Gastrointestinal Upper and Lower (Part 1) Lecture Notes Fall 2024 PDF

10/30/24 Gastrointestinal Upper and Lower (Part 1) LEC TU RE 9 C LINIC AL NU TRITIO N ASSESSMENT AND INTERV ENTIO N FAL L 2024 1 1 2 2...

10/30/24 Gastrointestinal Upper and Lower (Part 1) LEC TU RE 9 C LINIC AL NU TRITIO N ASSESSMENT AND INTERV ENTIO N FAL L 2024 1 1 2 2 1  10/30/24 3 3 4 4 2  10/30/24 5 5 GERD v Gastroesophageal Reflux Disease o Each year >20,000,000 Americans have daily symptoms o >100 million with occasional symptoms v Symptoms or complications result from the reflux of gastric contents into the esophagus or beyond (oral cavity, larynx, lung) o heartburn, increased salivation, belching, pain o in some instances pain may be severe; often worse when laying down v Etiology of the reflux is multifactorial; both physical and lifestyle factors o Increased abdominal pressure, reduced LES pressure, transient LES relaxation v Lower esophageal sphincter (LES) normally serves as barrier between esophagus and stomach o Under normal conditions, atmospheric pressure is greater in the esophagus than in stomach, prevents reflux of gastric contents § Transient relaxation of LES is normal § Becomes problem when ongoing LES incompetence develops 6 6 3  10/30/24 7 7 GERD v Factors that can lower lower esophageal sphincter pressure and contribute to LES incompetence include: o Increased secretion of hormones gastrin, estrogen, progesterone o Obesity o Presence of other medical conditions, such as hiatal hernia o Cigarette smoking o Medications § Morphine § Theophylline o Specific foods § High fat § Chocolate § Spearmint § Peppermint § Alcohol § Caffeine 8 8 4  10/30/24 Hiatal Hernia v Out-pouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm o Esophageal hiatus is an opening in the diaphragm through which esophagus passes from the thoracic to abdominal cavity 9 9 GERD v Possible complications of untreated or unresponsive GERD o Dysphagia and odynophagia o Aspiration of gastric contents into lungs § Pneumonia o Esophagitis o Esophageal erosion, ulceration, perforation o Esophageal strictures, scarring o Dental corrosion, tooth surface loss associated with acid regurgitation o Barrett's esophagus (5-15%) § Change in epithelial cells of esophageal mucosa Considered to be precursor to malignancy Higher risk for esophageal adenocarcinoma 10 10 5  10/30/24 GERD v Treatment: Medications o Antacids (Pepto-Bismol, Maalox, Mylanta) § Buffers gastric acid o H2 antagonists (Pepcid, Zantac, Tagamet) § Blocks action of histamine on parietal cells, decreases acid production o Proton pump inhibitors (PPI; Protonix, Prilosec, Nexium) § Inhibits acid secretion o Prokinetics (Reglan, Erythromycin) § Increase speed of gastric emptying o Mucosal protectants vTreatment: Nissen Fundoplication § Surgical procedure for severe GERD; LES is tightened by wrapping the top of the stomach around the outside of the esophagus 11 11 GERD v Potential Outcomes/Nutrition Considerations o Inadequate nutritional intake § changes in appetite § abdominal pain § specific food intolerances o Electrolyte imbalances secondary to vomiting o Iron deficiency secondary to blood loss (ulceration) o Possible decrease in iron, vitamin B-12, and calcium absorption associated with long-term use of medications that reduce acid production o Problems swallowing 12 12 6  10/30/24 GERD: MNT v Avoidance of certain foods, if with intolerance o Peppermint or spearmint o Chocolate o Alcohol o Caffeinated beverages o High-fat foods § 2% or whole milk/yogurt, cream, high-fat cheeses § fried meat, bacon, sausage, pepperoni, salami, hot dogs § fried food in general (fries, tempura, etc) § pastries, doughnuts, high-fat desserts § oil, butter, shortening o Acidic foods § tomatoes, tomato sauce o Garlic, onions, black pepper, spicy foods o Additional specific foods (vary from person to person) 13 13 GERD: MNT v Lifestyle suggestions o Weight loss recommended for overweight or obese patients § strong association between obesity and GERD § weight loss associated with overall improvement of GERD symptoms o Avoid tight clothes, wear loose-fitting clothes o No smoking o Raise head of bed 6-9 inches (foam wedge under top part of mattress) o Last meal at least 3 hours before bedtime o Sit upright after eating; do not lay down after eating o Limit volume of food consumed § small frequent meals throughout the day § large quantity à more acid production, delay gastric emptying v Monitor for potential nutrient deficiencies (long-term medication use) 14 14 7  10/30/24 Gastritis v Inflammation of the stomach o Symptoms: nausea, vomiting, malaise, anorexia, hemorrhage, pain o Could be acute or chronic § Acute gastritis: rapid onset of inflammation § Chronic gastritis: occurs over period of months to decades, reoccurring symptoms o Causes § Viral, fungal or bacterial infection § Food poisoning § Excessive/chronic alcohol ingestion § Tobacco § Medications (non-steroidal anti-inflammatory drugs) Ø Aspirin, Naproxen, Ibuprofen § Helicobacter pylori infection § Most commonly from NSAIDs and H. pylori 15 15 Gastritis v Infectious, chemical or neural abnormalities disrupt mucosal integrity v May result in o Atrophy and loss of parietal cells § affects hydrochloric acid secretion (hypochlorhydria, achlorhydria) o Loss of intrinsic factor o Pernicious anemia § from decreased B12 absorption v Treatment o Antibiotics o Acid-suppressing medications 16 16 8  10/30/24 Gastritis: MNT v Nutrition considerations o Monitor tolerances and avoid foods poorly tolerated o Avoid highly seasoned or spicy foods o Small frequent meals may help o Soft textural consistency may help o Chew foods thoroughly o Restricting fat intake may help o Monitor for nutrient deficiencies and address accordingly § B12 § Iron (non-heme), calcium gastric acid needed for bioavailability § Anemia iron, B12, bleeding, acid suppressing meds 17 17 Duodenal and Gastric Ulcers v Gastric and duodenal mucosa is protected from digestive actions of acid and pepsin § secretion of mucus, § production of bicarbonate, § removal of excess acid by normal blood flow § rapid renewal and repair of epithelial cell injury o Ulcers result from breakdown of normal defense and repair mechanisms o Typically evidence of chronic inflammation and repair process surrounding lesion o Four major complications: § bleeding § perforation § penetration § obstruction 18 18 9  10/30/24 Duodenal and Gastric Ulcers v Duodenal ulcer: typically within first few centimeters of duodenal bulb o Characterized by increased acid secretion throughout day, decreased bicarbonate v Gastric/peptic ulcer: usually occur along the lesser curvature o Breakdown of the gastric mucosa; primary causes are Heliobacter pylori (>75% peptic ulcers), aspirin and other NSAIDs, corticosteroids, gastritis v Stress ulcer: can occur anywhere o fundus (usually), antrum, duodenum, distal esophagus o Complication of metabolic stress (inflammation) caused by surgery, trauma (including burns), shock, renal failure, radiation therapy o Acute bleeding is a concern 19 19 Duodenal and Gastric Ulcers 20 20 10  10/30/24 Duodenal and Gastric Ulcers v Medical management o Antibiotics (H pypori infection) o Reduce or withdraw use of NSAIDs o Antacids o Histamine-2 antagonists, proton pump inhibitors o Avoid tobacco v Nutritional management o Limit or avoid § Alcohol § Coffee, caffeine § Spices (red and black pepper in particular, when inflamed) § Garlic o “liberal bland” diet o Monitor for anemia o Treat complications accordingly 21 21 Gastroparesis v Delayed gastric emptying in absence of mechanical obstruction v Also known as gastric stasis, diabetic gastropathy v Common symptoms o Early satiety o Fullness o Decreased appetite, anorexia o Nausea and vomiting o Abdominal bloating o Halitosis, bad breath o Upper abdominal pain v Diabetes, viral infection, or post-surgical complication are most common causes, but >30% are idiopathic (without known cause) v Intervention: Medical (motility agents) o metoclopramide (Reglan) o erythromycin 22 22 11  10/30/24 23 23 Gastroparesis: MNT o Avoid large portions o Small frequent meals (4-6 per day) o Avoid foods high in fat, may delay gastric emptying o Limit fiber intake, may delay gastric emptying o Chew foods thoroughly o 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 o For enteral nutrition, would need to feed into small bowel (J-tube) 24 24 12  10/30/24 Inflammatory Bowel Disease v Chronic inflammatory condition of the gastrointestinal tract o Ultimately damages intestinal mucosa v Etiology unknown: thought interaction of both environment and clinical factors, causing response in genetically predisposed individuals o Smoking, infectious agents, intestinal flora, western diet, physiological changes in the small intestine triggering abnormal inflammatory response v Two major forms: Crohn’s and Ulcerative Colitis o 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 small intestine; involvement of the small intestine places individuals at higher nutritional risk than disease involving only the colon 25 25 Inflammatory Bowel Disease v Two Clinical Phenotypes o Crohn’s Disease: mouth to anus o 5% gastroduodenal o 5% small intestine alone o 35% distal ileum o 20% colon alone o 35% right colon o Ulcerative Colitis: involves the colon/rectum o 40-50% have disease involving rectum only o can cure by removing the colon o always begins in the rectum and proceeds proximally 26 26 13  10/30/24 27 27 28 28 14  10/30/24 Inflammatory Bowel Disease v Crohn’s disease v Ulcerative colitis o Can affect any portion of the GI tract o Disease activity limited to large § 50-60% involve distal ileum & colon intestine & rectum § Rectum may not be involved § Rectum always involved o Not continuous; often with skipped areas o Always continuous, proximally from of GI tract; healthy segments rectum; no “skip lesions” o Symptoms: abdominal pain, diarrhea, o Symptoms: bloody diarrhea, fever, extra-intestinal manifestations abdominal pain/cramping, fever § Oral apthous ulcers o Diffuse ulceration; deep ulcers o Transmural inflammation; affects all layers o Limited to mucosa, epithelial lining of bowel wall o Strictures and fistulas are rare o Submucosal thickening, narrowed segments of bowel; obstruction o Strictures and fistulas more common o Malabsorption; disease involving small intestine has higher nutritional risk 29 29 30 30 15  10/30/24 Inflammatory Bowel Disease v Nutritional Considerations o Inadequate nutrient intake § Decreased appetite § Increased nutrients needs § Desire to limit post prandial diarrhea § Numerous food intolerances § Abdominal pain § Dietary restrictions actual & also self taught, information obtained from internet o Peristalsis from food intake causes cramping pain o Severe diarrhea leading to malabsorption o Drug-nutrient interactions; medication side effects o Self-taught information obtained from internet à many restrictions 31 31 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 Naik AS, Venu N. Nutritional care in adult inflammatory bowel disease. Pract Gastroenterol. 2012; 36(6): 18-26 32 32 16  10/30/24 Inflammatory Bowel Disease v 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) v Surgical intervention (next lecture) § Required in ~50-70% of patients with Crohn’s Disease § Total colectomy is the most common procedure for Ulcerative Colitis 33 33 IBD: MNT v High protein, high calorie, low fiber diet indicated during flare state o Avoid raw fruits & vegetables, nuts/seeds, whole grains o Protein: 1-1.5g/kg; 1.3-1.5g/kg during flare o Energy: 25-30kcal/kg (increase if with severe diarrhea, 30-35kcal/kg) § 30-35kcal/kg (BMI 15-19), 35-45kcal/kg (BMI