NUTRITION SAS 17-23.pdf

NUTRITION (LECTURE) SAS #17 Main Lesson Candidates for Tube Feedings Tube feedings are typically recommended for patients at risk of developing...

NUTRITION (LECTURE) SAS #17 Main Lesson Candidates for Tube Feedings Tube feedings are typically recommended for patients at risk of developing protein-energy Patients are often too sick to consume a regular diet. Moreover, malnutrition who are unable to consume adequate food and/or some illnesses may interfere with eating, digestion, or absorption oral supplements to maintain their health. The following medical to such a degree that oral intakes alone cannot supply the conditions or treatments may indicate the need for tube necessary nutrients. In such cases, nutrition support—the feedings: delivery of nutrients using a feeding tube or intravenous infusions—can meet a patient’s nutritional needs. Enteral ⎯ Severe swallowing disorders nutrition, the provision of nutrients using the gastrointestinal (GI) ⎯ Impaired motility in the upper GI tract tract, usually refers to the use of tube feedings, which deliver nutrient dense formulas directly to the stomach or small ⎯ GI obstructions and fistulas that can be bypassed with a intestine via a thin, flexible tube. Parenteral nutrition provides feeding tube nutrients intravenously to patients who do not have sufficient GI function to handle enteral feedings. If the GI tract remains ⎯ Certain types of intestinal surgeries functional, enteral nutrition is preferred over parenteral nutrition ⎯ Little or no appetite for extended periods, especially if the because it is associated with fewer infectious complications and patient is malnourished is significantly less expensive ⎯ Extremely high nutrient requirements Oral Supplements Patients who are weak or debilitated may find ⎯ Mechanical ventilation it easier to consume oral supplements than to consume meals. Moreover, a patient who can improve nutrition status with ⎯ Mental incapacitation due to confusion, neurological supplements may be able to avoid the stress, complications, and disorders, or coma expense associated with tube feedings. Hospitals usually stock Contraindications for tube feedings include severe GI bleeding, a variety of nutrient-dense formulas, milkshakes, fruit drinks, and high-output fistulas, intractable vomiting or diarrhea, and severe snack bars to provide to patients at risk of becoming malabsorption. The procedure may also be contraindicated if the malnourished. Note that similar products are sold in pharmacies expected need for nutrition support is less than 5 to 7 days in a and grocery stores for home use; examples of popular liquid malnourished patient or less than 7 to 9 days in an adequately supplements include Ensure, Boost, and Carnation Breakfast nourished patient. Essentials. These types of products can add energy and protein to the diets of patients and be a reliable source of nutrients. Tube Feeding Routes When a patient uses an oral supplement, taste becomes an The feeding route chosen depends on the patient’s medical important consideration. Allowing patients to sample different condition, the expected duration of tube feeding, and the products and select the ones they prefer helps to promote potential complications of a particular route. acceptance. Gastrointestinal Access. When a patient is expected to be tube fed for less than four weeks, the feeding tube is generally routed Selecting a Feeding Route into the GI tract via the nose (nasogastric or naso-enteric routes). The patient is frequently awake during trans nasal (through-the- nose) placement of a feeding tube. While the patient is in a slightly upright position with head tilted, the tube is inserted into a nostril and passed into the stomach (nasogastric route), duodenum (nasoduodenal route), or jejunum (nasojejunal route). The final position of the feeding tube tip is verified by abdominal X-ray or other means. In infants, orogastric placement, in which the feeding tube is passed into the stomach via the mouth, is sometimes preferred over transnasal routes; this placement allows the infant to breathe more normally during feedings. When a patient will be tube fed for longer than four weeks, or if the nasoenteric route is inaccessible due to an obstruction or other medical reasons, a direct route to the stomach or intestine may be created by passing the tube through an enterostomy, an opening in the abdominal wall that leads to the stomach (gastrostomy) or jejunum (jejunostomy). An enterostomy can be made by either surgical incision or needle puncture.  Comparison of Tube Feeding Routes Selecting a Feeding Route. Gastric feedings (nasogastric and gastrostomy routes) are preferred whenever possible. These feedings are more easily tolerated and less complicated to deliver than intestinal feedings because the stomach controls the rate at which nutrients enter the intestine. Gastric feedings are not possible, however, if patients have gastric obstructions or motility disorders that interfere with the stomach’s ability to empty. Gastric feedings are also avoided in patients at high risk of aspiration, a common complication in which substances from Enteral Formulas the GI tract (either GI secretions or refluxed stomach contents) ⎯ Standard formulas, also called polymeric formulas, are are drawn into the lungs, potentially leading to pneumonia (note provided to individuals who can digest and absorb nutrients that studies have not consistently shown that gastric feedings without difficulty. They contain intact proteins extracted from are associated with a higher pneumonia risk ). summarizes the milk or soybeans (called protein isolates) or a combination of advantages and disadvantages of the various tube feeding such proteins. The carbohydrate sources include hydrolyzed routes. cornstarch, glucose polymers (such as maltodextrin and corn Feeding Tubes. Feeding tubes are made from soft, flexible syrup solids), and sugars. A few formulas, called blenderized materials (such as silicone or polyurethane) and come in a formulas, are produced from whole foods such as chicken, variety of lengths and diameters. The tube selected largely vegetables, fruits, and oil, along with some added vitamins and depends on the patient’s age and size, the feeding route, and the minerals. formula viscosity. ⎯ Elemental formulas, also called hydrolyzed, chemically The outer diameter of a feeding tube is measured in French units, defined, or monomeric formulas, are prescribed for patients who in which each unit equals 1/3 millimeter; thus, a “12 French” have compromised digestive or absorptive functions. Elemental feeding tube has a 4-millimeter diameter (12 3 1/3 mm 5 4 formulas contain proteins and carbohydrates that have been mm). The inner diameter depends on the thickness of the tubing partially or fully broken down to fragments that require little (if material. Double-lumen tubes are also available; these allow a any) digestion. The formulas are often low in fat and may provide single tube to be used for both intestinal feedings and gastric fat from medium-chain triglycerides (MCT) to ease digestion and decompression, a procedure in which the stomach contents of absorption. patients with motility problems or obstructions are removed by ⎯ Specialized formulas, also called disease-specific or specialty suction. formulas, are intended to meet the nutrient needs of patients with particular illnesses. Products have been developed for individuals with liver, kidney, and lung diseases; glucose intolerance; severe wounds; and metabolic stress (later chapters provide details). Specialized formulas are generally expensive, and their effectiveness is controversial. ⎯ Modular formulas, created from individual macronutrient preparations called modules, are sometimes prepared for patients who require specific nutrient combinations. Vitamin and mineral preparations are also included in the formulas so that they can meet all of a person’s nutrient needs. In some cases, one or more modules are added to other enteral formulas to adjust their nutrient composition. Macronutrient Composition. The amounts of protein, carbohydrate, and fat in enteral formulas vary substantially. The protein content of most standard formulas ranges from 12 to 20 percent of total kcalories;5 note that protein needs are high in patients with severe metabolic stress, whereas protein ⎯ Stores opened cans or mixed formulas in clean, closed restrictions are necessary for patients with chronic kidney containers. Refrigerate the unused portion of formula promptly. disease. Carbohydrate and fat provide most of the energy in Discard unlabeled or improperly labeled containers and all open enteral formulas; standard formulas generally provide 30 to 60 containers of formula that are not used within 24 to 48 hours. percent of kcalories from carbohydrate and 15 to 30 percent of kcalories from fat. ⎯ Hang no more than an 8-hour supply of formula (or a 4-hour supply for newborn infants) when using liquid formula from a Energy Density. The energy density of most enteral formulas can. Formulas prepared from powders or modules should hang ranges from 1.0 to 2.0 kcalories per milliliter of fluid. The no longer than 4 hours. Discard any formula that remains, rinse formulas that have higher energy densities can meet energy and the feeding bag and tubing, and add fresh formula to the feeding nutrient needs in a smaller volume of fluid and therefore benefit bag. A new feeding container and tubing (except for the feeding patients who have high nutrient needs or fluid restrictions. tube itself) is necessary every 24 hours. Fiber Content. Fiber-containing formulas may be helpful for For closed systems, the hang time should be no longer than 24 to improving fecal bulk and colonic function, treating diarrhea or 48 hours. Contamination is more likely with the longer time constipation, and maintaining blood glucose control. periods. Conversely, fiber-containing formulas are avoided in patients Formula Delivery Methods. Nutrient needs may be met by with acute intestinal conditions or pancreatitis and before or delivering relatively large amounts of formula several times per after some intestinal examinations and surgeries. Osmolality. day (intermittent feedings) or smaller amounts continuously Osmolality refers to the moles of osmotically active solutes (or (continuous feedings). A patient may also start with continuous osmoles) per kilogram of solvent. An enteral formula with an osmolality similar to that of blood serum (about 300 feedings and gradually transition to intermittent feedings. Each milliosmoles per kilogram) is an isotonic formula, whereas a method has specific uses, advantages, and disadvantages. hypertonic formula has an osmolality greater than that of blood Parenteral Nutrition serum. Most enteral formulas have osmolalities between 300 and 700 milliosmoles per kilogram; generally, elemental Candidates for Parenteral Nutrition Parenteral nutrition is formulas and nutrient-dense formulas have higher osmolalities typically recommended for patients who are unable to digest or than standard formulas. Most people are able to tolerate both absorb nutrients and who are either malnourished or likely to isotonic and hypertonic feedings without difficulty. When become so. The following conditions may require use of medications are infused along with enteral feedings, however, parenteral nutrition: the osmotic load increases substantially and may contribute to ⎯ Intractable vomiting or diarrhea the diarrhea experienced by many tube-fed patients. ⎯ Severe GI bleeding Formula Selection. Some of the factors considered when choosing a formula. Generally, the formula chosen should meet ⎯ Intestinal obstructions or fistulas the patient’s medical and nutrient needs with the lowest risk of complications and the lowest cost. The main factors that ⎯ Paralytic ileus (intestinal paralysis) influence formula selection include: ⎯ Short bowel syndrome (a substantial portion of the small ⎯ GI function. Although the vast majority of patients can use intestine has been removed) standard formulas, a person with a functional but impaired GI ⎯ Bone marrow transplants tract may require an elemental formula. ⎯ Severe malnutrition and intolerance to enteral nutrition ⎯ Nutrient and energy needs. As with patients consuming regular diets, the tube-fed patient may require adjustments in Venous Access. The access sites for parenteral nutrition fall into nutrient and energy intakes. If fluids are restricted, the formula two main categories: the peripheral veins located in the hand or should have adequate nutrient and energy densities to provide forearm, and the large-diameter central veins located near the the required nutrients in the volume prescribed. heart. ⎯ Fiber modifications. The choice of formulas is narrower if fiber Peripheral Parenteral Nutrition In peripheral parenteral intake needs to be low or high. ⎯ Individual tolerances (food nutrition (PPN), nutrients are delivered using only the peripheral allergies and sensitivities). Nearly all formulas are lactose free veins. Peripheral veins can be damaged by overly concentrated and gluten free and can accommodate the needs of patients with solutions, however—phlebitis may develop characterized by lactose intolerance or gluten sensitivity. For patients with food redness, swelling, and tenderness at the infusion site. To prevent allergies, ingredient lists should be checked before providing a phlebitis, the osmolarity of parenteral solutions used for PPN is formula. generally kept below 900 milliosmoles per liter,18 a concentration that limits the amounts of energy and protein the Formula Safety Guidelines. After the formula reaches the solution can provide. PPN is used most often in patients who nursing station, the nursing staff assumes responsibility for its require short-term nutrition support (less than 2 weeks) and who safe handling. Clinicians should carefully wash hands and put on do not have high nutrient needs or fluid restrictions. The use of disposable gloves before handling formulas and feeding PPN is not possible if the peripheral veins are too weak to tolerate containers. The following steps can reduce the risk of formula the procedure. In many cases, clinicians must rotate venous contamination when using open feeding systems: access sites to avoid damaging veins. ⎯ Before opening a can of formula, clean the lid with a disposable Total Parenteral Nutrition Most patients meet their nutrient alcohol wipe and wash the can opener (if needed) with detergent needs using the larger central veins, where blood volume is and hot water. If you do not use the entire can at one feeding, greater and nutrient concentrations do not need to be limited. label the can with the date and time it was opened. This method can reliably provide all of a person’s nutrient requirements and therefore is called total parenteral nutrition kcalories per milliliter, respectively. Therefore, a 500-milliliter (TPN). Because the central veins carry a large volume of blood, container of 10 percent lipid emulsion would provide 550 the parenteral solutions are rapidly diluted; thus, patients with kcalories; the same volume of a 20 percent lipid emulsion would high nutrient needs or fluid restrictions can receive the nutrient- provide 1000 kcalories). dense solutions they require. TPN is also preferred for patients Lipid emulsions are often provided daily and may supply 20 to who require long-term parenteral nutrition. To access central 30 percent of total kcalories. Including lipids as an energy source veins, the tip of a central venous catheter can either be placed reduces the need for energy from dextrose and thereby lowers directly into a large-diameter central vein or threaded into a the risk of hyperglycemia in glucose-intolerant patients. Lipid central vein through a peripheral vein (see Figure 16-10). infusions must be restricted in patients with Peripheral insertion of central catheters is less invasive and hypertriglyceridemia, however. There is also some concern that lower in cost than direct insertion into central veins. lipid emulsions that contain excessive amounts of linoleic acid Parenteral Solutions. The pharmacies located within health may suppress some aspects of the immune response. care institutions are often responsible for preparing parenteral Fluids and Electrolytes. Daily fluid needs range from 30 to 40 solutions; this arrangement is convenient because the milliliters per kilogram body weight in stable patients. The pharmacist can customize the solutions to meet patients’ amount of fluid provided is adjusted according to daily fluid nutrient needs and because the solutions have a limited shelf losses and the results of hydration assessment. The electrolytes life. The physician typically submits an order form to the added to parenteral solutions include sodium, potassium, pharmacy. Prescriptions for parenteral solutions are highly chloride, calcium, magnesium, and phosphate. The amounts individualized and may need to be recalculated daily until the infused differ from DRI values because they are not influenced by patient’s condition is stable. Because the nutrients are provided absorption, as they are when consumed orally. In the parenteral intravenously, they must be given in forms that are safe to inject nutrition order, most electrolyte concentrations are expressed in directly into the bloodstream. milli-equivalents (mEq), which are units that indicate the number of ionic charges provided by the electrolyte. Vitamins and Trace Minerals. All vitamins are usually included in parenteral solutions, although a preparation without vitamin K is available for patients using warfarin therapy. The trace minerals typically added to parenteral solutions include chromium, copper, manganese, selenium, and zinc. Iron is often excluded because it can destabilize parenteral solutions that contain lipid emulsions; therefore, special forms of iron may need to be injected separately. Medications. To avoid the need for a separate infusion site, medications are occasionally added directly to parenteral solutions or infused through a separate port in the catheter. Parenteral Formulations When a parenteral solution contains dextrose, amino acids, and lipids, it is called a total nutrient admixture (TNA), a 3-in-1 solution, or an all-in-one solution. A 2-in-1 solution excludes lipids, and the lipid emulsion is administered separately, often using a second port in the Accessing Central Veins for Total Parenteral Nutrition catheter. Although the administration of TNA solutions is simpler because only one infusion pump is required, the addition of lipid Amino Acids Parenteral solutions contain all of the essential emulsion to solutions may reduce their stability, a major concern amino acids and various combinations of the nonessential when TNA solutions are compounded. Thus, lipids are often amino acids. The amino acid concentrations in commercial administered separately when they are not a major energy source solutions range from 3 to 20 percent the more concentrated and are used only to provide essential fatty acids. solutions are used only for TPN. Just as in regular foods, the amino acids provide 4 kcalories per gram. Disease-specific Osmolarity Recall that the osmolarity of PPN solutions is limited products are available for patients with liver disease, kidney to 900 milliosmoles per liter because peripheral veins are disease, and metabolic stress, but they are rarely used in sensitive to high nutrient concentrations, whereas TPN solutions practice due to lack of evidence of their benefit. may be as nutrient dense as necessary. Amino acids, dextrose, and electrolytes contribute the most to a solution’s osmolarity. Carbohydrate Glucose is the main source of energy in parenteral Because lipids contribute little to osmolarity, lipid emulsions can solutions. It is provided in the form dextrose monohydrate, in be used to increase the energy provided in PPN solutions which each glucose molecule is associated with a single water molecule. Dextrose monohydrate provides 3.4 kcalories per Administering Parenteral. Nutrition Parenteral nutrition is a gram, slightly less than pure glucose, which provides 4 kcalories complex treatment that requires skills from a variety of per gram. Commercial dextrose solutions are available in disciplines. Many hospitals organize nutrition support teams, concentrations between 2.5 and 70 percent; concentrations consisting of physicians, nurses, dietitians, and pharmacists, greater than 10 percent are usually used only in TPN solutions. that specialize in the provision of both enteral and parenteral nutrition. The nurse, who performs direct patient care, plays a Lipids Lipid emulsions supply essential fatty acids and are a central role in administering and monitoring parenteral significant source of energy. Lipid emulsions are available in 10, infusions. 20, and 30 percent solutions, containing 1.1, 2.0, and 3.0 Care of Intravenous. Catheters Catheter-related problems frequently cause complications. Catheters may be improperly 2. In selecting an appropriate enteral formula for a patient, the positioned or may dislodge after placement. Air can leak into primary consideration is: catheters and escape into the bloodstream, obstructing blood flow. Catheters in peripheral veins may cause phlebitis, a. formula osmolality. necessitating insertion at an alternate site. A catheter may become clogged from blood clotting or from a buildup of scar b. the patient’s nutrient needs. tissue around the catheter tip. Catheters are also a leading cause c. availability of infusion pumps. of infection: contamination may be introduced during insertion or may develop at the placement site. To reduce the risk of d. formula cost. complications, nurses use aseptic techniques when inserting catheters, changing tubing, or changing a dressing that covers the catheter site. Unusual bleeding or a wet dressing suggests a 3. An important measure that may prevent bacterial problem with catheter placement. A change in infusion rate may contamination in tube feeding formulas is: a. nonstop feeding of indicate a clogged catheter. Infection may be indicated by formula. redness or swelling around the catheter site or by an unexplained fever. Routine inspections of equipment and frequent monitoring b. using the same feeding bag and tubing each day. of patients’ symptoms help to minimize the problems associated c. discarding opened containers of formula not used within 24 with catheter use. hours. Administration of Parenteral Solutions Infusion protocols vary d. adding formula to the feeding container before it empties among institutions. One approach is to start the infusion at a completely. slow rate (with a solution that is either full strength or nutrient dilute) and increase the rate gradually over a 2- to 3-day period. Parenteral solutions are usually infused continuously over 24 hours (continuous parenteral nutrition) in acutely ill patients. 4. The nurse using a feeding tube to deliver medications Patients who require long-term parenteral nutrition often receive recognizes that: infusions for 10- to 14-hour periods only (cyclic parenteral a. medications given by feeding tubes generally do not cause GI nutrition), allowing more freedom of movement during the day. complaints. Regular monitoring can help to prevent complications. The b. medications can usually be added directly to the feeding parenteral solution and tubing are checked frequently for signs container. of contamination. Routine testing of glucose, lipid, and electrolyte levels helps to determine tolerance to solutions. c. enteral formulas do not interact with medications in the same Frequent reassessment of nutrition status may be necessary way that foods do. until a patient has stabilized. d. thick or sticky liquid medications and crushed tablets can clog Discontinuing Parenteral Nutrition. The patient must have feeding tubes. adequate GI function before parenteral nutrition can be tapered off and enteral feedings begun. During the transition to oral feedings, a combination of methods is often necessary. 5. For a patient receiving central TPN who also receives Parenteral infusions are usually tapered off at the same time that intravenous lipid emulsions two or three times a week, the lipid tube feedings or oral feedings are begun, such that the two emulsions serve primarily as a source of: methods can together supply the needed nutrients. Once about two-thirds to three-fourths of nutrient needs can be provided by a. essential fatty acids. other means, the parenteral infusions may be discontinued. b. cholesterol. Transitioning to an oral diet is sometimes difficult because a person’s appetite remains suppressed for several weeks after c. fat-soluble vitamins. parenteral nutrition is terminated d. concentrated energy Complications involving catheters include improper placement or dislodgement, infection, clotting, embolism, and phlebitis. Metabolic complications include hyperglycemia, hypoglycemia, hypertriglyceridemia, refeeding syndrome, and diseases of the liver, gallbladder, and bone. CHECK FOR UNDERSTANDING 1. For a patient who is at high risk of aspiration and is not expected to be able to eat table foods for several months, an appropriate placement of a feeding tube might be: a. nasogastric. b. nasoenteric. c. gastrostomy. d. jejunostomy. SAS #18 MAIN LESSON Modifications in Food Texture and Consistency A. Conditions Affecting the Mouth and Esophagus ⎯ Mechanically altered diets, which contain foods that are Dry mouth (xerostomia), caused by reduced salivary flow, is a modified in texture or consistency, are frequently recommended side effect of many medications and is associated with a number for individuals with chewing or swallowing difficulties. The foods of diseases and disease treatments. Poorly controlled diabetes in these diets are typically liquid, pureed, ground, chopped, is often associated with dry mouth, as are conditions that directly minced, or soft in texture. A diet that contains foods that have affect salivary gland function, such as Sjögren’s syndrome. Dry been mechanically altered to modify texture or consistency; mouth can impair health in a variety of ways. It can interfere with foods may be liquid, pureed, ground. speaking and swallowing. Mouth infections, bad breath, and dental diseases are more common. Dentures may be ⎯ Clear liquid diet may be prescribed before or after certain uncomfortable to wear, and ulcerations may develop where they types of medical procedures. A diet that consists of foods that contact the mouth. Taste sensation is often diminished, and salty are liquid at room temperature, require minimal digestion, and or spicy foods may cause pain. Dry mouth may cause a person to leave little residue (undigested material) in the colon. reduce food intake and may thereby increase malnutrition risk. Food and Beverage Tips: ⎯ Take frequent sips of water or another sugarless beverage. ⎯ Suck on ice cubes or frozen fruit juice bars (unless their coldness causes discomfort). ⎯ Consume foods that have a high fluid content, such as soups, stews, sauces and gravies, yogurt, and pureed fruit. ⎯ Avoid dry foods like toast, chips, and crackers. ⎯ void citrus juices and spicy or salty foods if they cause mouth irritation. Dysphagia is generally caused by either a problem affecting the muscles involved with swallowing or a physical obstruction between the mouth and stomach. A blenderized diet is most often recommended following oral or facial surgeries (for example, jaw wiring). Foods that can be Oropharyngeal Dysphagia A person with oropharyngeal blenderized (often with added liquid) are available from all food dysphagia has difficulty transferring food from the mouth and groups: they include breads and cereals; boiled rice and pasta; pharynx to the esophagus. This is typically due to a cooked vegetables; fresh or cooked fruit without skins or seeds; neuromuscular disorder that inhibits the swallowing reflex or and cooked, tender meats and fish. Foods that do not blend well impairs the strength or coordination of the muscles involved with should be excluded; examples include hard or rubbery foods swallowing. Symptoms include an inability to initiate swallowing, such as nuts and seeds, coconut, dried fruit, hard cheese, coughing during or after swallowing (due to aspiration), and sausages and frankfurters, and some raw vegetables. nasal regurgitation. Clear liquids, which require minimal digestion and are easily Esophageal Dysphagia. A person with esophageal dysphagia tolerated by the GI tract, are often the foods recommended has difficulty passing materials through the esophageal lumen before some GI procedures (such as GI examinations, X-rays, or and into the stomach, usually due to an obstruction in the surgeries), after GI surgery, or after fasting or intravenous esophagus or a motility disorder. The main symptom is the feeding. The clear liquid diet consists of clear fluids and foods sensation of food “sticking” in the esophagus after it is that are liquid at room temperature and leave little undigested swallowed. An obstruction can be caused by a stricture material (called residue) in the colon. Permitted foods include (abnormal narrowing), tumor, or compression of the esophagus clear or pulp-free fruit juices, carbonated beverages, clear meat by surrounding tissues. Whereas an obstruction can prevent the and vegetable broths (such as consommé and bouillon), fruit- passage of solid foods but may not affect liquids, a motility flavored gelatin, fruit ices made from clear juices, frozen juice disorder hinders the passage of both solids and liquids bars, and plain hard candy. Although the clear liquid diet provides Complications of Dysphagia If dysphagia restricts food fluid and electrolytes, its nutrient and energy contents are consumption, malnutrition and weight loss may occur. extremely limited. If used for longer than a day or two, this diet Individuals who cannot swallow liquids are at increased risk of should be supplemented with commercially prepared low dehydration. If aspiration occurs, it may cause choking, airway residue formulas that provide required nutrients. obstruction, or respiratory infections, including pneumonia. A liquid diet that includes milk and other opaque liquids (such as Nutrition Intervention for Dysphagia fruit nectars, yogurt, and oral supplements) is called a full liquid diet. Although rarely necessary, it is sometimes used as a ⎯ Level 1: Dysphagia Pureed Foods should be pureed or well transitional diet between the clear liquid diet and diets that mashed, homogeneous, and cohesive. This diet is for patients contain solid foods with moderate to severe dysphagia and poor oral or chewing ⎯ Consume only small meals and drink liquids between meals so ability. that the stomach does not become overly distended, which can exert pressure on the lower esophageal sphincter. ⎯ Level 2: Dysphagia Mechanically Altered Foods should be moist, cohesive, and soft textured and should easily form a ⎯ Limit foods or substances that increase gastric acid secretion bolus. This diet is for patients with mild to moderate dysphagia; (such as alcohol and coffee) or weaken the pressure of the lower some chewing ability is required. esophageal sphincter (such as alcohol, chocolate, fried or fatty foods, peppermint, and spearmint). ⎯ Level 3: Dysphagia Advanced Foods should be moist and in bite-sized pieces when swallowed; foods with mixed textures are ⎯ During periods of esophagitis, avoid foods and beverages that included. This diet is for patients with mild dysphagia and may irritate the esophagus, such as citrus fruits and juices, adequate chewing ability. tomato products, garlic, onions, pepper, spicy foods, carbonated beverages, and very hot or very cold foods (depending on Liquid Consistencies (only those tolerated are allowed in the individual tolerances). diet) ⎯ Avoid eating bedtime snacks or lying down after meals. Meals ⎯ Thin: Watery fluids; may include milk, coffee, tea, juices, should be consumed at least three hours before bedtime. carbonated beverages. Reduce nighttime reflux by elevating the head of the bed on 6- ⎯ Nectarlike: Fluids thicker than water that can be sipped inch blocks, inserting a foam wedge under the mattress, or through a straw; may include buttermilk, eggnog, tomato juice, propping pillows under the head and upper torso. cream soups. ⎯ Avoid bending over and wearing tight-fitting garments; both can ⎯ Honeylike: Fluids that can be eaten with a spoon but do not cause pressure in the stomach to increase, heightening the risk hold their shape; may include honey, some yogurt products, of reflux. tomato sauce. ⎯ Avoid cigarette smoking, which relaxes the lower esophageal ⎯ Spoon-thick: Thick fluids that must be eaten with a spoon and sphincter. can hold their shape; may include milk pudding, thickened ⎯ Avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) applesauce such as aspirin, naproxen, and ibuprofen, which can damage the Gastroesophageal reflux disease (GERD) is characterized by esophageal mucosa. frequent reflux (backward flow) of the stomach’s acidic contents Food tolerances among people with GERD can vary markedly. into the esophagus, leading to pain, inflammation, and, possibly, Health practitioners can help patients pinpoint food intolerances tissue damage. People who suffer from GERD often refer to these by advising them to keep a record of the foods and beverages symptoms as heartburn or acid indigestion. The reflux itself does they consume, as well as any resulting symptoms. not necessarily cause symptoms or injury—it occurs occasionally in healthy people and is a problem only if it creates B. Conditions Affecting the Stomach complications and requires lifestyle changes or medical Dyspepsia: symptoms of pain or discomfort in the upper treatment. abdominal area, often called “indigestion”; a symptom of illness Causes of GERD. The lower esophageal sphincter is the main rather than a disease itself. “dys” bad; impaired and “pepsis” barrier to gastric reflux, so GERD can result if the sphincter digestion. muscle is weak or relaxes inappropriately. Other factors that Bloating and Stomach Gas The feeling of bloating may be predispose a person to GERD include high stomach pressures caused by excessive gas in the stomach, which accumulates and inadequate acid clearance from the esophagus. Conditions when air is swallowed. Air swallowing often accompanies gum associated with high rates of GERD include obesity, pregnancy, chewing, smoking, rapid eating, drinking carbonated beverages, and hiatal hernia, in which a portion of the stomach protrudes and using a straw. Omitting these practices generally helps to above the diaphragm. correct the problem. Consequences of GERD Gastritis is a general term that refers to inflammation of the ⎯ Reflux esophagitis: inflammation in the esophagus resulting gastric mucosa. Acute cases of gastritis typically result from from the reflux of acidic stomach contents. irritating substances or treatments that damage stomach tissue, resulting in tissue erosions, ulcers, or hemorrhaging (severe ⎯ Barrett’s esophagus: a condition in which esophageal cells bleeding). Chronic gastritis may be caused by long-term damaged by chronic exposure to stomach acid are replaced by infection or autoimmune disease; it can progress to widespread cells that resemble those in the stomach or small intestine, inflammation and tissue atrophy and is also a risk factor for sometimes becoming cancerous. gastric cancer. In most cases, gastritis results from Helicobacter Treatment of GERD. Treatment objectives are to alleviate pylori infection or the use of nonsteroidal anti-inflammatory symptoms and facilitate the healing of damaged tissue. Severe drugs (NSAIDs), which are both primary causes of peptic ulcer ulcerative disease may require immediate acid suppressing disease as well. medication, whereas a mild case may be managed with dietary Complications of Gastritis and lifestyle changes. Lifestyle modifications that may help to prevent the recurrence of gastrointestinal reflux. ⎯ Hypochlorhydria: abnormally low gastric acid secretions. Management of GERD may require modifications in diet and ⎯ Achlorhydria: absence of gastric acid secretions. lifestyle to reduce the recurrence of acid reflux or minimize This can lead to Pernicious anemia, characterized by discomfort. Recommendations typically include the following: autoimmune destruction of the gastric cells that produce hydrochloric acid and intrinsic factor, is a form of atrophic than large ones. Patients should avoid food consumption for at gastritis that is usually associated with the macrocytic anemia of least two hours before bedtime. There is no evidence that dietary vitamin B12 deficiency. adjustments alter the rate of healing or prevent recurrence. Dietary Interventions for Gastritis. Dietary recommendations DRUG – DIET INTERACTIONS depend on an individual’s symptoms. In asymptomatic cases, no dietary adjustments are needed. If pain or discomfort is present, the patient should avoid irritating foods and beverages; these often include alcohol, coffee (including decaffeinated), cola beverages, spicy foods, and fried or fatty foods. If food consumption increases pain or causes nausea and vomiting, food intake should be avoided for 24 to 48 hours to rest the stomach. If hypochlorhydria or achlorhydria is present, supplementation of iron and vitamin B12 may be warranted. Peptic Ulcer Disease is an open sore that develops in the GI mucosa when gastric acid and pepsin overwhelm mucosal defenses and destroy mucosal tissue. A primary factor in peptic ulcer development is H. pylori infection, which is present in approximately 30 to 60 percent of patients with gastric ulcers and 70 to 90 percent of those with duodenal ulcers.13 Another major factor is the use of NSAIDs, which have both topical and systemic effects that can damage the GI lining. Modifying Dietary Fiber Intake Effects of Emotional Stress Although most ulcers are associated with H. pylori infection or NSAID use, about 5 to 20 Diets can be modified by either increasing or decreasing dietary percent of ulcers develop for other reasons. fiber. As discussed, insoluble fibers increase stool weight and speed the passage of wastes through the large intestine. Soluble, Psychological stress by itself is not believed to cause ulcers, but viscous fibers slow the passage of food through the GI tract, it has effects on physiological processes and behaviors that may which increases satiety and delays glucose absorption in the increase a person’s vulnerability. The physiological effects of small intestine. People can increase their fiber-rich foods by stress vary among individuals but may include hormonal emphasizing the consumption of whole grains, legumes, nuts changes that impair immune responses and wound healing, and seeds, and fruits and vegetables. Individuals who must increased secretions of hydrochloric acid and pepsin, and rapid restrict dietary fiber can limit their consumption of these foods. stomach emptying (which increases the acid load in the duodenum). Stress may also lead to behavioral changes, Indications for Modifying Fiber Intake including the increased use of cigarettes, alcohol, and NSAIDs— all potential risk factors for ulcers. Thus, stress may contribute to ulcer development although its precise effects are not fully understood. Symptoms of Peptic Ulcers Peptic ulcer symptoms vary. Some people are asymptomatic or experience only mild discomfort. In others, ulcer pain may be experienced as a hunger pain, a sensation of gnawing, or a burning pain in the stomach region. The pain or discomfort of ulcers may be relieved by food and recur several hours after a meal, especially if the ulcer is duodenal. Gastric ulcers may be aggravated by food and can cause loss of appetite and eventual weight loss. Ulcer symptoms tend to go into remission regularly and recur every few weeks or months. Increased intestinal gas (flatulence) may be an unpleasant side Complications of Peptic Ulcers Peptic ulcers are a major cause effect of consuming a high-fiber diet. Because dietary fibers are of GI bleeding, which occurs in up to 15 percent of ulcer cases. not digested, they pass into the colon and are fermented by Bleeding is a potential cause of death and, if severe, may indicate bacteria, which produce gas as a by-product (soluble fibers are the need for surgical intervention. Severe bleeding is evidenced more readily fermented than the insoluble fibers). Therefore, by black, tarry stool samples or, occasionally, vomit that health practitioners advise that fiber-containing foods be added resembles coffee grounds. Other serious complications of ulcers gradually at first and portions increased as tolerance improves. include perforations of the stomach or duodenum and gastric Intestinal gas also develops when people consume other outlet obstruction due to scarring or inflammation. incompletely digested or poorly absorbed carbohydrates; these Nutrition Care for Peptic Ulcers The goals of nutrition care are include fructose, sugar alcohols (sorbitol, xylitol, mannitol), the to correct nutrient deficiencies, if necessary, and encourage indigestible carbohydrates in beans (raffinose and stachyose), dietary and lifestyle practices that minimize symptoms. Patients and some forms of resistant starch, found in grain products and should avoid dietary items that increase acid secretion or irritate potatoes. the GI lining; examples include alcohol, coffee and other Malabsorption disorders can cause considerable flatulence caffeine-containing beverages, chocolate, and pepper, although because the undigested nutrients can be metabolized by colonic individual tolerances vary. Small meals may be better tolerated bacteria. Swallowed air that is not expelled by belching may the amount that can be reabsorbed by intestinal cells. Secretory travel to the intestines and be a source of intestinal gas as well. diarrhea is often due to foodborne illness but can also be caused Note that many people attribute abdominal bloating and pain to by intestinal inflammation and various chemical substances excessive gas, but these symptoms do not correlate well with an (such as medications or unabsorbed bile acids). Motility increase in intestinal gas. disorders may also result in diarrhea because they accelerate the transit of colonic residue, reducing the contact time available for A. Disorders of Bowel Function fluid reabsorption. Constipation. A diagnosis of constipation is based, in part, on a Medical Treatment of Diarrhea. Correcting the underlying defecation frequency of fewer than three bowel movements per medical problem is the first step in treating diarrhea. For week. Other symptoms may include the passage of hard stools example, antibiotics are prescribed to treat intestinal infections. and excessive straining during defecation. In some cases, a If a medication is the cause of diarrhea, a different drug may be person’s perception of constipation may be due to a mistaken prescribed. If certain foods are responsible, they can be omitted notion of what constitutes “normal” bowel habits, so the from the diet. Bulk forming agents such as psyllium (Metamucil) person’s expectations about bowel function may need to be or methylcellulose (Citrucel) can help to reduce the liquidity of addressed. Constipation is particularly prevalent among women the stool. If chronic diarrhea does not respond to treatment, and all adults over 70 years of age. antidiarrheal drugs may be prescribed to slow GI motility or Causes of Constipation The risk of constipation is increased in reduce intestinal secretions. Probiotics (live bacteria provided in individuals with a low-fiber diet, low food intake, inadequate fluid foods or dietary supplements) may be beneficial for treating intake, or low level of physical activity. All of these factors can certain types of diarrhea (especially infectious diarrhea), but extend transit time, leading to increased water reabsorption standard treatment protocols have not been developed. within the colon and dry, hard stools that are difficult to pass. Oral Rehydration Therapy Severe diarrhea requires the Treatment of Constipation in individuals with a low fiber intake, replacement of lost fluid and electrolytes. Oral rehydration the primary treatment for constipation is a gradual increase in solutions can be purchased or easily mixed using water, salts, fiber intake to at least 25 grams per day. High-fiber diets increase and glucose or sucrose. stool weight and fecal water content and promote a more rapid Nutrition Therapy for Diarrhea Nutrition care depends on the transit of materials through the colon. Foods that increase stool cause of diarrhea and its severity and duration. The dietary weight the most include wheat bran, fruits, and vegetables. Bran treatment often recommended is a low-fiber, low-fat, lactose- intake can be increased by adding bran cereals and whole-wheat free diet, which limits foods that contribute to stool volume, such bread to the diet or by mixing bran powder with beverages or as those with significant amounts of fiber, resistant starch, foods. The transition to a high-fiber diet may be difficult for some fructose, sugar alcohols, and lactose (in lactose-intolerant people because it can increase intestinal gas, so high-fiber foods individuals). Avoidance of fatty foods may be advised if they should be added gradually, as tolerated. Fiber supplements like aggravate diarrhea. Gas-producing foods (those with poorly methylcellulose (Citrucel), psyllium (Metamucil, Fiberall), and digested or absorbed carbohydrates) can increase intestinal polycarbophil (Fiber-Lax) are also effective; these supplements distention and cause additional discomfort. Although fluid can be mixed with beverages and taken several times daily. intakes must usually be increased to replace fluid losses, Unlike other fibers, methylcellulose & polycarbophil do not patients should avoid caffeinated coffee and tea because increase intestinal gas. caffeine stimulates GI motility and can thereby reduce water Several other dietary measures may also help to relieve reabsorption. In the treatment of formula-fed infants, apple constipation. Consuming adequate fluid (usually 1.5 to 2 liters pectin or banana flakes are sometimes added to formulas to help daily) can help to increase stool frequency in people who are thicken stool consistency. already consuming a high-fiber diet. An appropriate fluid intake Irritable Bowel Syndrome. People with irritable bowel syndrome prevents excessive reabsorption of water from the colon, experience chronic and recurring intestinal symptoms that resulting in wetter stools. Adding prunes or prune juice to the diet cannot be explained by specific physical abnormalities. The is often recommended because prunes contain compounds that symptoms usually include disturbed defecation (diarrhea and/or have a mild laxative effect. constipation), flatulence, and abdominal discomfort or pain; the Diarrhea. Diarrhea is characterized by the passage of frequent, pain is often aggravated by eating and relieved by defecation. In watery stools. In most cases, it lasts for only a day or two and some patients, symptoms are mild; in others, the disturbances subsides without complication. Severe or persistent diarrhea, in colonic function can interfere with work and social activities however, can cause dehydration and electrolyte imbalances. enough to dramatically alter the person’s lifestyle and sense of Diarrhea may be accompanied by other symptoms, such as well-being. fever, abdominal cramps, dyspepsia, or bleeding, which help in Although the causes of irritable bowel syndrome remain elusive, diagnosing the cause. people with the disorder tend to have excessive colonic Causes of Diarrhea. Diarrhea is a complication of multiple GI responses to meals, GI hormones, and psychological stress. disorders and may also be caused by infections, medications, or Treatment of Irritable Bowel Syndrome. Medical treatment of dietary substances. It results from inadequate fluid reabsorption irritable bowel syndrome often includes dietary adjustments, in the intestines, sometimes in conjunction with an increase in stress management, and behavioral therapies. Medications may intestinal secretions. In osmotic diarrhea, unabsorbed nutrients be prescribed to manage symptoms but they are not always or other substances attract water to the colon and increase fecal helpful. The drugs prescribed may include laxatives, water content; common causes include high intakes of poorly antidiarrheal agents, antidepressants, antispasmodics (which absorbed sugars (such as sorbitol, mannitol, or fructose) and reduce pain by relaxing GI muscles), and antibiotics (which alter lactase deficiency (which causes lactose malabsorption). In bacterial populations in the colon). secretory diarrhea, the fluid secreted by the intestines exceeds Nutrition Therapy for Irritable Bowel Syndrome. Although may extend deeply into intestinal tissue and be accompanied by dietary adjustments may reduce symptoms, responses among ulcerations, fissures, and fistulas. The resultant scar tissue can patients vary considerably. The most common recommendation eventually thicken, narrowing the lumen and possibly causing is to gradually increase fiber intake from food or supplements to strictures or obstructions. About 40 percent of patients require relieve constipation and improve stool bulk. However, clinical surgery within 10 years of diagnosis.11 Patients with Crohn’s studies suggest that additional fiber has little or no effectiveness disease are also at increased risk of developing intestinal in improving symptoms and may worsen flatulence.8 Psyllium cancers. supplementation may be helpful for individuals with Complications of Ulcerative Colitis. Ulcerative colitis always constipation. Some individuals have fewer symptoms when they involves the rectum and usually extends into the colon consume small, frequent meals instead of larger ones. Foods (inflammation is continuous along the length of intestine that aggravate symptoms may include fried or fatty foods, gas- affected, ending abruptly at the area where healthy tissue begins. producing foods, milk products (not necessarily due to lactose The erosion or ulceration affects the mucosa and submucosa intolerance), wheat products, and coffee (with or without only (the tissue layers closest to the lumen). During active caffeine); however, individual tolerances are best determined by episodes, patients may have frequent, urgent bowel movements trial and error. A careful evaluation of the dietary patterns that that are small in volume and contain blood and mucus. exacerbate symptoms may uncover the foods and habits most Symptoms may include diarrhea, constipation, rectal bleeding, closely associated with intestinal discomfort. Treatments under and abdominal pain. investigation for irritable bowel syndrome include peppermint oil, which relaxes smooth muscle within the GI tract, and various Drug Treatment of Inflammatory Bowel Diseases. Medications types of probiotics help to control symptoms, reduce inflammation, and minimize complications. The drugs prescribed include antidiarrheal B. Inflammatory Bowel Diseases agents, immunosuppressant, anti-inflammatory drugs (usually Crohn’s disease: an inflammatory bowel disease that usually corticosteroids and salicylates), and antibiotics. occurs in the lower portion of the small intestine and the colon; Nutrition Therapy for Inflammatory Bowel Diseases. Crohn’s the inflammation may pervade the entire intestinal wall. U disease often requires aggressive dietary management because Ulcerative colitis): an inflammatory bowel disease that it can lead to protein-energy malnutrition, nutrient deficiencies, involves the rectum and colon; the inflammation affects the and growth failure in children. Specific dietary measures depend mucosa and submucosa of the intestinal wall. on the symptoms and complications that develop. High-calorie, high-protein diets may be prescribed to prevent or treat malnutrition or promote healing. Oral supplements may help to increase energy intake and improve weight gain. Vitamin and mineral supplements are usually necessary, especially if nutrient malabsorption is present. During disease exacerbations, a low- fiber, low-fat diet provided in small, frequent feedings can minimize stool output and reduce symptoms of malabsorption. In some instances, tube feedings are used to supplement the diet or may be the sole means of providing nutrients. As in Crohn’s disease, the symptoms and complications that arise are managed with appropriate dietary measures. During disease exacerbations, emphasis is given to restoring fluid and electrolyte balances and correcting deficiencies that result from protein and blood losses. A low-fiber diet may reduce irritation by minimizing fecal volume. If colon function becomes severely impaired, food and fluids may be withheld and fluids and electrolytes supplied intravenously until colon function returns. C. Colostomies and Ileostomies An ostomy is a surgically created opening (called a stoma) in the abdominal wall through which dietary wastes can be eliminated. Whereas a permanent ostomy is necessary after a partial or total colectomy, a temporary ostomy is sometimes constructed to bypass the colon after injury or extensive surgery. To create the stoma, the cut end of the remaining segment of the functional intestine is routed through an opening in the abdominal wall and stitched in place so that it empties to the exterior. The stoma can be formed from a section of the colon (colostomy) or ileum (ileostomy). Conditions that may require these procedures include inflammatory bowel diseases, diverticulitis, and colorectal cancers. Complications of Crohn’s Disease. Crohn’s disease may occur in any region of the GI tract, but most cases involve the ileum To collect wastes, a disposable bag is affixed to the skin around and/or large intestine. Lesions may develop in different areas in the stoma and emptied during the day as needed. In some cases, the intestine, with normal tissue separating affected regions an internal pouch is constructed from ileal tissue and attached (called “skip” lesions). During exacerbations, the inflammation to the anus so that the anal sphincter can control output. Stool consistency varies according to the length of colon that is CHECK FOR UNDERSTANDING functional. If a small portion of the colon is absent or bypassed, 1. Foods permitted on the clear liquid diet include all of the the stools may continue to be semi-solid. If the entire colon has following except: been removed or is bypassed, the ability to absorb fluid and electrolytes is substantially reduced, and the output is liquid. a. milk. In a colostomy (LEFT), a portion of the colon is removed b. fruit ices. or bypassed, and the stoma is formed from the remaining section of functional colon. c. flavored gelatin. In an ileostomy (RIGHT), the entire colon is removed or d. consommé. bypassed, and the stoma is formed from the ileum. 2. If a patient with dysphagia has difficulty swallowing solids but Nutrition Care for Patients with Ostomies Dietary adjustments can easily swallow liquids: are individualized according to the surgical procedure and symptoms that develop afterward. Following surgery, the diet a. the problem is most likely a motility disorder. may progress from clear liquids (low in sugars) to regular foods, b. the patient may have achalasia. as tolerated. To reduce stool output, a low-fiber diet may be recommended. Small, frequent meals may be more acceptable c. the problem is probably an esophageal obstruction. than larger ones. To determine food tolerances, patients should try small amounts of questionable foods and assess their d. the patient most likely has oropharyngeal dysphagia. effects; a food that causes problems can be tried again later. Appropriate fluid and electrolyte intakes should be encouraged when a large portion of the colon has been removed. 3. Possible consequences of GERD include all of the following except: People with ileostomies need to chew thoroughly to ensure that foods are adequately digested and to prevent obstructions, a a. reflux esophagitis. c. Barrett’s esophagus. common complication due to the small diameter of the ileal b. dysphagia. d. gastric ulcer lumen. Foods high in insoluble fibers are sometimes discouraged because they reduce transit time, may cause obstructions, and increase stool output. To replace electrolyte losses, patients are encouraged to use salt liberally and to ingest 4. Chronic gastritis may increase risk of: beverages with added electrolytes (such as sports drinks and a. dumping syndrome. rehydration beverages), if necessary. If a large portion of the ileum has been removed, fat malabsorption may occur due to b. bone disease. bile acid depletion, and vitamin B12 injections may be required. c. iron and vitamin B12 deficiencies. Dietary concerns after colostomies depend on the length of d. gallbladder disease. colon remaining. Most patients have no dietary restrictions and can return to a regular diet. Patient concerns may include stool odors, excessive gas production, and diarrhea. If a large portion of colon was removed, recommendations may be similar to 5. The main dietary recommendation for patients with gastritis or those given to ileostomy patients. peptic ulcers is to consume foods that: a. neutralizes stomach acidity. Obstructions as mentioned, foods that are incompletely digested can cause obstructions, a primary concern of ileostomy b. is well tolerated and does not cause discomfort. patients. Although these patients can consume almost any food c. coat the stomach lining. that is cut in small pieces and carefully chewed, the following foods may cause difficulty: celery, coconut, coleslaw, d. promotes healing of mucosal tissue. mushrooms, peas, salad greens, dried fruit, unpeeled fresh fruits, pineapple, nuts, seeds, popcorn, frankfurters, sausages, 6. The health practitioner advising an elderly patient with and tough, chewy meats. constipation encourages the patient to: a. consumes a low-fat diet low in sodium. Reducing Gas and Odors. Persons with ostomies are often concerned about foods that may increase gas production or b. consumes a high-protein diet rich in calcium. cause strong odors. Foods that sometimes produce unpleasant c. gradually adds high-fiber foods to the diet. odors include asparagus, beer, broccoli, brussels sprouts, cabbage, cauliflower, dried beans and peas, eggs, fish, garlic, d. eliminates gas-forming foods from the diet. and onions. Foods that may help to reduce odors include buttermilk, cranberry juice, parsley, and yogurt. 7. Osmotic diarrhea often results from: Diarrhea. Foods that may thicken stool include applesauce, banana, cheese, pasta, potatoes, smooth peanut butter, a. excessive colonic contractions. tapioca, and white rice. What works may differ for each individual, however, and is best determined by trial and error. b. excessive fluid secretion by the intestines. c. nutrient malabsorption. d. viral, bacterial, or protozoal infections’ 8. Symptoms of irritable bowel syndrome most often include: a. constipation and/or diarrhea and flatulence. b. weight loss and malnutrition. c. strong odors and obstructions. d. nausea and vomiting. 9. Ulcerative colitis may afflict which region of the digestive tract? a. Ileum, rectum, and colon b. Rectum and colon c. Stomach and duodenum d. Most regions of the GI tract can be affected 10. After an ileostomy, the most serious concern is that: a. the diet is too restrictive to meet nutrient needs. b. waste disposal causes frequent daily interruptions. c. incompletely digested foods may cause obstructions. d. fluid restrictions prevent patients from drinking beverages freely SAS #19 Malabsorption Syndromes emptying or intestinal transit can cause fat malabsorption because they prevent the normal mixing of dietary fat with lipase To digest and absorb nutrients, we depend on normal digestive and bile. Fat malabsorption can also be caused by conditions or secretions and healthy intestinal mucosa. Malabsorption can treatments that damage the intestinal mucosa, such as therefore be caused by pancreatic disorders that cause enzyme inflammatory bowel diseases, AIDS, and radiation treatments for or bicarbonate deficiencies, disorders that result in bile cancer deficiency, and inflammatory diseases or medical treatments that damage intestinal tissue. In some cases, the treatment of an intestinal disease requires surgical removal of a section (resection) of the small intestine, leaving minimal absorptive capacity in the portion that remains. In addition, various medications can damage the mucosa and impair the digestive and absorptive functions of the small intestine. Malabsorption rarely involves a single nutrient. When malabsorption is caused by pancreatic enzyme deficiencies, all macronutrients—protein, carbohydrate, and fat— may be affected. When fat is malabsorbed, fat-soluble nutrients and some minerals are usually malabsorbed as well. Malabsorption disorders and their treatments can tax nutritional status further by causing complications that alter food intake, raise nutrient needs, or promote additional nutrient losses. Evaluating Malabsorption. A number of clinical procedures and laboratory tests are used to determine whether an individual has a malabsorption problem. Nutrition Therapy for Fat Malabsorption. If steatorrhea does not Examples include the following: improve, a fat-restricted diet may be recommended. The diet may help to relieve intestinal symptoms that are aggravated by ⎯ Endoscopy or biopsy. Direct examination of the duodenal fat intake (such as diarrhea and flatulence) and reduce vitamin mucosa with an endoscope may reveal physical changes and mineral losses. Because fat is a primary energy source, it characteristic of intestinal diseases that cause malabsorption. A should not be restricted more than necessary. Medium-chain biopsy can be taken during the procedure for further analysis. triglycerides (MCT), which do not require lipase or bile for digestion and absorption, can be used as an alternative source ⎯ Stool fat analysis. Fat malabsorption can be determined by of dietary fat, although MCT oil does not provide essential fatty placing the patient on a high-fat diet (80 to 100 grams per day), acids. performing a 48- to 72-hour stool collection, and measuring the stool’s fat content. Healthy individuals generally eliminate less Bacterial Overgrowth. Ordinarily, the GI tract is protected from than 7 grams of fat per day under these conditions. Excessive fat bacterial overgrowth by gastric acid, which destroys bacteria; in the stools is known as steatorrhea. peristalsis, which flushes bacteria through the small intestine before they multiply; and immunoglobulins secreted into the GI ⎯ Hydrogen breath test. When carbohydrate is malabsorbed, lumen. When bacterial overgrowth does occur, it can lead to fat colonic bacteria digest the carbohydrate and produce hydrogen malabsorption because the bacteria dismantle the bile acids gas, which is absorbed and later can be measured in the breath. needed for fat emulsification. Deficiencies of the fat-soluble The hydrogen breath test is often used to diagnose lactose vitamins A, D, and E may eventually develop. The bacteria also intolerance, but it can diagnose malabsorption of other types of produce enzymes and toxins that disturb the intestinal mucosa, carbohydrate as well. This test is also used to determine the destroying some mucosal enzymes (especially lactase) and presence of excessive bacteria in the small intestine. possibly reducing the absorptive surface area. Some types of ⎯ Xylose absorption. Xylose, a sugar that is readily absorbed but bacteria metabolize vitamin B12, reducing its absorption and is not well metabolized, can be used to test whether the small increasing the risk of deficiency. Although symptoms of bacterial intestine is able to absorb nutrients normally. In the xylose overgrowth are often minor and nonspecific, severe cases may absorption test, the patient is given an oral dose of xylose, and lead to chronic diarrhea, steatorrhea, flatulence, bloating, and blood and urine tests determine whether appropriate amounts of weight loss. xylose were absorbed. Causes of Bacterial Overgrowth. Conditions that impair Fat Malabsorption. intestinal motility and allow material to stagnate can greatly increase susceptibility to bacterial overgrowth. For example, in Fat is the nutrient most frequently malabsorbed because both some types of gastric surgery, a portion of the small intestine is digestive enzymes and bile must be present for its digestion. bypassed, preventing the flow of material in the bypassed region Thus, fat malabsorption often develops when an illness reduces and allowing bacteria to flourish. Intestinal motility can also be either pancreatic or bile secretions. For example, both reduced by strictures, obstructions, and diverticula in the small pancreatitis and cystic fibrosis can decrease the secretion of intestine, as well as by some chronic illnesses, including pancreatic lipase, whereas severe liver disease can cause bile diabetes mellitus and scleroderma.3 Reduced secretions of insufficiency. Motility disorders that accelerate gastric gastric acid can also lead to bacterial overgrowth. Possible causes include atrophic gastritis, acid-suppressing medications, and some gastrectomy procedures. Treatment for Bacterial Overgrowth. Treatment may include helpful for patients with symptoms of fat malabsorption (such as antibiotics to suppress bacterial growth and surgical correction steatorrhea and abdominal pain). In severe pancreatitis, of the anatomical defects that contribute to a motility disorder. continuous tube feedings, started within the initial 48 hours of Medications may be given to stimulate peristalsis, and acid- treatment, may lead to improved outcomes compared with suppressing medications should be discontinued. A lactose- withholding intakes; the use of elemental formulas (formulas restricted diet may reduce flatulence and diarrhea in some that contain hydrolyzed nutrients) may improve patient individuals. Dietary supplements can correct nutrient tolerance. Protein needs are generally high in pancreatitis deficiencies, especially deficiencies of fat-soluble vitamins, patients (between 1.2 and 1.5 grams per kilogram body weight calcium (which combines with malabsorbed fatty acids), and per day10) due to the catabolic effects of inflammation. Patients vitamin B12. should be given multivitamin/mineral supplements until food intakes can meet their nutritional needs. Lactose Intolerance Chronic Pancreatitis. Chronic pancreatitis is characterized by Approximately 75 percent of people worldwide have some progressive, permanent damage to pancreatic tissue, resulting in degree of lactose intolerance, which is caused by the loss or the impaired secretion of digestive enzymes and bicarbonate. reduction of lactase, the intestinal enzyme that digests the About 70 to 80 percent of cases are caused by excessive alcohol lactose in milk products. Lactose intolerance is especially consumption. Most patients with chronic pancreatitis prevalent among individuals of certain ethnic groups, including experience persistent abdominal pain, which may worsen with Asians, African Americans, Native Americans, Ashkenazi Jews, eating and be accompanied by nausea and vomiting. Although all and Latinos. It may also result from GI disorders, medications, or macronutrients are maldigested, the symptoms of fat medical treatments that damage the small intestinal mucosa. malabsorption are typically the most severe. Long-term illness is The primary symptoms of lactose intolerance are diarrhea and associated with reduced secretion of insulin and glucagon, and increased intestinal gas. diabetes eventually develops in 30 to 50 percent of patients. Lactose intolerance is rarely serious and is easily managed by Nutrition Therapy for Chronic Pancreatitis. The objectives of simple dietary adjustments. Although people with the condition nutrition therapy are to reduce malabsorption and correct are sometimes reluctant to consume milk products, clinical malnutrition. Pancreatic enzyme replacement is the main studies have found that individuals with lactose intolerance can treatment for steatorrhea and other symptoms of malabsorption. tolerate up to 2 cups of milk daily without significant symptoms. Most enzyme preparations are enteric coated to resist the acidity In addition, the regular consumption of milk products increases of the stomach and do not dissolve until they reach the small the amount of lactose metabolized by intestinal bacteria, which intestine. If nonenteric-coated preparations are used, acid- improves lactose tolerance.6 People who avoid milk for fear of suppressing drugs are also required. Fecal fat concentrations intestinal discomfort can be urged to gradually increase their can be monitored to determine if the enzyme treatment has been consumption of lactose-containing foods. effective. Patients with chronic pancreatitis who are People who develop lactose intolerance as a result of intestinal hypermetabolic and underweight have high protein and energy illness are often advised to temporarily restrict milk and milk requirements; protein needs may range between 1.0 and 1.5 products. Foods that contain lactose can be reintroduced in grams per kilogram body weight per day and energy intakes small amounts once the condition improves. Individuals who should be about 35 kcalories per kilogram daily. Dietary restrict milk products should be encouraged to consume supplements are used to correct nutrient deficiencies, which alternative food sources of calcium and vitamin D. may be due to malabsorption or to the alcohol abuse that caused the disease. Patients should avoid alcohol completely and quit Disorders of the Pancreas smoking cigarettes, as these substances can exacerbate illness and interfere with healing. Pancreatitis is an inflammatory disease of the pancreas. Although mild cases may subside in a few days, other cases can Cystic fibrosis is the most common life-threatening genetic persist for weeks or months. Chronic pancreatitis can lead to disorder among Caucasians, with an incidence of approximately irreversible damage to pancreatic tissue and permanent loss of 1 in 3000 to 5000 white births. The condition is characterized by function. a mutation in the protein that regulates chloride transport across epithelial cell membranes. The abnormality alters the ion Acute Pancreatitis. In acute pancreatitis, the digestive enzymes concentration and/ or viscosity of exocrine secretions, causing a within pancreatic cells become prematurely activated, causing broad range of serious complications. destruction of pancreatic tissue and subsequent inflammation. About 70 to 80 percent of acute cases are caused by gallstones Consequences of Cystic. Fibrosis Cystic fibrosis is or alcohol abuse; less frequent causes include elevated blood characterized by abnormal chloride and sodium levels in triglyceride levels or exposure to various toxins. Common exocrine secretions. These altered secretions ultimately disrupt symptoms include severe abdominal pain, nausea and vomiting, the functioning of multiple tissues and organs. Common and abdominal distention. In most patients, the condition complications of cystic fibrosis involve the lungs, pancreas, and resolves within a week with no complications. More serious sweat glands. cases may lead to chronic pancreatitis, infection, the systemic inflammatory response syndrome or multiple organ failure. ⎯ Lungs. Changes in bronchial secretions lead to an impaired ability to clear airway mucus, resulting in chronic respiratory Nutrition Therapy for Acute Pancreatitis. The initial treatment infections, progressive inflammation, and airway obstruction. for acute pancreatitis is supportive and includes pain control and The eventual lung damage causes breathing difficulties, chronic intravenous hydration. In cases of mild to-moderate pancreatitis, coughing, and lower exercise tolerance. Nutrition status may oral fluids and food are withheld until the patient is pain free and become impaired due to hypermetabolism, the greater energy experiences no nausea or vomiting. Afterward, patients can cost of labored breathing, and anorexia (loss of appetite). usually consume a regular diet; a fat-restricted diet may be ⎯ Pancreas. Most patients produce thickened pancreatic until the intestine has recovered. The gluten-free diet eliminates secretions that obstruct the pancreatic ducts. The trapped foods that contain wheat, barley, and rye. Because many foods pancreatic enzymes eventually damage pancreatic tissue, contain ingredients derived from these grains, foods that are leading to progressive atrophy and scarring. Few pancreatic problematic are not always obvious. Gluten sources that may be enzymes reach the small intestine, resulting in severe overlooked include beer, brewer’s yeast, caramel coloring, malabsorption of protein, fat, and fat-s