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Transcript of CHAPTER 18 1. 2 Identify problems of the upper gastrointestinal tract Identify problems of the lower...
CHAPTER 18
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Chapter 18Gastrointestinal and Accessory Organ Problems
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Objectives:Identify problems of the upper
gastrointestinal tractIdentify problems of the lower
gastrointestinal tractIdentify food allergies and intolerancesIdentify problems of the gastrointestinal
accessory organs
Key Concepts3
Diseases of the gastrointestinal tract and its accessory organs interrupt the body’s normal cycle of digestion, absorption, and metabolism
Food allergies result from sensitivity to certain proteins
Underlying genetic diseases may cause metabolic defects that block the body’s ability to handle specific food nutrients.
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Problems of the Mouth Dental problems
◦ Tooth decay◦ Ill-fitting dentures, loss of teeth
problems with eating, swallowing, and overall nutrition
◦ Mechanical soft diet helpful Post Surgical procedures ◦ E.g. fx. Jaw, head/neck surgeries◦ Healing nutrients administered with
high-protein, high-caloric milk shakes
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Gingivitis/TMJ problems
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Problems of the MouthOral tissue inflammation – malnutrition
causes deterioration of oral tissues resulting in local infection or injury pain and difficulty eating◦ Gingivitis – inflammation of the gums
+ the tissues encircling the base of the teeth
◦ Stomatitis –inflammation of the oral mucous lining of the mouth
◦ Glossitis – inflammation of the tongue◦ Cheilosis – a cracking and dry scaling
process at the corners of the mouth affecting the lips and corner angles making opening the mouth to eat painful
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Mouth ulcers may develop from 3 infections:◦ Herpes Simplex Virus mouth sores on the inside
mucous lining of the cheeks and lips or on the external portion of the lips (cold sores, blisters)
◦ Candida Albicans – a fungus causing similar sores on the oral mucosa (thrush)
◦ Hemolytic Streptococcus – bacteria causing canker sores
Eating is painful and adequate nutrition becomes a major problem◦ Nutritionally dense liquids soft, nonacidic and
nonspicy, room temperature foods
8Salivary gland problems
Infections – e.g. virus that attacks the parotid gland (mumps)
Excess salivation – e.g. Parkinson’s, local mouth infections, injury and drug reactions
Xerostomia (permanent dry mouth) – sometimes in middle-aged and elderly adults often associated with RA, radiation therapy, drug side effect
Problems of the Mouth9
Swallowing disordersDysphagia (difficulty
swallowing) fairly common problem
Variety of causes: Insufficient production
of saliva Dry mouth Abnormal peristaltic
motility of the esophagus Complications of
medication Neurologic problems
Problems of the Mouth10
Swallowing Disorders cont. To treat dysphagia, the problem must be
identified as either mechanical obstruction or a neuromuscular disorder
Dysfunctional swallowing aspirate food particles
Swallowing disorders common in trauma, brain injury, and stroke patients
Diet adaptations may be necessary Special feeding techniques
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Problems of the Mouth
Warning signs of swallowing disorders: Reluctance to eat certain food
consistencies or any food at all Very slow chewing or eating Fatigue from eating Frequent throat clearing Complaints of food “sticking” in throat Holding pockets of food in cheeks Painful swallowing Regurgitation, coughing, choking
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Problems of the Esophagus
Central tube (esophagus) – problems interrupt normal swallowing: Muscle spasms or uncoordinated
contractions Stricture (narrowing) of the tube
Lower esophageal sphincter problems May come from changes in the smooth
muscle itself or from the nerve-muscle hormone control of peristalsis
Problems of the Esophagus13
Lower Esophageal Sphincter Problems cont. Achalasia or cardiospasm –spasms occur when
the LES muscles maintain an excessively high muscle tone, even while resting, thus failing to open normally when a person swallows Sx. – swallowing problems, frequent vomiting,
feeling of fullness in chest, weight loss from eating difficulty, serious malnutrition, pulmonary complications
Treatment – surgical – dilate the LES or slit the muscle
Diet: oral liquids and progress to regular diet
GI Cocktail14
Mixture of liquid antacid
Viscous lidocaineDonnatol
Useful as part of the diagnostic protocol for patients complaining of chest pain
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Problems of the Esophagus
Gastroesophageal Reflux Disease (GERD)◦Caused by constant regurgitation of
acid gastric contents into lower esophagus esophagitis
◦Pregnancy, obesity, pernicious vomiting, or nasogastric tubes are factors
◦Gastric acid and pepsin cause tissue erosion
◦Stenosis (narrowing or stricture) most common complication + peptic ulcer
Problems of the Esophagus16
GERD cont.Treatment:
Weight management
Acid control Low-fat diet Sleep with HOB
elevated
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Normal Stomach
Hiatal hernia
Hiatal hernia Portion of
upper stomach protrudes through opening in the diaphragm membrane (hiatus)
Especially common in obese adults
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Peptic Ulcer DiseaseIncidence:
Lifetime prevalence of PUD is approx. 10%, occurring simultaneously in men and women
Seen mostly in middle adulthood between the ages of 45-55
80-90% caused by Helicobacter pylori (H. pylori) infection (bacteria) Persons with chronic H. Pylori are at
greater risk for gastric cancerTobacco smoking linked to PUD
Peptic Ulcer Disease 20
Chronic use of nonsteroidal anti-inflammatory (NSAID) drugs may contribute to development in some persons irritate the gastric mucosa bleeding, erosion, and ulceration
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Physical Factors: Lesion can occur in the lower esophagus,
stomach, or the first portion of the duodenum
Most occur in the first portion of the duodenum (duodenal bulb) because the gastric contents emptying there are more concentrated
The lesion results from an imbalance between: 1. the amount of gastric acid and pepsin
secretions plus the extent of H. pylori infection
2. the degree of tissue resistance to these secretions and infection
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Psychological Factors: Stress during young- and middle- adult years may
contribute Stress of emergency trauma and injury Long term rehab processes
Clinical symptoms: Increased gastric muscle tone and painful
contractions when stomach empty Hemorrhage Dx. Confirmed by radiographs and gastroscopy
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Peptic Ulcer Disease
Peptic Ulcer Disease 24
Medical Management:
4 basic goals: Alleviate the
symptoms Promote healing Prevent
recurrences by eliminating the cause
Prevent complications
Peptic Ulcer Disease 25
Treatment: REST: adequate rest, relaxation, and
sleep – enhances the body’s healing process
Anxiety Management: incorporate positive coping skills into
daily life encourage pts. to talk about anxieties,
anger, frustrations Appropriate physical activity Smoking, alcohol use should be
eliminated Some common drugs (e.g. ASA, NSAIDS)
should be avoided
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Drug therapy Blocking agents that control acid secretion
Tagamet, Zantac Proton Pump Inhibitors – inhibit HCl
production Omeprazole, Pantoprazole
Mucosal protectors inactivate pepsin and produce gel-like substance to cover ulcer Sucralfate (Carafate)
Antibiotics control H. pylori Amoxicillin, Tetracycline, Metronidazole
Antacids counteract or neutralize acid
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Peptic Ulcer Disease Dietary management
Well-balanced, healthy diet Avoid acid stimulation
Food quantity Milk intake Seasonings Dietary Fiber Avoid caffeine, citric acid juices, alcohol Avoid smoking
Bland diets have been proven to be ineffective and lacking in adequate nutrition
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Small Intestine Diseases
Malabsorption syndromes are characterized by a defect in the absorption of fats, proteins, carbohydrate, vitamins, minerals, and/or water.
Small Intestine Diseases29
Malabsorption results from a disturbance in the normal digestive process and the defect may include any of the following processes: Digestion of macronutrients (CHO, proteins,
fats) Terminal digestion at the brush border
mucosa Transport
Chronic Diarrhea/Steatorrhea – most common symptom of malabsorption disorders
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Small Intestine DiseasesMalabsorption -Causes: Maldigestion problems – pancreatic disorders,
bacterial overgrowth, Inflammatory bowel disease
Intestinal mucosal changes – mucosal surface alterations; surgery
Genetic disease – e.g. cystic fibrosis (pancreatic insufficiency, lack of pancreatic enzymes
Intestinal enzyme deficiency – e.g. lactose intolerance
Cancer and its treatment – effects of radiation and chemotherapy
Metabolic defects – absorbing surface effects of pernicious anemia and gluten-induced mucosal disease
Small Intestine Diseases31
3 common malabsorption conditions:
Cystic FibrosisInflammatory
Bowel DiseaseDiarrhea
Small Intestine Disease32
Cystic Fibrosis Most fatal genetic disease in North America Metabolic defect characterized as a pulmonary
disease with a profound GI impact Life expectancy now to adulthood Inhibits movement of chloride and sodium ions in
the body tissue fluids These ions become trapped in cells causing thick
mucous to form that clogs ducts and passageways
CF symptoms: Thick mucous in the lungs damaged airways
difficulty breathing and lung infections
Small Intestine Disease33
Cystic Fibrosis symptoms cont. Pancreatic Insufficiency lack of normal
pancreatic enzymes and progressive loss of insulin-producing beta cells diabetes mellitus
Malabsorption of undigested food nutrients malnutrition and stunted growth
Liver disease from progressive degeneration of functional liver tissue d/t clogged bile ducts
Salt concentration increased in body perspiration salt depletion
Cystic Fibrosis
Symptoms of CF35
Clinical manifestations: very salty-tasting skin; persistent coughing, at times with phlegm; frequent lung infections; wheezing or shortness of breath; poor growth/weight gain in spite of a good
appetite; and frequent greasy, bulky stools or difficulty in
bowel movements
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Small Intestine DiseasesCystic fibrosis cont.Nutrition Management
Treated with pancreatic replacement products
Children with CF require 105% - 150% of recommended nutrients for their age
Nutritionally adequate high-protein, normal-to-high fat diet recommended
Regular Nutritional Assessment, Education, and follow up care
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Intestine DiseasesInflammatory Bowel Disease
Applies to both Ulcerative Colitis and Crohn’s disease
Related condition: Short-bowel syndrome - results from repeated surgical removal of parts of the small intestine as disease progresses
Reduces absorption of nutrients because absorbing surfaces are reduced
Considered “idiopathic” diseases because their etiology is unknown
Intestinal Diseases39
Inflammatory Bowel Disease cont. Crohn’s Disease: most commonly
localized in the ileum and colon Inflammation may skip sections of the GI
tract and affect more than 1 section at a time
Ulcerative Colitis: limited to the colon Symptoms include: diarrhea with blood
and mucous, abdominal pain, cramping Progressive from the anus
Intestinal Diseases40
All inflammatory bowel conditions can have severe nutritional results as more and more of the absorbing surface area becomes involved.
Intestinal Disease41
Inflammatory Bowel Disease cont.Restoring positive nutrition is a basic
requirement for tissue healing and health Elemental Formulas of amino acids,
glucose, fat, minerals, and vitamins are more easily absorbed and support initial healing in response to antibacterial and anti-inflammatory medications.
Principles of continuing dietary management: High protein (omitting milk at first) High energy 2500-3000 kcal/day Increased vitamins and minerals
Intestinal Disease42
Diarrhea Typically not a disease of
the small intestine A symptom or result of
another underlying cause
May result from: Intolerance to specific
foods Acute food poisoning
from a specific food-borne organism or toxin
Viral infections
Small Intestine Diseases43
Diarrhea cont. Organisms include:
Parasites: Giardia, Cryptsporidium, Entamoeba Bacteria: Campylobacter, Clostridium Difficile, E.
coli, Listeria Monocytogenes, Salmonella, Shigella
Virus: HIV, rotovirus Chronic diarrhea can be life-threatening for
infants, young children and those with compromised immune systems dehydration and nutrient loss
Fluid and electrolyte replacement needed
Large Intestine Diseases44
Diverticular diseaseDiverticulosis: lower intestinal conditionFormation of many small
pouches (diverticula) along muscular mucosal lining
Develop at points of weakened muscles in the bowel wall Diverticulitis caused by
pockets becoming infected
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Large Intestine Diseases46
Diverticular Disease cont. Symptoms: as the
inflammatory process advances: Increase pain localized
in LLQ of abdomen N/V/D, distention,
intestinal spasm Fever Perforation surgery
Nutritional Therapy – increase dietary fiber; avoid nuts, seeds
Large Intestine Diseases47
Irritable bowel syndromeMulticomponent disorder
of physiologic, emotional, environmental, psychologic function
3 major types of symptoms:
Chronic recurrent pain in abdomen
Small-volume bowel dysfunction (constipation, diarrhea, or both)
Excess gas formation
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Irritable Bowel Syndrome
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Large Intestine DiseasesIrritable bowel syndrome Individual approach to nutrition care
essential Food Plan Basic Principles:
Increase dietary fiber Recognize gas formers Respect food intolerances Reduce total fat content Avoid large meals Decrease air-swallowing habits
Large Intestine Diseases 50
ConstipationCommon short-term
problem Nervous tension
and worry Changes in routines Constant laxative
use Low-fiber diets Lack of exercise
Dietary management rather than laxatives
Food Allergies and Intolerances51
Allergic reaction is body’s immune system reacting to a protein as a threatening foreign object
“Allergy”: from 2 Grk. words meaning “altered reactivity” and refers to the abnormal reactions of the immune system to a number of substances in the environment.
Food Allergies and Intolerances52
Most common food allergens include proteins in: Cow’s milk Eggs Peanuts Wheat Soy Fish/shellfish Tree nuts
Food Allergies and Intolerances53
If a child is showing signs of allergic reaction, a process of food elimination is sometimes used to identify disagreeable foods.If a given food causes an allergic
reaction, the food is identified as an allergen and eliminated from use. The food may be tried again later to see if it still causes the same reaction, validating the initial response.
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Food AllergiesRecognizing s/sx of
allergic reactions may save a life
Anaphylaxis is the most severe response to an allergen Swelling of the face and
throat Respiratory distress Decreased blood pressure Death
Food Allergies and Intolerances55
Most common symptoms of food allergies are: Hives, nausea, diarrhea,
and abdominal pain
Dietitian can provide guidance on food substitutions or special food products
Recipes modified to maintain nutritional needs for growth
Large Intestine Diseases56
Celiac Sprue/Celiac Disease The cause:
Hypersensitivity to the protein gluten in certain grains – wheat, barley, rye
GI tract has damaged mucosal surface villi and microvilli that are malformed and deficient in number
Steatorrhea (approx. 80% of fat appears in the stool) and progressive malnutrition are secondary effects to gluten reaction
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Small Intestine Diseases Celiac Sprue cont.Nutrition management:
Goal: to control dietary gluten intake and prevent malnutrition
Avoid wheat, rye, oats, barley Adhering to a low-gluten or gluten-free
diet is the only effective tx. in maintaining a healthy mucosa
Must be followed for life Possible vitamin supplementation
Problems of the GI Accessory Organs58
3 major accessory organs: Liver Gallbladder Pancreas
Produce digestive agents
Diseases of these organs affect GI function and cause problems with the handling of specific foods
Liver Function59
Essential functions: Bile production Synthesis of proteins and blood clotting
factors Metabolism of hormones, medications,
macronutrients and micronutrients Regulation of blood glucose levels Urea production to remove the waste
products of normal metabolism
Liver Disease60
Steatohepatitis “the silent liver disease” – inflammation
and fat accumulation Exact cause is unknown Most often associated with alcohol abuse However, approx. 2-5% of Americans who
drink little are also affected. “Nonalcoholic steatohepatitis”. Higher incidence for individuals with
diabetes or obesity.
Liver Disease61
HepatitisAcute Hepatitis is an
inflammatory condition caused by viruses, alcohol, drugs, or toxins
Virus often transmitted via the oral-fecal route
The carrier is usually contaminated food or water
Other modes of transmission: blood transfusion, contaminated syringes, needles
Liver Disease62
Hepatitis cont.Symptoms: anorexia, jaundice, underlying
malnutritionTreatment : rest, nutrition therapyNutritional Therapy:
Adequate protein, high CHO, low fat, high kcals;
Progress from liquid feedings full diet
63
Liver Diseases Cirrhosis
Often a chronic state Fatty cirrhosis associated with
malnutrition and alcoholism Fatty infiltration kills liver cells, leaving
nonfunctioning scar tissue Low plasma protein levels ascites (fluid
collection in the abdomen) Scar tissue impairs blood circulation
elevated venous pressure esophageal varices
Rupture of varices massive hemorrhage
Liver Disease64
Nutritional Therapy Protein according to
tolerance If no s/sx hepatic
coma, 80-100 g of protein per day to correct severe malnutrition, heal liver tissue, and restore plasma protein
Low sodium Soft texture Optimal general
nutrition : No alcohol
Liver Disease65
Hepatitis cont. Treatment based
on bed rest and nutrition therapy: High protein,
high CHO, moderate fat, high energy; liquid diet full diet as tolerated
66
Liver Diseases Hepatic Encephalopathy
As cirrhosis continues, the blood, carrying its ammonia load, cannot get to the liver for its normal removal of the ammonia and nitrogen
Ammonia intoxication and coma occur Blood by passes the liver through
collateral circulation and goes brain Hepatic encephalopathy apathy,
confusion, inappropriate behavior, drowsiness, and coma
Treatment focuses on removing sources of excess ammonia – reduce protein intake
67
Advanced Liver Disease
Gall Bladder Disease68
Basic function of the Gall bladder: to concentrate and store bile
Releases concentrated bile into small intestine in response to fat
Bile emulsifies fat and then carries it into the cells of the intestinal wall for continued metabolism
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Gallbladder DiseaseCholecystitis – inflammation of the GB
Usually results from low-grade chronic infection
Continued infection alters solubility of bile ingredients, cholesterol separated out, and forms gallstones cholelithiasis
When infection, stones or both are present, the normal contraction of the GB (triggered by fat entering the intestine) causes pain
May need surgery for treatment: Cholecystectomy
Diet therapy centers on controlling fat intake
70
Gallstones
Pancreatic Disease71
Pancreas:Key organ in normal
digestion and metabolism
Digestive enzymes and bicarbonates Breakdown
carbohydrates, proteins, and fats
Blood glucose regulation Glucagon Insulin
Pancreatic Diseases72
Diabetes mellitus Acute
pancreatitis Chronic
pancreatitis Pancreatic
enzyme deficiency
Pancreas tumor
Pancreatic Disease73
Pancreatitis – acute inflammation of the pancreas occurs when the very enzyme that the pancreas produces (trypsin) digests the organ tissue Symptoms:
Severe pain Recurrent episodes Excessive alcohol
and gallstones are the major causes
74
Pancreatic DiseasePancreatitis cont.Obstruction of common duct causes
enzymes and bile to back up into pancreasResults in acute inflammation as enzymes
digest organ tissueCaused by gallstones and excessive alcohol
consumptionTreatment includes: fluid and electrolyte
replacement, antibiotics, pain med, sometimes gastric suctioning
Avoid alcohol and caffeine