with Crohn's Disease.
    • Total colectomy is the most common procedure for Ulcerative Colitis.

    IBD: MNT

    • High protein, high calorie, low fiber diet indicated during flare state.
    • Avoid raw fruits & vegetables, nuts/seeds, whole grains.
    • Protein: 1-1.5g/kg, 1.3-1.5g/kg during flare.
    • Energy: 25-30kcal/kg (increase if with severe diarrhea, 30-35kcal/kg).
      • 30-35kcal/kg (BMI 15-19), 35-45kcal/kg (BMI 20-24.9).
      • 45-55kcal/kg (BMI 25-29.9), 55-65kcal/kg (BMI 30-34.9).
      • 65-100kcal/kg (BMI 35 >).

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    Description

    This quiz provides an overview of Gastroesophageal Reflux Disease (GERD), including its symptoms, causes, and the role of the lower esophageal sphincter (LES). Test your understanding of the multifactorial etiology and contributing factors to LES incompetence. Gain insight into how lifestyle choices and medical conditions can impact GERD.

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