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Nutrition and Nutrition and Gastrointestinal Gastrointestinal DisordersDisorders
Amanda Gordon, RD, LD, CNSCAmanda Gordon, RD, LD, CNSCAdvanced Practice Clinical DietitianAdvanced Practice Clinical DietitianThe George Washington University The George Washington University HospitalHospitalWashington, DCWashington, DCamanda.gordon@gwu-hospital.comamanda.gordon@gwu-hospital.com
Review Anatomy and PhysiologyReview Anatomy and Physiology
Review Digestion and Absorption of Review Digestion and Absorption of Macro and MicronutrientsMacro and Micronutrients
Introduce Common Clinical Introduce Common Clinical Presentations of GI DisordersPresentations of GI Disorders
Highlight MNT Highlight MNT (Medical Nutrition (Medical Nutrition Therapy) Therapy) for each GI Disorderfor each GI Disorder
Agenda and GoalsAgenda and Goals
The GI TractThe GI Tract
MouthMouth EsophagusEsophagus StomachStomach Small Intestine (Small Bowel)Small Intestine (Small Bowel) DuodenumDuodenum JejunumJejunum IleumIleum
The GI Tract: AnatomyThe GI Tract: Anatomy
The GI Tract: AnatomyThe GI Tract: Anatomy Large Intestine (Large Bowel)Large Intestine (Large Bowel) CecumCecum ColonColon AscendingAscending TransverseTransverse DescendingDescending SigmoidSigmoid RectumRectum Anal CanalAnal Canal
The GI Tract: Accessory The GI Tract: Accessory OrgansOrgans
Salivary GlandsSalivary Glands TongueTongue TeethTeeth LiverLiver GallbladderGallbladder PancreasPancreas AppendixAppendix PeritoneumPeritoneum MesenteryMesentery
The GI TractThe GI Tract
The digestion of nutrients from The digestion of nutrients from dietary food sources requires a dietary food sources requires a coordinated process of coordinated process of mechanicalmechanical and and chemicalchemical processes. Defects in processes. Defects in any of these phases of digestion or any of these phases of digestion or absorption can lead to maldigestion or absorption can lead to maldigestion or malabsorption of nutrients.malabsorption of nutrients.
2002 Canadian Medical Association
The EsophagusThe Esophagus
Function: The Transport TubeFunction: The Transport Tube Protected on two sides by two Protected on two sides by two
sphincterssphincters Upper Esophageal SphincterUpper Esophageal Sphincter Lower Esophageal SphincterLower Esophageal Sphincter
Disorders of the Esophagus : Disorders of the Esophagus : GERD GERD
LES malfunction, does not close properlyLES malfunction, does not close properly Stomach contents leak back, or reflux, into Stomach contents leak back, or reflux, into
the esophagus and irritate itthe esophagus and irritate it Can cause BarrettCan cause Barrett’’s Esophagus (tissue s Esophagus (tissue
changes in the esophagus)changes in the esophagus)
Treatment: Treatment: Antacids (Maalox, Tums, Mylanta)Antacids (Maalox, Tums, Mylanta) H2 blockers (Pepcid, Zantac, Tagamet)H2 blockers (Pepcid, Zantac, Tagamet) Proton pump inhibitors (Prevacid, Protonix, Proton pump inhibitors (Prevacid, Protonix,
Prilosec)Prilosec)
Limit or avoid peppermint, spearmint, Limit or avoid peppermint, spearmint, chocolate, alcohol, caffeinated and chocolate, alcohol, caffeinated and carbonated beveragescarbonated beverages
Limit or avoid high fat foodsLimit or avoid high fat foods Wait 3 hours after eating before lying downWait 3 hours after eating before lying down Raise the HOB by 6-9 inchesRaise the HOB by 6-9 inches Eat several small meals throughout the dayEat several small meals throughout the day
★★ GERD: MNTGERD: MNT
GERD: Surgical intervention GERD: Surgical intervention Nissen FundoplicationNissen Fundoplication
www.clevelandclinic.org
The StomachThe Stomach Where it all begins…Where it all begins… AnatomyAnatomy
FundusFundus BodyBody PylorusPylorus Pyloric SphincterPyloric Sphincter
PhysiologyPhysiology Chief cellsChief cells Parietal cells (HCl)Parietal cells (HCl) Endocrine cells (gastrin, ghrelin)Endocrine cells (gastrin, ghrelin)
The Stomach: The Stomach: DigestionDigestion
Process of emptying takes 2-6 hoursProcess of emptying takes 2-6 hours Most occurs in the pyloric regionMost occurs in the pyloric region Beginning of protein digestion Beginning of protein digestion
(proteolysis) via Pepsin(proteolysis) via Pepsin
Caused by delayed gastric emptyingCaused by delayed gastric emptying
Often occurs in people with Type 1 or Type 2 Often occurs in people with Type 1 or Type 2 DiabetesDiabetes
Symptoms include nausea, vomiting, early Symptoms include nausea, vomiting, early satiety, erratic BGsatiety, erratic BG
MNTMNTProkinetic agents (Reglan), small, frequent Prokinetic agents (Reglan), small, frequent meals (4-6x day), avoid high fat foods, full meals (4-6x day), avoid high fat foods, full liquids if needed, jejunostomy tubeliquids if needed, jejunostomy tube
Disorders of the Stomach: Disorders of the Stomach: GastroparesisGastroparesis
The Bowel: Digestion/AbsorptionThe Bowel: Digestion/Absorption
Remember: The intestines can adapt/compensateRemember: The intestines can adapt/compensate
The Small BowelThe Small Bowel Where the REAL action is…Where the REAL action is… AnatomyAnatomy
Duodenum, Jejunum, IleumDuodenum, Jejunum, Ileum Villi and MicrovilliVilli and Microvilli
PhysiologyPhysiology Gastric Inhibitory PeptideGastric Inhibitory Peptide Secretin: stimulates bicarbonateSecretin: stimulates bicarbonate CCK: stimulates ejection of bile from CCK: stimulates ejection of bile from
gallbladdergallbladder
Small Bowel Disorders: Small Bowel Disorders: Inflammatory Bowel DiseaseInflammatory Bowel Disease
CrohnCrohn’’s Diseases DiseaseInflammatory disease in the terminal Inflammatory disease in the terminal ileumileumWeight loss, anorexia, diarrheaWeight loss, anorexia, diarrheaB12 deficiencyB12 deficiencyMedications: Antibiotics, Sulfasalazine, Medications: Antibiotics, Sulfasalazine, CorticosteroidsCorticosteroids
Ulcerative ColitisUlcerative ColitisUlcerative disease of the colonUlcerative disease of the colonBloody diarrhea, weight loss, anorexiaBloody diarrhea, weight loss, anorexiaMedications: Mesalamine, Corticosteroids, Medications: Mesalamine, Corticosteroids, Anti-diarrhealsAnti-diarrheals
CrohnCrohn’’s vs. s vs. Ulcerative ColitisUlcerative Colitis
Disease UC Crohn’s
Anatomy Affected
Rectum, Colon
Mouth to Anus
Depth of Involvement
Mucosa, submucosa
Transmural
Distribution of Disease
Continuous Segmental
Malnutrition and Nutrient Deficiency Malnutrition and Nutrient Deficiency Concerns:Concerns:
Iron deficiencyIron deficiency Zinc deficiencyZinc deficiency Folate deficiency Folate deficiency (with use of (with use of
Sulfasalazine)Sulfasalazine) Vitamin B12 deficiency Vitamin B12 deficiency (Crohn’s Disease)(Crohn’s Disease) Vitamin D and Calcium Vitamin D and Calcium (bone disease (bone disease
concerns with long term steroid use)concerns with long term steroid use)
Small Bowel Disorders: Small Bowel Disorders: Inflammatory Bowel DiseaseInflammatory Bowel Disease
Maintain/correct fluid and electrolyte imbalancesMaintain/correct fluid and electrolyte imbalances
High calorie, high protein dietHigh calorie, high protein diet
(BEE x 1.5, 1-1.5 g/kg protein)(BEE x 1.5, 1-1.5 g/kg protein)
Low residue/low fiber diet Low residue/low fiber diet (during flare ups)(during flare ups)
Repletion and supplementation of micronutrientsRepletion and supplementation of micronutrients
Bowel Rest/TPN for acute flare-upsBowel Rest/TPN for acute flare-ups
Anti-diarrheal agentsAnti-diarrheal agents
Monitor closely for lactose intoleranceMonitor closely for lactose intolerance
★★ IBD: MNTIBD: MNT
Integrity of the ileocecal valveIntegrity of the ileocecal valve
Encourage early PO or enteral nutritionEncourage early PO or enteral nutrition
Villi adaption Villi adaption
Feeding transitions/overlapping feeding modalitiesFeeding transitions/overlapping feeding modalities
Use of soluble-fiber (pectins) may be beneficialUse of soluble-fiber (pectins) may be beneficial
Low-fat diet, lactose-free dietLow-fat diet, lactose-free diet
★★ IBD: MNTIBD: MNTSpecific Concerns After an Intestinal ResectionSpecific Concerns After an Intestinal Resection
Diarrhea/steatorrhea Diarrhea/steatorrhea malabsorption malnutritionmalabsorption malnutrition
Occurs after extensive small bowel Occurs after extensive small bowel resection (Crohn’s Disease, Radiation resection (Crohn’s Disease, Radiation Enteritis, Weight loss surgery)Enteritis, Weight loss surgery)
Small Bowel Disorders: Small Bowel Disorders: Short Bowel Syndrome (SBS)Short Bowel Syndrome (SBS)
Typically a 70-75% loss of small bowel (100-Typically a 70-75% loss of small bowel (100-120 cm of small bowel without a colon or 50 120 cm of small bowel without a colon or 50 cm of SB with a colon)cm of SB with a colon)
Resultant short-term and long-term Resultant short-term and long-term
problems with malabsorption which lead to problems with malabsorption which lead to fluid imbalance, weight loss, micronutrient fluid imbalance, weight loss, micronutrient deficienciesdeficiencies
Small Bowel Disorders: Small Bowel Disorders: Short Bowel Syndrome (SBS)Short Bowel Syndrome (SBS)
Comparison of Normal to Adapted Villihttp://www.shortbowel.com/information/beyond/intestinal.adaptation.asp
Disruption of Ileocecal valve and Ileal breakDisruption of Ileocecal valve and Ileal break Small bowel bacterial overgrowthSmall bowel bacterial overgrowth Role of bile salts in ileumRole of bile salts in ileum
Unabsorbed bile salts enter colon and Unabsorbed bile salts enter colon and cause osmotic diarrheacause osmotic diarrhea
Bile salt deficiency can lead to fat Bile salt deficiency can lead to fat malsorption and steatorrheamalsorption and steatorrhea
Small Bowel Disorders: Small Bowel Disorders: Short Bowel Syndrome (SBS)Short Bowel Syndrome (SBS)
Medications:Medications: Proton Pump Inhibitors (Nexium, Protonix, Proton Pump Inhibitors (Nexium, Protonix,
Prilosec, Prevacid) –Prilosec, Prevacid) – acid reductionacid reduction H2 Receptor Antagonists (Tagamet, Pepcid, H2 Receptor Antagonists (Tagamet, Pepcid,
Zantac) – Zantac) – acid reductionacid reduction Anti-secretory agents (Octreotide) – Anti-secretory agents (Octreotide) – reduce reduce
electrolyte and fluid losseselectrolyte and fluid losses Anti-diarrheals (Immodium, Lomotil, Paragoric)Anti-diarrheals (Immodium, Lomotil, Paragoric) Antibiotics – Antibiotics – treat small bowel bacterial treat small bowel bacterial
overgrowthovergrowth Bile Acid Sequesters (Cholestyramine) Bile Acid Sequesters (Cholestyramine) – preserve – preserve
bile acids to aid with fat absorption/prevent bile acids to aid with fat absorption/prevent steatorrheasteatorrhea
Small Bowel Disorders: Small Bowel Disorders: Short Bowel Syndrome (SBS)Short Bowel Syndrome (SBS)
Whole food dietWhole food diet High calorie (often 200-400% over their needs)High calorie (often 200-400% over their needs) Adequate fat (as calorie source, despite risk of Adequate fat (as calorie source, despite risk of
steatorrheasteatorrhea Avoid concentrated sweets/simple carbsAvoid concentrated sweets/simple carbs Lactose free (only if lactose intolerant)Lactose free (only if lactose intolerant) Moderate fiber (if colon is intact)Moderate fiber (if colon is intact) Oral rehydration agentsOral rehydration agents Nutrition support (TPN versus enteral nutrition)Nutrition support (TPN versus enteral nutrition) Replace vitamins and minerals (zinc, Replace vitamins and minerals (zinc,
potassium, Magnesium, fat soluble vitamins, potassium, Magnesium, fat soluble vitamins, Vitamin B12)Vitamin B12)
★★ SBS: MNTSBS: MNT
The Large BowelThe Large Bowel
The often overlooked powerhouse…The often overlooked powerhouse… AnatomyAnatomy
Cecum, Colon, Rectum, Anus Cecum, Colon, Rectum, Anus PhysiologyPhysiology
Absorptive cells (water, Na, Cl, Vit K)Absorptive cells (water, Na, Cl, Vit K) Goblet cells (secrete mucus)Goblet cells (secrete mucus)
FunctionsFunctions AbsorptionAbsorption Bacterial digestionBacterial digestion DefecationDefecation
Diverticulosis: small pouches in lining of Diverticulosis: small pouches in lining of colon that bulge outward through weak colon that bulge outward through weak spotsspots
Diverticulitis: small pouches become Diverticulitis: small pouches become inflamed, usually treated with antibioticsinflamed, usually treated with antibiotics
Role of fiber: Role of fiber:
High fiber versus low fiber?High fiber versus low fiber?
Large Bowel Disorders: Large Bowel Disorders: Diverticular DiseaseDiverticular Disease
Chronic gastrointestinal condition with Chronic gastrointestinal condition with symptoms including excess flatulence, symptoms including excess flatulence, abdominal discomfort, bloatingabdominal discomfort, bloating
Causative factors can include abnormal gut Causative factors can include abnormal gut motility, visceral hypersensitivity, imbalance motility, visceral hypersensitivity, imbalance of the gut floraof the gut flora
Lactose intoleranceLactose intolerance
Bowel Disorders: Bowel Disorders: Irritable Bowel Syndrome (IBS)Irritable Bowel Syndrome (IBS)
Foods that Can Aggravate Symptoms of IBSFoods that Can Aggravate Symptoms of IBS
MilkMilkCaffeinated beveragesCaffeinated beveragesAlcoholAlcoholFruitsFruitsSpicesSpicesFast Foods/Chinese FoodFast Foods/Chinese FoodCertain vegetables, including cabbage, broccoli, Certain vegetables, including cabbage, broccoli, cauliflower and corncauliflower and cornLegumes and beansLegumes and beansPreservatives and artificial flavoringPreservatives and artificial flavoringBaked productsBaked products
Maintain food record to help ID problem Maintain food record to help ID problem foodsfoods
Eliminate foods that aggravate symptoms Eliminate foods that aggravate symptoms (see prior list)(see prior list)
Restrict lactose as neededRestrict lactose as needed Eat small, frequent mealsEat small, frequent meals Aim to consume 6-8 cups of water dailyAim to consume 6-8 cups of water daily Exercise regularlyExercise regularly Gradually increase fiber content of diet Gradually increase fiber content of diet
(goal: 25-30 gm/day)(goal: 25-30 gm/day)
Role of probioticsRole of probiotics
★★ IBS: MNTIBS: MNT
Soluble fiberSoluble fiber: : Dissolves in water, slows Dissolves in water, slows intestinal transit timeintestinal transit time Pectins, gums, mucilages, some Pectins, gums, mucilages, some
hemicelluloseshemicelluloses Found in oat bran, legumes, psyllium Found in oat bran, legumes, psyllium
(Metamucil)(Metamucil)
Insoluble fiberInsoluble fiber: : Does not dissolve in water, Does not dissolve in water, speeds intestinal transit timespeeds intestinal transit time Lignans, cellulose, some hemicellulosesLignans, cellulose, some hemicelluloses Found in wheat bran, most fruits and Found in wheat bran, most fruits and
vegetablesvegetables
Fiber and the GI System: A Fiber and the GI System: A ReviewReview
DiarrheaDiarrheaMany clinical and medical causes. Many clinical and medical causes. (1st - identify the underlying cause)(1st - identify the underlying cause)
FeverFever DehydrationDehydration Infection (bacterial, viral)Infection (bacterial, viral) Hospital/community borneHospital/community borne Secretory Secretory (laxatives, bile acids)(laxatives, bile acids) Medications, antibioticsMedications, antibiotics Electrolyte repletion Electrolyte repletion (MagOx, (MagOx,
Neutraphos)Neutraphos) MalabsorptionMalabsorption Malnutrition/HypoalbuminemiaMalnutrition/Hypoalbuminemia Post-op lactose intolerancePost-op lactose intolerance Clear liquid dietsClear liquid diets PSBOPSBO
“Patient presents with diarrhea. Consult nutrition, it ’s probably the tube feed.”
Common Causes:Common Causes: Low fiber dietLow fiber diet Inadequate fluid intake/calorie intakeInadequate fluid intake/calorie intake Medication Medication Vitamin/Mineral supplementationVitamin/Mineral supplementation Food SensitivitiesFood Sensitivities
Treatment:Treatment: Fiber supplementation Fiber supplementation Potential role of prebiotics/probioticsPotential role of prebiotics/probiotics
ConstipationConstipation
““I know I learned this at some pointI know I learned this at some point””
The GallbladderThe Gallbladder
PhysiologyPhysiology Stores and concentrates bile that enters Stores and concentrates bile that enters
from the hepatic and cystic ductsfrom the hepatic and cystic ducts Ejects bile into the duodenum during Ejects bile into the duodenum during
digestiondigestion
Disorders of the Gallbladder, Disorders of the Gallbladder, Bile DuctBile Duct
CholecystitisCholecystitis Inflammation of the gallbladderInflammation of the gallbladder Gallstones (Choleliathsis)Gallstones (Choleliathsis)
JaundiceJaundice Obstruction of the bile duct, bile pigment Obstruction of the bile duct, bile pigment
builds up in the blood streambuilds up in the blood stream
CholecystectomyCholecystectomy Surgical removal of the gallbladderSurgical removal of the gallbladder
MNTMNTLow-fat dietLow-fat diet
ReferencesReferences
American Dietetic Association, Evidence Analysis American Dietetic Association, Evidence Analysis Library, Accessed electronically, August 2012.Library, Accessed electronically, August 2012.American Dietetic Association, Nutrition Care Manual. American Dietetic Association, Nutrition Care Manual. Accessed electronically, August 2012.Accessed electronically, August 2012.Clark, Christian and Mark DeLegge. Irritable Bowel Clark, Christian and Mark DeLegge. Irritable Bowel Syndrome: A Practical Approach. Nutr Clin Pract 2008 Syndrome: A Practical Approach. Nutr Clin Pract 2008 23: 263.23: 263.Hark, L, Morrison, G (eds). Medical Nutrition and Hark, L, Morrison, G (eds). Medical Nutrition and Disease: A Case Based Approach: 3rd Edition. 2003: Disease: A Case Based Approach: 3rd Edition. 2003: Blackwell Publishing.Blackwell Publishing.Jeejeebhoy, K. Short Bowel Syndrome: a Nutritional and Jeejeebhoy, K. Short Bowel Syndrome: a Nutritional and Medical Approach. Canadian Medical Association Journal Medical Approach. Canadian Medical Association Journal 2002 166: 1297-1302. 2002 166: 1297-1302. Lykins, TC, Stockwell, J. Comprehensive Modified Diet Lykins, TC, Stockwell, J. Comprehensive Modified Diet Simplifies Nutrition Management of Adults with Short-Simplifies Nutrition Management of Adults with Short-Bowel Syndrome. JADA. 98(3): 309-315. March 1998.Bowel Syndrome. JADA. 98(3): 309-315. March 1998.
Naik, A. and Nanda Venu. Nutritional Care in Adult Naik, A. and Nanda Venu. Nutritional Care in Adult Inflammatory Bowel Disease. Practical Inflammatory Bowel Disease. Practical Gastroenterology, June 2012: 18-27.Gastroenterology, June 2012: 18-27.
Rees Parrish, C. The Clinicians Guide to Short Bowel Rees Parrish, C. The Clinicians Guide to Short Bowel Syndrome. Practical Gastroenterology, September Syndrome. Practical Gastroenterology, September 2005: 67-106.2005: 67-106.
Sanjeevi, A. et al. The Role of Food and Dietary Sanjeevi, A. et al. The Role of Food and Dietary Intervention in the Irritable Bowel Syndrome. Practical Intervention in the Irritable Bowel Syndrome. Practical Gastroenterology, July 2008: 33-42.Gastroenterology, July 2008: 33-42.
Schiller, L. Nutrition and Constipation: Cause or Cure? Schiller, L. Nutrition and Constipation: Cause or Cure? Practical Gastroenterology, April 2008: 43-49Practical Gastroenterology, April 2008: 43-49
Thibodeau, G. et al. Anatomy and Physiology: 5th Thibodeau, G. et al. Anatomy and Physiology: 5th Edition. 2003: Mosby Publishers.Edition. 2003: Mosby Publishers.
ReferencesReferences
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