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Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders
Esophagus Tube from pharynx to stomach Upper esophageal sphincter (UES or
cardiac sphincter) closed except when swallowing
Lower esophageal sphincter (LES) closes entrance to stomach; prevents reflux of stomach contents back into esophagus
Common Symptoms of Gastrointestinal Disease
Cancer of the Oral Cavity, Pharynx, Esophagus
Existing nutritional problems and eating difficulties caused by the tumor mass,
obstruction, oral infection and ulceration, or alcoholism
Chewing, swallowing, salivation, and taste acuity are often affected.
Weight loss is common.
Head and Neck Cancers
Can affect any part of the head and neck area
Surgical treatment can have profound effect on ability to take food orally
Often feeding tubes are placed at the time of surgery
Head and Neck Cancers
MNT in Head and Neck Cancers
Address nutritional consequences of disease and treatments (radiation therapy, surgery)
Radiation therapy can alter taste sensation, result in dry mouth, loss of appetite, mucositis and dysphagia
Malnutrition is reported to affect 30 to 50% of patients with head and neck cancers.
MNT in Head and Neck Cancers
Goal is to maintain adequate intake to promote healing and allow aggressive treatment
May involve enteral feedings, liquid oral supplements, dietary changes (liquid, moist, soft-textured foods and small, frequent meals
Artificial saliva solutions, increased fluids, topical anaesthetics to relieve pain
Aggressive oral hygiene, fluoride, treatment of fungal infections
Gastroesophageal Reflux Disease (GERD) Defined as symptoms or mucosal damage
produced by the abnormal reflux of gastric contents into the esophagus
Symptoms: Burning sensation after meals; heartburn, regurgitation or both, especially after meals
Symptoms often aggravated by recumbency or bending over and are relieved by antacids
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Hiatal Hernia An outpouching of a portion of the
stomach into the chest through the esophageal hiatus of the diaphragm
Heartburn after heavy meals or with reclining after meals
May worsen GERD symptoms
Anatomy of Esophagus and Hiatal Hernia
Complications of GERD Esophagitis, stricture or ulcer Barrett’s Esophagus (premalignant state)
Diagnosis of GERD
Empirically, via symptoms (symptoms don’t always correlate with the degree of damage)
Endoscopy – to confirm Barrett’s Esophagus and dysplasia (a negative endoscopy does not rule out the presence of GERD)
Ambulatory reflux monitoring
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Ambulatory Reflux Monitoring
Goals of Nutrition Intervention in GERD Increasing lower esophageal sphincter competence Decreasing gastric acidity, which results in
decreasing severity of symptoms Improving clearance of contents from the
esophagus Identification of drug-nutrient interaction Prevention of obstruction if esophageal stricture
present Improvement of nutritional intake if appropriate
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for GERD
Initiate weight-reduction program if overweight Initiate smoking cessation (lowers LES pressure) Improve clearing of materials from esophagus Remain upright after eating Avoid eating within 3 hours of bedtime Wear loose-fitting clothing Raise the head of bed for sleeping
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for GERD
Reduce gastric acidity by eliminating the following: Black and red pepper Coffee (caffeinated and decaffeinated) AlcoholSubstitute smaller more frequent meals Restrict foods that lessen lower esophageal sphincter
pressure by eliminating the following: Chocolate Mint Foods with a high fat content.
ADA Nutrition Care Manual, accessed 4-06
Nutrition Prescription for GERD
Spicy, acidic foods may be irritating if esophagitis is present
Limitation of these foods should be based on individual tolerance
Nutritional Care for Patients with Reflux and Esophagitis
Evidence reflecting the true efficacy of these maneuvers in patients is almost completely lacking– American College of Gastroenterology
Guidelines, 2005
Drugs Commonly Used to Treat Gastrointestinal Disorders Antibiotics: eradicate Helicobacter pylori,
prevent or treat infection after abdominal wounds or surgery
Antacids: neutralize gastric acid in acid reflux, peptic ulcer
Proton pump inhibitors (omeprazole, lansoprazole): decrease gastric acid secretion
Histamine-2 receptor antagonists (cimetidine, ranitidine): inhibit gastric acid secretion
Sucralfate (sulfated disaccharide): protects stomach lining and may increase mucosal resistance to acid or enzyme damage
Medications Used to Tx GERD
Antacids: Mylanta, Maalox: neutralize acids
Gaviscon: barrier between gastric contents and esophageal mucosa
H2 receptor antagonists available over the counter and by prescription (reduce acid secretion): cimetadine, ranitidine, famotidine, nizatidine
Medications Used to Treat GERD
Proton Pump Inhibitors (PPIs) Omeprazole (Prilosec), lansoprazole, rabeprazole, pantoprazole, esomeprazole
Some available over the counter now
Decrease gastric acid secretion
Medications Used to Treat GERD
Acid suppression is the mainstay of therapy for GERD. Proton pump inhibitors provide the most rapid symptomatic relief and heal esophagitis in the highest percentage of patients.
Although less effective than PPIs, Histamine-2 receptor blockers given in divided doses may be effective in persons with less severe GERDDeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Medications Used to Treat GERD
Promotility agents may be used in selected patients, especially as an adjunct to acid suppression. Currently available promotility agents are not ideal monotherapy for most patients with GERD
DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200
Medications Used to Tx GERD
Promotility Agents (enhance esophageal clearing and gastric emptying)
Cisapride, bethanechol
Surgical Treatment of GERD Fundoplication: Fundus of stomach is
wrapped around lower esophagus to limit reflux
Illustration of Fundoplication
Source: http://www.medformation.com/ac/adamsurg.nsf/page/100181#
MNT in NAUSEA/VOMITING
Nausea & Vomiting
Prolonged vomiting = hyperemesis– Loss of nutrients, fluids, electrolytes– Dehydration, electrolyte imbalance, wt. loss
Medications:– Antinauseants– Antiemetics
Goals of MNT in Nausea/Vomiting
Decrease the frequency and severity of nausea and/or vomiting
Maintain optimal fluid balance and nutritional status
Prevent development of anticipatory nausea, vomiting, and learned food aversions
ADA Nutrition Care Manual, accessed 4-06
MNT for Nausea/Vomiting
When vomiting stops, introduce ice chips if older than 3 years of age. If tolerated, start with rehydration beverage or clear liquids, 1 tsp every 10 minutes. Increase to 1 Tbsp every 20 minutes. Double amount of fluid every hour. If diarrhea is present, use only rehydration beverage.
Apple juice Sports drink Warm or cold tea Lemonade
ADA Nutrition Care Manual, accessed 4-06
MNT for Nausea/Vomiting When there has been no vomiting for at least 8 hours,
initiate oral intake slowly with adding one solid food at a time in very small increments. Choose the following types of foods:
Without odor Low in fat Low in fiber (see Client Education - Detailed, Foods
Recommended). Take prescribed antiemetics and other medications on a
regular schedule to assist in prevention of nausea and vomiting. Take all other medications after eating.
ADA Nutrition Care Manual, accessed 4-06
Nausea/Vomiting: Food and Feeding Issues Keep patient away from strong food odors Provide assistance in food preparation so as to
avoid cooking odors Eat foods at room temperature Keep patient's mouth clean and perform oral
hygiene tasks after each episode of vomiting Offer fluids between meals Patient should sip liquids throughout the day Cold beverages may be more easily tolerated Keep low-fat crackers or dry cereal by the bed to
eat before getting out of bed
Nausea/Vomiting: Lifestyle Issues
Relax after meals instead of moving around Sit up for 1 hour after eating Wear loose-fitting clothes Provide fresh air with a fan or open window Limit sounds, sights, and smells that may trigger nausea
and vomiting Other complementary and alternative medicine
interventions that have anecdotal evidence (though clinical trials have not been conducted):
Relaxation techniques Acupuncture Hypnosis
ADA Nutrition Care Manual, accessed 4-06
Diseases of Stomach Indigestion Acute gastritis from: H. pylori
tobacco, chronic use of drugs such as:
—Alcohol
—Aspirin
—Nonsteroidal antiinflammatory agents
Indigestion (Dyspepsia)Symptoms
Abdominal pain Bloating Nausea Regurgitation Belching
Dyspepsia Treatment
Avoid offending foods
Eat slowly Chew thoroughly Do not
overindulge
Gastritis
Normally gastric & duodenal mucosa protected by:– Mucus
– Bicarbonate (acid neutralized)
– Rapid removal of excess acid
– Rapid repair of tissue
Gastritis
Erosion of mucosal layer
Exposure of cells to gastric secretions, bacteria
Inflammation & tissue damage
Gastritis
Helicobacter Pylori (H. pylori)
– Bacteria, resistant to acid
– Damages mucosa
– Treat with bismuth, antibiotics, antisecretory agents
– Causes ~92% duodenal ulcers; 70% gastric ulcers
Atrophic Gastritis
Loss of parietal cells in stomach– Hypochloria = in HCl production– Achlorhydria = loss of HCl production– Decrease or loss of intrinsic factor production
• Malabsorption of vitamin B12
• Pernicious anemia
• vitamin B12 injections or nasal spray
Endoscopy
Peptic Ulcer Disease (PUD)
Gastric or duodenal ulcers Asymptomatic or sx similar to gastritis
or dyspepsia Danger of hemorrhage, perforation,
penetration into adjacent organ or space– Melena = black, tarry stools from GI
bleeding
Characteristics and Comparisons Between Gastric and Duodenal Ulcers
Gastric ulcer formation involves inflammatory involvement of acid-producing cells but usually occurs with low acid secretion; duodenal ulcers are associated with high acid and low bicarbonate secretion.
Increased mortality and hemorrhage are associated with gastric ulcers.
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
Gastric and Duodenal Ulcers
Peptic Ulcer Disease (PUD)Definition and Etiology Erosion through mucosa into submucosa
– H. pylori– Aspirin, NSAIDs– Stress:
• Severe burns, trauma, surgery, shock, renal failure, radiation
Peptic Ulcer Disease (PUD)Medical Management Plays a more important role than diet
or stop aspirin, NSAIDs
– Use antibiotics, antacids
– Use sucralfate (Carafate) = gastric mucosa protectant – forms barrier over ulcer
Peptic Ulcer Disease (PUD)Behavioral Management
Avoid tobacco• Risk factor for ulcer development complications – impairs healing,
increases incidence of recurrence
• Interferes with tx
• Risk of recurrence, degree of healing inhibition correlate with number of cigarettes per day
MNT for Peptic Ulcer Disease and GastritisMNT for Peptic Ulcer Disease and Gastritis
Avoid foods that increase gastric acid secretion, such as the following:
Alcohol Pepper Caffeine Tea Coffee (including noncaffeinated) Chocolate
Avoid foods that increase gastric acid secretion, such as the following:
Alcohol Pepper Caffeine Tea Coffee (including noncaffeinated) Chocolate
ADA Nutrition Care Manual, accessed 4-06
MNT for Peptic Ulcer Disease
Identify foods that directly irritate the gastric mucosa or are not generally tolerated
Avoid eating at least 2 hours before bedtime
Peptic Ulcer Disease Treatment with Diet
Meal frequency is controversial: small, frequent meals may increase comfort but may also increase acid output
There is little evidence to support eliminating specific foods unless they cause repeated discomfort
Overall good nutritional status helps H. pylori
Gastric Surgery
Indicated when ulcer complicated by:– Hemorrhage– Perforation– Obstruction– Intractability (difficult to manage, cure)– Pt unable to follow medical regimen
Ulcers may recur after medical or surgical tx
Gastric Surgery Resective surgical procedures “anastamosis” – connection of two
tubular structures Gastrectomy – surgical removal of part
or all of stomach– Hemigastrectomy = half– Partial gastrectomy– Subtotal gastrectomy = 30-90% resected
Gastric surgical procedures.
Fig. 30-7. p. 661.Fig. 30-7. p. 661.
Carcinoma of the Stomach Obstruction and mechanical interference Surgical resection or gastrectomy Prevention of GI cancers: fruits,
vegetables, and selenium Increase risk of GI cancers: alcohol,
overweight, high salted or pickled foods, inadequate micronutrients
Gastric Surgery Billroth I = gastroduodenostomy
– Partial gastrectomy – anastomosis to duodenum
– To remove ulcers, other lesions (cancer)
Billroth II = gastrojejunostomy– Partial gastrectomy - anastomosis to jejunum
Allows resection of damaged mucosa Reduces number of acid producing cells Reduces ulcer recurrence
Gastric Surgery Total gastrectomy
– Removal of entire stomach– Rarely done = negative impact on digestion,
nutritional status– In extensive gastric cancer & Zollinger-
Ellison syndrome not responding to medical management
– Anastomosis from esophagus to duodenum or jejunum
Zollinger-Ellison Syndrome PUD caused by “gastrinoma”
– Gastrin producing tumor in pancreas– Gastrin = hormone stimulates HCl prod– Causes mucosal ulceration– 50 – 70% are malignant– Any part of esoph., stomach, duod., jejun.– Removal of tumor, gastrectomy
Gastric surgical procedures. (cont.)
Fig. 30-7. p. 661.Fig. 30-7. p. 661.
Pyloroplasty Surgical enlargement of pylorus or
gastric outlet To improve gastric emptying with
obstructions or when vagotomy interferes with gastric emptying
May contribute to Dumping Syndrome Ulcer recurrence is common
Roux-en-Y
Gastric partitioning – distal ileum, proximal jejunum
Often for “bariatric” purposes (wt. loss)
Wt loss for 12 – 18 wks with 50 – 60% excess wt. Loss
Roux-en-Y
Nutritional Goals:– Prevent deficiencies– Promote eating, lifestyle changes to maintain
losses– Mechanical soft diet ~ 3 mo., then solid foods– Small amounts – 1 oz. To 1 cup– Overeating = N & V, reflux
Vagotomy Severing all or part of the vagus nerves
to the stomach With partial gastrectomy or pyroplasty Significant decrease in acid secretion “truncal vagotomy” – no vagal
stimulation to liver, pancreas, other organs, stomach
“selective vagotomy” or “parietal cell vagotomy” – eliminates stimulation to stomach
Diet Post Gastric Surgery Ice chips allowed 24-48 hours after
surgery. Some tolerate warm water better than ice chips or cold water
Clear liquids such as broth, bouillon, unsweetened gelatin, diluted unsweetened fruit juice
Initiate postgastrectomy diet and gradually progress to general diet as tolerated
Monitor iron, B12, and folic acid status
Dumping Syndrome Complex physiologic response to the rapid
emptying of hypertonic contents into the duodenum and jejunum
Dumping syndrome occurs as a result of total or subtotal gastrectomy and is associated with mild to severe symptoms including abdominal distention, systemic systems (bloating, flatulence, pain, diarrhea), and reactive hypoglycemia.
Dumping Syndrome Rapid movement of hypertonic chyme into
jejunum Fluid drawn into bowel by osmosis to
dilute concentrated mass of food Volume of circulating blood decreases
ADA Nutrition Care Manual, accessed 4-06
Dumping Syndrome Symptoms
Cramping Abdominal pain Hypermotility Diarrhea Dizziness Weakness Tachycardia within 10-20 minutes after
eating
MNT for Dumping Syndrome Prevent onset of early and late dumping syndromes. Initially avoid all hypertonic, concentrated sweets. Do not
start clear liquids as first oral feeding. The first meals should consist of protein, fat, and complex
carbohydrate, but with only 1-2 food items at a time. Patients may be initially lactose intolerant. Slowly progress to 5-6 small meals each day.
Consume liquids 30 minutes to 1 hour after consuming solid food.
Lie down after eating. Consider addition of functional fibers to delay gastric
emptying and assist with treatment of diarrhea.
MNT for Dumping Syndrome
These foods may exacerbate symptoms: Sucrose Fructose Sugar alcohols:
– Xylitol – Mannitol – Sorbitol
Source: ADA Nutrition Care Manual, accessed 4-06
Malabsorption, steatorrhea Post-surgical complications affecting
nutrition:• Fat soluble vitamins, calcium
• Folate, B12 (loss of intrinsic factor)
• Iron – better absorbed with acid– Supplement may help
Drugs Commonly Used to Treat Gastrointestinal Disorders Antacids: lower acidity Cimetidine (Tagamet), ranitidine (Zantac):
block acid secretion by blocking histamine H2 receptors
Prostaglandins Sucralfate: coats and protects surface Colloidal bismuth: coats and protects surface Carbenoxolone: strengthens mucosal barrier Tinidazole: antibiotic
Diabetic Gastroparesis (Gastroparesis Diabeticorum)
Delayed stomach emptying of solids Etiology—autonomic neuropathy Nausea, vomiting, bloating, pain Insulin action and absorption of food not
synchronized Prescribe small frequent meals (may need
liquid diet) Adjust insulin
Summary
Upper GI disorders—H. pylori plays an important role
Maintain individual tolerances as much as possible.