Upper gi disorders mnt

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


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



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.



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


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


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


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


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


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.


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


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


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


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.

Upper gi disorders mnt

Health & Medicine

Transcript of Upper gi disorders mnt