Upper GI Disorders PDF

MNT FOR UPPER GI DISORDERS Allison Charny, MS, RD, CDE, CDN Krause’s Food & the Nutrition Care Process Ch 28 and pp 929-933 Upper GI Overview Disorders of Esophagus Disorders of the Stomach  Dysphagia...

MNT FOR UPPER GI DISORDERS Allison Charny, MS, RD, CDE, CDN Krause’s Food & the Nutrition Care Process Ch 28 and pp 929-933 Upper GI Overview Disorders of Esophagus Disorders of the Stomach  Dysphagia  Dypepsia  Esophagitis  Gastritis  Hernia  PUD  Cancer  Cancer  Surgery  Surgery GI Physiology  GI System  Nutrient Absorption  Pathophysiology Disorders of the Esophagus ❑ Dysphagia ❑ Esophagitis ❑ Hernia ❑ Cancer ❑ Surgery Disorders of the Esophagus  Abnormal swallowing mechanism  Neurologic  Inflammation  Irritation, infection, cancer  Abnormal sphincter function  GERD  Obstruction  Tumor Disorders of the Esophagus Esophagitis  Acute  Due to ingestion of irritating agent, virus, intubation  Chronic  Due to hiatal hernia, LES pressure, ↑abdominal pressure, recurrent vomiting, gastric emptying, H.Pylori, aspirin, NSAID  Gastric acid reflux onto the lower esophageal mucosa  Symptoms ◼ Heartburn, regurgitation, dysphagia  Severity ◼ GERD gastroesophageal reflux disorder ◼ Barrett’s Esophagus Esophagitis: Paraesophageal / Hiatal Hernia A Normal anatomy B Pre-stage C Hiatal hernia D Paraesophageal hernia Esophagitis: GERD https://www.youtube.com/watch?v=TdK0jRFpWPQ Esophagitis: Barrett’s Esophagus https://www.youtube.com/watch?v=tQ6a4arjFdE Esophagitis  LES pressure decreased by  Fats, ETOH, carminatives  Smoking  Smooth muscle relaxants (meds)  Sclerosis  Hormones ◼ LES pressure s due to ↑ progesterone levels ◼ pregnancy ◼ late stage of the menstrual cycle ◼ OCAs All could cause GERD Esophagitis Treatments  Behavior Modification  Avoid: Lying down after meals, tight clothes, smoking  Nutritional  Goal: prevent reflux Avoid: high fat, ETOH, carminatives  Goal: decrease gastric acidity Avoid: coffee, ETOH  Goal: prevent pain and irritation Avoid: acidic foods, spices-chili powder, black pepper Esophagitis Treatments  Medical Management  Surgery: fundoplication  Meds: ◼ Increase LES pressure ◼ Antibiotics ◼ Sucralfate (Carafate) ◼ Increase gastric emptying ◼ Prokinetic agents (Reglan) ◼ Decrease acidity ◼ Proton pump inhibitors (Nexium, Prilosec) ◼ H2 receptor blockers (Tagamet, Pepcid, Zantac) ◼ Antacids (Tums, MOM, Mylanta, Maalox) Disorders of the Esophagus Hernia  Hiatal / Paraesophageal Hernias  Both increase risk of reflux  MNT same as for reflux esophagitis  Nutritional and medical treatment preferred over surgery Disorders of the Esophagus Oral, Esophageal CA  May have existing eating and nutrition problems: Malnutrition, oral infection, ulceration  Nutritional Problems with Ca treatment:  Surgical resection  Regional irradiation  Chemotherapy  Treatment: individualize to any chew/swallow/salivation/taste difficulty  Soft/moist food  Artificial saliva Disorders of the Esophagus Surgery  Tonsillectomy:  Soft, cold, mild foods → warm, soft →hot; resume regular diet 3-5 days  Enteral Nutrition Support  Oral nutrition – purees; liquid form, formulas  G or J tube (if extensive oral problem / surgery)  Parenteral Nutrition Support  PRN (rare) Disorders of the Stomach ❑ Dypepsia ❑ Gastritis ❑ PUD ❑ Cancer ❑ Surgery Disorders of the Stomach Dyspepsia/Indigestion  Discomfort of digestive tract; may warn of GBD, CA, appendicitis, ulcer  Causes: stress, rapid eating, poor mastication, overeating, caffeine, spices, ETOH  Therapy: toward offending factor(s) Disorders of the Stomach Gastritis Inflammation, erosion of mucous layer of stomach due to gastric fluids and microbes Acute – rapid onset of symptoms  Symptoms: n/v, anorexia, hemorrhage, pain,  appetite, belching  Causes: overeating, ETOH, tobacco, aspirin, NSAIDS  Nutritional Therapy  Hold food 24-40 hours or more  NG ice water if bleeding  IV fluids  Avoid irritating foods  Advance diet as tolerated Gastritis Chronic – occurs over months or years  May precede gastric cancer or ulcer  Vague symptoms come and go; endoscopy assists diagnosis  Common cause is H. pylori infection → inflammatory response  Nutritional Therapy:  Eliminate offending foods  Adequate kcal, soft, regular meal times  Avoid gastric stimulants and irritants: Chili powder, onions, garlic, black pepper, excess fluids (distension) Gastritis Atrophic Gastritis  Atrophy of stomach parietal cells, leading to   HCl production (achlorhydria)   intrinsic factor production ◼ monitor B12 Disorders of the Stomach Peptic Ulcer Disease (PUD)  Ulceration within the stomach or duodenum due to breakdown of normal defense and repair by:  Mucus, bicarbonate, acid removal by normal blood flow, rapid epithelial cell renewal  Symptoms: similar to dyspepsia and gastritis; melena and GI bleeding when severe  Causes: H.Pylori, aspirin, NSAIDs, steroids, stress, alcohol, smoking PUD Gastric Ulcer  Mucosal disruption followed by ulceration from acid; Causes of mucosal disruption:  H.Pylori – bacterial infection  Duodenal reflux – detergent effect of bile salts  NSAIDS -  prostaglandin production – impairs normal defense against acidity by stomach mucosa  Gastric ulcers NOT caused by  acid production  Medical University of South Carolina website, Digestive Health Videos: Gastric Ulcers http://www.muschealth.com/video/Default.aspx?videoId=10135&cId=15&type=rel PUD Duodenal Ulcer Causes:  H.pylori   acid secretion   gastric emptying rates-duodenum has  time to buffer chyme   bicarbonate (tobacco) to buffer acidic chyme   prostaglandins (NSAIDS) PUD PUD Treatment  Relieve pain, heal, prevent recurrence  Etiologies of PUD differ; therapies similar  Dietary therapy 2 drug therapy PUD  Medical Therapy  Neutralization of acid ◼ Antacids (Tums, MOM, Maalox, Mylanta)  Reduction of acid secretion by the stomach ◼ H2 Blockers (Pepcid (famotidine), Tagamet, Zantac) ◼ Proton Pump Inhibitors (Prilosec (omeprazole), Nexium, Protonix; (monitor B12)  Protect mucosa from destruction by gastric juices ◼ Sucralfate (Carafate)  Eliminate H. pylori from gastric mucosa ◼ Antibiotics PUD Nutrition Therapy  Reduce or neutralize stomach acid secretion  Maintain acid resistance of GI epithelial tissue  Limit patient discomfort  Restore good nutritional status PUD Nutrition Therapy  No ETOH, beer, wine, coffee, milk  Ph of food – little importance as gastric acid has normal pH of 1.6; OJ and grapefruit juice 3.2 – 3.6. If not tolerated, avoid  No Red or black pepper  No cigarettes  Omega 3’s and probiotics for anti-inflammatory benefits against H. pylori  Small frequent meals Disorders of the Stomach Cancer Etiology:  H. pylori Treatment:  Nonoperative gastric cancer - diet individualized to tolerance  Surgery - MNT for gastrectomy  Chemo, radiation - nutrition guidelines for these treatments  Medical University of South Carolina website, Digestive Health Videos: Gastric Cancer Animation Disorders of the Stomach Gastric Surgical Procedures (Fig 26-6) Disorders of the Stomach Gastric Bypass Weight Loss Surgery  Medical University of South Carolina website, Digestive Health Videos:  VerticalBanded Gastroplasty Animation  Weight loss surgery – how and what to eat after surgery http://www.muschealth.com/video/Default.aspx?videoId=10135&cId=15&type=rel Disorders of the Stomach Gastric / Esophageal Surgery  Esophagectomy  Treats cancer of the esophagus  Removal of all or part of the esophagus  Esophagus is rebuilt from stomach or part of large intestine Gastric Surgery 1. Dumping Syndrome  Physiologic response to undigested food in the jejunum, following gastric surgery (2/3 stomach removed) or vagotomy  Food is not gradually released in small amounts (normal) but “dumped” into jejunum 10-15 minutes after eating  Hypertonic chyme → cramping, hypermotility, diarrhea and sharp  in blood volume (weak, rapid pulse, dizzy, cold sweat)  Diminishes over time with increased stomach size; some continue with dumping syndrome Gastric Surgery 2. Alimentary Hypoglycemia  Caused by rapid digestion and absorption of food dumped into duodenum  Glucose → rapid  blood glucose → overproduction of insulin → hypoglycemia (1-2 hr after meal)  Symptoms of hypoglycemia: weak, hungry, nausea, anxiety, sweating Gastric Surgery 3. Malabsorption  Mainly with Billroth II (gastrojejunostomy)  Food bypasses the duodenum with this surgery  Lipase and biliary insufficiency ◼ Steatorrhea - fat in stool Gastric Surgery 4. Anemia  Fe deficiency  Bleeding  Fe absorption ◼ With rapid stomach emptying, less mix with HCl; Fe is not changed to its absorbable form (ferrous) ◼ 50% Fe is absorbed in the duodenum; with surgery, iron may not be absorbed  B12 abs   intrinsic factor → pernicious anemia; B12 injections needed Gastric Surgery  Nutritional Problems Post Gastrectomy  Intake of food   Diarrhea  Weight loss  Malnutrition Gastric Surgery  Nutrition Therapy Post Gastrectomy  High protein (20% kcal), moderate fat (35-45%), high kcal  Simple CHO - lactose, sucrose, dextrose – limited  Protein, fats, complex CHO better tolerated  MCT with steatorrhea  Lie down after eating  Small frequent meals  Limit liquids at meals Gastroparesis  Delayed gastric emptying  Complex etiology: neuro, chemical  Diabetes*,viral, gastric conditions & surgeries, pychogenic  Symptoms: Fullness, early satiety, poor intake  Medical Management:  Scintigraphy  Prokinetics, aniemetics, gastric pacemaker  MNT: SFM, liquids, puree /liquid foods; avoid high fiber (bezoars)