medical nutrition therapy . lower gi

MNT in Lower GI tract disorders

Dr. Louay Labban

Common Intestinal Symptoms and Complications

Constipation - Definition

Medical Diagnosis Definition – based in part on defecation frequency of fewer than three bowel movements per week

• Higher among women

• Increases somewhat with aging

• Elderly report greater straining with defecation rather than reduced frequency

• 40% of pregnant women report some degree of constipation

• Low food intake

• Low-fiber diets

• Inactivity

• Systemic disorders – hypothyroidism, diabetes mellitus, and chronic renal failure

• Neurological conditions – Parkinson’s disease, spinal cord lesions, multiple sclerosis

• Psychological problems – depression, anxiety

• Side effects of medications and dietary supplements – opiate-containing analgesics, tricycles antidepressants, antihistamines, calcium channel blockers, aluminum-containing antacids, iron and calcium supplements

Constipation – Treatment

• Gradual increase in fiber – wheat bran, fruits and vegetables

• Add fiber supplements

• Make sure that patient has sufficient fluid intake

• Add prunes or prune juice to the diet

• Increasing daily exercise

Intestinal Gas

• Unpleasant side effect of high-fiber diet

• Incompletely digested or absorbed carbohydrates – fructose, sugar alcohols – and undigestible carbohydrates in beans

• Conditions that cause malabsorption – chronic pancreatitis, celiac disease

• Swallowed air

Diarrhea

• Characterized by passage of frequent, watery stools

• May cause dehydration and electrolyte imbalances

• If chronic, may lead to weight loss and malnutrition

• Serious cases may be accompanied by fever, cramps, dyspepsia and intestinal bleeding

Diarrhea - Causes

• nutrient malabsorption

• acceleration of entry of fluids into the colon, followed by inadequate reabsorption

• food poisoning, intestinal inflammation

• Acute diarrhea – Lasts for less than several weeks

• Chronic diarrhea – Lasts for a month or longer

Diarrhea - Treatment

• Rehydration therapy

–Containing water, salts, glucose or sucrose

–Commercial sports drinks are generally not recommended because sodium content too low

Dietary adjustments

–Elimination of offending food(s)/beverage(s)

–Antidiarrheal treatment

–Probiotics

Bacterial Overgrowth -Symptoms

• Chronic diarrhea

• Abdominal discomfort

• Bloating

• Weakness

Bacterial Overgrowth -Symptoms

• Weight loss

• Fat and carbohydrate malabsorption

–Vitamin A deficiency

–Vitamin D deficiency

–Vitamin K deficiency

–B12 deficiency

Bacterial Overgrowth Causes

• Some types of gastric surgery

• Strictures, obstructions, diverticula

• Reduced gastric acid secretions

Bacterial Overgrowth - Treatment

• Antibiotics

• Surgical correction of anatomical defects

• Discontinue acid reducing therapies

• Dietary supplements to reverse nutrient deficiencies – fat-soluble vitamins, calcium, B12, medium chain triglycerides (MCT)

Steatorrhea - Causes

Excessive fat in stools resulting from fat maldigestion or malabsorption caused by:

• Conditions that interfere with the availability of bile or pancreatic lipase (pancreatitis or cystic fibrosis)

Steatorrhea - Causes

• Inflammatory intestinal disorders (Crohn’s or celiac disease)

• Motility disorders that cause rapid gastric emptying or rapid intestinal transit

Steatorrhea - Consequences

Losses of:

• Food energy

• Fatty acids

• Fat-soluble vitamins

• Some minerals – calcium, magnesium, and zinc - oxalate kidney stones

Steatorrhea – Dietary Adjustments

• May recommend a fat-restricted diet

• Inclusion of MCT oil

Malabsorption Syndromes

Pancreatitis - Acute

• Often a consequence of gallstones or excessive alcohol use – 70% of the acute cases

• Less common causes – hypertriglyceridemia (>1000 mg/dL), exposure to toxins, some medications


• Begins with premature activation of digestive enzymes within pancreatic tissue –leading to the destruction of pancreatic cells and the inflammatory process


Signs and symptoms:

• Severe abdominal pain

• Nausea and vomiting

• Abdominal distention

• Elevated serum amylase and lipase levels

• Moderate-to-severe cases may lead to renal failure, sepsis and other complications

Medical Nutrition Therapy: • Nothing by Mouth (NPO) until pain and

tenderness subsided

• Fluids and electrolytes given intravenously

• Mild cases – oral intake of low-fat diet begins in 3-7 days of disease onset

• Severe cases – elemental jejunal tube feedings

• When beginning oral feedings –

–Small amounts given (½-1 cup of fluids)

–Diet is progressed to soft foods

–Solid foods are introduced last

–Small, frequent feedings

– Low-fat diets (decrease stimulation of pancreas)

–High protein and high kcalorie needs due to catabolic and hypermetabolic effects of inflammation

Pancreatitis - Chronic

Results in permanent damage to structure and function of pancreatic tissue

Causes:

• Alcohol consumption – 70% of cases

• In children – most cases attributable to cystic fibrosis

Pancreatitis - Chronic

Signs and Symptoms:

• Abdominal pain – severe, worsened by eating

• Steatorrhea

• Weight loss and malnutrition

• Reduction of insulin and glucagon – 30% of the patients

Medical Nutrition Therapy: • Steatorrhea treated with enteric-

coated pancreatic enzymes; if non-enteric-coated enzymes used – acid-suppressing drugs may be required

• Monitor fecal fat – adjust enzyme dose

• Low-fat diet – if fat malabsorption resistant to treatment – MCT oil recommended

Celiac Disease

• Characterized by an abnormal immune response to a protein fraction in wheat gluten and related proteins found in rye and barley

Celiac Disease

• Immune reaction to gluten causes intestinal mucosa changes

• Absorptive surface appears flattened due to shortening or absence of villi and overdeveloped crypts

• Restricted to small intestines

Consequences:

• Results in malabsorption of macronutrients, fat-soluble vitamins, electrolytes, calcium, magnesium, zinc, iron, folate, and vitamin B12

Symptoms:

• Diarrhea

• Steatorrhea

• Flatulence

• Lactase deficiency

• Stunted growth, underweight

• Severe rash – dermatitis herpetiformis

Medical Nutrition Therapy:

• Lifelong adherence to a gluten-free diet

• Avoid lactose-containing foods

• Eliminate wheat, rye, barley (oats – controversial)

• Read labels carefully – replace bread, pasta, cereal

• Can be social liability

• Diet counseling


Inflammatory Bowel Disease


• Conditions having patterns of inflammation resulting from excessive immune responses in intestinal tissue

• Exact cause unknown

• Complex set of genetic and environmental factors contribute to the development

• Occurs most frequently in persons 15-30 years of age

Crohn’s • Located in any part of GI tract

• Most often located in ileum and colon

• Can cause ulceration, fissures, fitulas (abnormal passages between tissues)

• Symptoms include:

–Diarrhea

–Abdominal pain

–Weight loss


Normal Colon Crohn’s Disease

Ulcerative Colitis • Involves rectum and extends into the

colon

• Tissue erosion or ulceration develops

• Symptoms:

–Diarrhea

–Rectal bleeding

–Abdominal pain during active episodes


Normal Colon Ulcerative Colitis

Complications - Crohn’s Disease:

• Narrowing of lumen

–Fibrous scar tissue

–Obstructions

• Strictures

–Pain

–Risk of bacterial overgrowth

• Malnutrition

• Malabsorption of fat, fat-soluble vitamins, calcium, magnesium, zinc, B12

• Anemia

• Increased risk of cancer in small intestines

Complications – Ulcerative Colitis:

• Weight loss

• Fever

• Weakness

• Anemia

• Protein losses

• High risk of developing colon cancer

Treatment

• Drug therapy

–Antidiarrheal agents

– Immunosuppressants

–Anti-inflammatory agents

• Surgical interventions

Medical Nutrition Therapy – Crohn’s:

• High-kcalorie, high-protein diet

• Liquid supplements

• Restriction of high-fiber and lactose-containing foods

• Low-fiber diets

• Vitamin and mineral supplements

Medical Nutrition Therapy – Ulcerative Colitis:

• Replace fluid and electrolyte losses

• Correction of deficiencies due to protein and blood losses

• Low-fiber diet

Medical Nutrition Therapy – Ulcerative Colitis:

• Bowel rest during exacerbations

• IV fluids

• TPN

• Colectomy

Conditions Affecting the Large Intestine

Irritable Bowel Syndrome

Motility disorder of small and large intestine.

Characterized by alterations in:

• Stool frequency

• Stool consistency

• Diarrhea

• Constipation


Characterized by alterations in:

• Flatulence

• Bloating

• Distention

• Abdominal pain relieved by defecation

• Occurs more frequently in women


Causes:

• Stress and anxiety

• Psychological stress

• Hypersensitivity to intestinal distention

• Hyperactivity of smooth muscle tissue or of the nervous system

• Possibly an infection

Treatment

• Dietary adjustments

• Medications

–Antidiarrheal agents

–Antidepressants

– Laxatives

Medical Nutrition Therapy

• Increase fiber intake – gradually

• Avoid foods that produce gas

• Bulk agent (psyllium)

• Avoid lactose-containing foods if lactose intolerant

• Small, frequent meals

• Eat slowly to avoid swallowing air

• Low-fat diet

• Adequate fluid intake

• Avoid foods and habits that cause intestinal discomfort

Diverticular Disease of the Colon

• Development of pebble-sized herniations in the intestinal wall

• Most often occurs in sigmoid colon

• Prevalence increases with age


Diverticular Disease

Diverticular Disease of the Colon

• Development is influenced by the amount of dietary fiber a person consumes

• Low-fiber diet increases the pressure in the intestines causing small areas of the intestinal tissue to balloon outward over time

• Localized inflammation or infection develops in the area around a diverticulum

• Thought to result from hardened or impacted fecal matter that abrades the mucosal lining –Causes inflammation

–May cause microperforation – infection – fistulas - peritonitis

Diverticular Disease of the Colon - Diverticulitis

Symptoms:

• Persistent abdominal pain

• Fever

• Alternating constipation and diarrhea

Treatment for diverticular disease

• Increase dietary fiber

• Bulk-forming agents (psyllium)

• Avoid nuts, popcorn, and foods that contain seeds – no evidence that this reduces complications

Treatment for diverticulitis

• Antibiotics

• Medications for pain control

• Clear liquid diet – advised initially - gradually progressed to solid foods as tolerated

• Bowel rest – for severe cases

• Surgical interventions may be needed for affected portion of colon (colectomy)

medical nutrition therapy . lower gi

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