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

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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