Lower GI Tract Disorders PDF

MNT FOR LOWER GI TRACT DISORDERS Allison Charny, MS, RD, CDE, CDN Krause’s Food & the Nutrition Care Process Ch 29 Lower GI Overview  Modified Fiber Diets  Inflammatory Bowel Diseases  Symptoms of Intestinal...

MNT FOR LOWER GI TRACT DISORDERS Allison Charny, MS, RD, CDE, CDN Krause’s Food & the Nutrition Care Process Ch 29 Lower GI Overview  Modified Fiber Diets  Inflammatory Bowel Diseases  Symptoms of Intestinal  Crohn’s Disease Problems  Ulcerative Colitis  Flatulence  Constipation  Other Disorders of the Large  Diarrhea Intestine  Irritable Bowel Syndrome  Diseases of the Small  Diverticular Disease Intestine  Colon Cancer  Celiac Disease  Lactose Intolerance  Intestinal Surgeries  Bowel Resections  Ostomies Fiber, Roughage, Residue  Dietary Fiber  water soluble and insoluble ◼ Fruits, vegetables, cereal grains ◼ Fiber preferred term, not “roughage”  Residue  Undigested fiber and other unabsorbed dietary elements ◼ Minerals (Fe, Ca+) ◼ undigested starch, sugar (lactose), gristle ◼ up to ½ of feces = bacteria (US diet) ◼ 60-80% of stool wt = H2O and bacteria Modified Fiber Diets  Restricted Fiber Diet  Reduces fecal output due to ◼ obstruction or blocked GI tract ◼ phytobezoar – blockage due to food  ~ 5-10 g fiber/day  Avoid whole grains, cereals, nuts, seeds, legumes  Limit fruits/veg to those without nuts, hulls or seeds  High Fiber Diet  30g or > dietary fiber w/ min 8 - 8 oz glasses water/day  Start slowly  Fiber supplements may be needed  > 50g does not seem to improve bowel function Modified Fiber Diets  Low Residue (not often used)  Limit fiber content, dairy products and meat with connective tissue  Nutritionally inadequate  May be ordered to “clean bowel” before surgery or bowel exams  Elemental (formula) = low residue Common Symptoms of Intestinal Dysfunction  Flatulence  Constipation  Diarrhea Flatulence Causes  Aerophagia – swallowing of air while drinking or eating  Eat slowly, chew with mouth closed, avoid soda, straws  Lactose intolerance  Indigestible CHOs  beans  Other “gas forming” foods Constipation Infrequent and difficult passage of stool: transit time causes absorption of H2O causing hard stool Causes  Poor response to defecation urge  Poor nutritional habits; fiber, fluid, exercise  Laxative habit  Other medical conditions: neuromuscular, pregnancy, obstruction (i.e. tumor), or motility problem Constipaton  Treatment with Laxatives  Nutritional  Both soluble and insoluble fiber  Bulking agents – cellulose, hemicellulose, psyllium – Metamucil  Prunes – prune juice (dihydroxyphenylisatin) stimulates intestinal motility  Medical  Lubricants - Mineral oil - interferes with absorption of fat soluble vitamins  Osmotic – MOM, Miralax, Lactulose  Stimulant – Dulcolax, Senekot  Stool softeners – Colace Diarrhea Frequent evacuation of liquid stool  Causes: inflammation, infection, meds, excess sugars,  absorptive surface area in the gut, malnutrition  Results in: decreased enzymatic digestion, excessive loss of fluids, electrolytes (Na and K) and other nutrients  If chronic: malnutrition, fluid, electrolyte imbalance  If bleeding: anemia Diarrhea  Medication-induced diarrhea  Indirect effects- antibiotics- reduce normal bacteria ◼ C.difficile proliferates  Direct effect- cause diarrhea ◼ Lactulose  Osmotic diarrhea: solutes present in intestinal tract are poorly absorbed  Dumping syndrome  Lactose intolerance  Secretory diarrhea: secretion of water and electrolytes by the intestinal epithelium due to:  Bacteria, viruses,  intestinal hormone secretion Diarrhea  Exudative diarrhea: always associated with mucosal damage  Mucus, blood, and plasma proteins, water and electrolytes in the gut  Diarrhea of Crohn’s, ulcerative colitis and radiation enteritis  Malabsorptive diarrhea: due to decreased surface area of the mucosa  Lack of absorption of nutrients due to rapid, inadequate exposure of chyme in the intestine  Steatorrhea- malabsorption of fat  Diarrhea of Crohn’s and extensive bowel resection Diarrhea Nutritional Care  Remove cause  Prebiotics  Maintains good bacteria, prevents overgrowth of disease causing organisms: whole grains, honey, leeks, bananas, garlic, artichokes, pectin, oats  Probiotics   good bacteria harmful ones; can reduce risk of intestinal viruses: yogurt with active cultures, Kefir, Lactobacillus  Diarrhea Nutritional Care continued Adults  Replace fluids and electrolytes  Fruit juice, Gatorade, high Na and K  Add pectin - hydrophilic fiber; H2O soluble  Scraped apple, applesauce  Gradual increase to regular diet once symptoms subside  Start low fiber; add fiber as tolerated  Limit lactose, excess sucrose, ETOH  Avoid milk at first  Fat - need not be limited usually Diarrhea Nutritional Care continued Infants and Children  Dangerous due to rapid dehydration  Rapid replacement of fluid and electrolytes needed  WHO and AAP: ◼ Oral rehydration solution ◼ Commercial solutions (Pedialyte, Rehydralyte)  Early re-feeding promotes repair of damaged gut by infection  Parenteral hydration may be needed Steatorrhea Unabsorbed fat remaining in the stool  Indicates fat malabsorption  Dx - ratio of fecal fat to ingested fat Causes  Failure of proper digestion – pancreatitis, lipase deficiency, short bowel syndrome  Bile salt deficiency – liver dz, biliary dz, blind loop syndrome, ileal resection  Mucosal damage – celiac dz, IBD, radiation enteritis Steatorrhea Nutritional Care  Treat cause  Treat weight loss   protein, CHO, fats as tolerated  Supplement fat sol vitamins, and Ca, Zn, Mg, Fe, and MCT oil, as needed Steatorrhea Nutritional Care continued  Medium Chain Triglycerides (MCTs) ◼ Does not need pancreatic lipase or bile acids for absorption ◼ Enters portal venous circulation for direct transport to the liver w/o being re-synthesized to TG ◼ Provided in some enteral formulas ◼ Provided as MCT oil ◼ 8.3 kcal/g; 1 T = 116 kcal ◼ 50 ml / day (418 kcal) Disease of Small Intestine  Celiac Disease  Intestinal Brush Border Enzyme Deficiencies Celiac Disease AKA Gluten Sensitive Enteropathy or Non-Tropical Sprue  Etiology: Genetic and autoimmune   action of GI enzymes on gluten, from wheat, rye, barley, trigger inflammatory response  Damage to villi of mucosa of jejunum or ileum results in malabsorption of nutrients   in cholecystokinin causes  gallbladder and pancreatic stimulation Celiac Disease  Symptoms: Many  May or may not have diarrhea  Dermatitis herpetiformis – skin lesions  Diagnosis: Mucosal biopsy  Treatment:  Endopeptidases  Gluten-free diet Celiac Disease Nutritional Care  Gluten-free diet – re-biopsy – gluten challenge – another biopsy in 6 weeks  Once on gluten free diet symptoms cease  Eliminate:  Barley  Rye  Oats (maybe)  Wheat  In first weeks supplement vits, min, protein, fluids and electrolytes and keep lactose free  Allow: arrowroot, soybean, corn, potato, rice, tapioca  Label reading very important  Intestinal Brush Border Enzyme Deficiencies  Lack of disaccharidases to hydrolyze disaccharides  Causes:  Congenital (birth) defect – sucrase, isomaltase, deficiency (rare)  Diseases i.e. Crohn’s  Lactase deficiency → Lactose intolerance (common) ◼ Highest prevalence: Blacks, Asians, S. Americans, East European Jews Lactose Intolerance ❑ Genetically acquired ❑ Usually after age 2 ❑ Lactose not hydrolyzed into galactose and glucose – stays in gut – osmotic diarrhea results ❑ Bacteria ferments indigestible lactose: bloating, flatulence, cramps, diarrhea  Lactose Intolerance Lactose Tolerance Tests  Oral lactose given (up to 50 g)  If lactose intolerant:  Blood glucose does not rise much above fasting level; GI symptoms may appear  Intestinal production of H increases – can measure with H breath test: ◼ Measure of H produced by colonic bacteria in the presence of unabsorbed sugars (lactose) Lactose Intolerance Nutritional Care  Omit or reduce lactose containing foods  Usually can consume some lactose, dairy  Aged cheese low in lactose  Yogurt with cultures – microbial galactosidase – not frozen (galactosidase sensitive to freezing)  Lactase treated products: Lactaid Inflammatory Bowel Disease (IBD)  Crohn’s Disease  Ulcerative Colitis Inflammatory Bowel Disease (IBD) Crohn’s and Ulcerative Colitis  Typical onset age 15-30  May be associated with overall poor diet and malnutrition → affects GI  GI tract is immune organ ◼ Over-reactive immune response; doesn’t “turn off” ◼ Causes prolonged inflammation and mucosal destruction, either mild or severe   Risk of cancer IBD  Crohn’s  Affects segments of the small and large intestine  Ulcerative Colitis  Affects continuous area of large intestine, retrograde Crohn’s Crohn’s AKA Regional Enteritis  Chronic, progressive disorder; surgery often does not help  Location  S. Intestine or colon or both  Watery loose stool suggests ileum  Stool incontinence, urgency, rectal bleeding suggests colon  Symptoms / Problems  Fatigue, anorexia, wt loss, rt LQ pain, cramping, diarrhea, fever  Chronic diarrhea ◼ Bile salt malabsorption, inadequate intestinal surface area, fistulas, bacterial overgrowth  Oxalate renal stones ◼ Steatorrhea promotes excessive oxalate absorption ◼ Diarrhea causes  fluids  Malabsorption, malnutrition, anemia Ulcerative Colitis Ulcerative Colitis  Chronic inflammation and ulcerations of large intestine; begins in the rectum  Symptoms / Problems  Young – 20-40 years old; 2 peak 50-60  Rectal bleeding, diarrhea, pain / spasm, fever, dehydration, electrolyte imbalance, anorexia, malnutrition  Anemia – blood loss  Intestinal muscles may be damaged - colonic dilitation – megacolon  Medical treatment  Meds: antiinflammatory, antibiotics, immunosuppressive  Surgery: colon resection / removal IBD Treatment  During acute periods –  Fluid / electrolyte balance  Meds ◼ Anti-diarrheal ◼ Anti-inflammatory ◼ Immunosupressive  Surgery  Removal of the diseased portion of the ileum or colon  Crohn’s – intestinal resection, with ileostomy as needed, preserving as much bowel as possible  Ulcerative colitis – colon resection, with colostomy as needed, can end disease process IBD Nutritional Problems  Malnutrition  Fear of eating – pain, diarrhea  Food intake, altered taste, malabsorption, steatorrhea, protein loss, blood loss, meds inhibit folate  Growth failure In children and adolescents Nutritional Goals  Restore good nutritional status loss and promote N balance  Outpatient management IBD Nutritional Care  Perform in-depth assessment; Individualize care  Flares  Bowel rest (questionable), parenteral or elemental tube feed or small frequent oral feedings  High protein, high kcal, > 50% of needs  Low fat (~25% total kcal), MCT if steatorrhea  Low fiber  Low lactose  General  Prebiotics and probiotics  Omega 3 fatty acids  Folate, Fe, B12 – anemia because of meds and blood loss   fiber, depending on symptoms of disease Disease of the Large Intestine  Irritable Bowel Syndrome (IBS)  Diverticular Disease  Colon Cancer Irritable Bowel Syndrome (IBS) Abnormal stooling pattern persisting > 3 mos  Cause unknown; r/o other diseases  Possibly: excess laxatives, antibiotics, caffeine; ↓ rest  Underweight; afraid to eat; fear pain Nutritional Care  Goals: relieve condition, nourish, promote wt gain  May be hypersensitive to certain foods; try elimination diet  chocolate, dairy, eggs, wheat may be offenders,  High fiber diet, pre and probiotics  Low FODMAPs  Exclude stimulants Diverticular Disease  Diverticulosis - herniations in colonic wall  Diverticulitis - infection and inflammation; sometimes ulceration or perforation  fecal matter in diverticular herniations / pockets Nutritional Care  Diverticulosis: high fiber; start slowly as many have been low fiber for years  Diverticulitis: low fiber /residue, elemental, antibiotics  Maybe low fat -  contractions of colon after  fat meal  Note: next slide is no longer a figure in the text.  Colon Cancer  Prevention  Dietary Guidelines for Americans  Polyps  Precursors of colon CA  Colon CA treatments  Radiation, chemotherapy, surgery Intestinal Surgeries  Intestinal Surgeries  Bowel Resections  Surgery of the Small Intestine  Surgery of the Large Intestine  Ostomies Surgery of the Large Intestine Conditions Leading to Surgery Types of Surgery Surgery of Small Intestine  Small bowel resection  For cancer, radiation enteritis, fistula, ischemic bowel, volvulus  Short bowel syndrome ◼ Lack of adequate intestinal length due to surgical resection, resulting in malnutrition despite normal intake ◼ Permanent parenteral nutrition may be needed Surgery of Small Intestine  Functions of SI  Duodenum: digestive secretions and nutrient absorption  Jejunum: remaining sugars, starch, fiber, lipids, fluids are digested, fermented and absorbed  Ileum: absorption of fat-soluble vits, lipids, bile salts, B12- intrinsic factor and fluid (see Krause Figure 1-9)  Duodenal Resection (rare)  Jejunal Resection  Decreased surface area and increased transit time leads to some decreased absorption of remaining nutrients  However, ileum adapts and assumes the absorptive functions of the jejunum Surgery of Small Intestine  Ileal Resection Major nutritional consequences of malabsorption of bile salts:  Bile salts not “recycled” but are excreted  Liver increases bile salt production to compensate but can not maintain this  An overall decrease in bile salt production results in fat malabsorption and steatorrhea Fat malabsorption causes:  Fat soluble vitamin deficiencies ◼ Poor absorption of fat soluble vits A, D, E, K  Mineral deficiencies ◼ Ca, Mg, Zn combine with unabsorbed fats and are excreted in steatorrhea, resulting in Ca, Mg, Zn deficiencies  Oxalate kidney stones ◼ Oxalate normally binds to Ca, Mg, Zn, but Ca, Mg, Zn now unavailable as bound to fatty acids ◼  oxalate absorption in the colon → hyperoxaluria → oxalate renal stones ◼ poor fluid reabsorption and dehydration contributes to stone formation as well Surgery of Small Intestine Nutrition Care  Immediate post-op: TPN  Advance to enteral ASAP  Glutamine is preferred nutrient for enterocytes - consider supplementation  Narcotics given post-op  GI motility w/ side effects of cramps, distension  Food provides widest variety of necessary nutrients  Absorptive adaptation can take up to ~ 1 year Surgery of Small Intestine Nutrition Care  Jejunal Resection  Adapts quickly to normal diet  Six small meals  Avoid lactose   concentrated sweets   caffeine  Diet quality most important Surgery of Small Intestine Nutrition Care  Ileal Resection  Parenteral nutrition  with oral nutrition, to nourish enterocytes  Transition feedings from parenteral → enteral  preserves intestinal function, prevent gut atrophy  Small, frequent meals  with fluids/electrolytes  Limit fat  MCT for kcal and absorption of fat soluble vitamins  Supplement water miscible fat soluble vitamins A, D, E, K and minerals Ca, Mg, Zn Ileostomy & Colostomy  Ileostomy (opening into ileum)  Colon, rectum, anus removed or bypassed  Stool from ileostomy is liquid  Those w/ ileostomy have  need for water and salt  Colostomy (opening into colon)  Rectum and anus removed or bypassed  Stool output from opening (stoma) depends on location  Certain foods cause more odor or problems w/ stool  May be permanent or temporary Rectal Surgery Rectal Surgery  Elemental diet decreases stool output for healing  May decrease as low as 50g (~2oz) of stool output every 6 days Other Conditions  Blind Loop  Bacterial overgrowth due to stasis of intestinal tract: obstruction, radiation enteritis, fistula, surgical repair of the intestine  Remove blind loop, antibiotics, lactose free, MCT, B12 (microbes compete for B12)  Fistula  Abnormal passage between two internal organs or from an internal organ to the surface of the body; severely deplete nutritional status. Aggressive nutrition support needed.  TPN, elemental, depends on location, cause, pts condition  Ileus  Intestinal obstruction, paralysis