Medical Nutrition Therapy for Gastrointestinal Tract

Disorders
Diseases of Stomach
Indigestion
 Acute gastritis from: H. pylori tobacco, chronic use of drugs such as:
o Alcohol
o Aspirin
 Nonsteroidal antiinflammatory agent

Indigestion (Dyspepsia)
o Symptoms
 Abdominal pain
 Bloating
 Nausea
 Regurgitation
 Belching

o 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
 Erosion of mucosal layer
 Exposure of cells to gastric secretions, bacteria
 Inflammation & tissue damage
 Helicobacter Pylori (H. pylori)
o Bacteria, resistant to acid
o Damages mucosa
o Treat with bismuth, antibiotics, antisecretory agents
o Causes ~92% duodenal ulcers; 70% gastric ulcers

Atrophic Gastritis
 Loss of parietal cells in stomach
o Hypochloria =  in HCl production
o Achlorhydria = loss of HCl production
o Decrease or loss of intrinsic factor production
 Malabsorption of vitamin B12
  Pernicious anemia
 Vitamin B12 injections or nasal spray

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
o 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.

Definition and Etiology

 Erosion through mucosa into submucosa
 H. pylori
 Aspirin, NSAIDs
 Stress:
o Severe burns, trauma, surgery, shock, renal failure, radiation

Medical Management
 Plays a more important role than diet
o  or stop aspirin, NSAIDs
o Use antibiotics, antacids
o Use sucralfate (Carafate) = gastric mucosa protectant – forms barrier over ulcer

Behavioral Management
 Avoid tobacco
o Risk factor for ulcer development
o  complications – impairs healing, increases incidence of recurrence
o Interferes with tx
o Risk of recurrence, degree of healing inhibition correlate with number of
cigarettes per day

Treatment with Diet

 Reduce decaffeinated and regular coffee, cocoa, and tea intake
 Avoid alcohol or pepper
 Avoid low-pH juices if they cause problems (generally pH in foods is not an issue)
 Avoid large meals, especially right before bedtime
 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:
o Hemorrhage
o Perforation
o Obstruction
o Intractability (difficult to manage, cure)
o Pt unable to follow medical regimen
 Ulcers may recur after med. or surgical tx

Resective surgical procedures

 “Anastamosis” – connection of two tubular structures
 Gastrectomy – surgical removal of part or all of stomach
o Hemigastrectomy = half
o Partial gastrectomy
o Subtotal gastrectomy = 30-90% resected
 Billroth I = gastroduodenostomy
o Partial gastrectomy – anastomosis to duodenum
o To remove ulcers, other lesions (cancer)
 Billroth II = gastrojejunostomy
o Partial gastrectomy - anastomosis to jejunum
‐ Allows resection of damaged mucosa
‐ Reduces number of acid producing cells
‐ Reduces ulcer recurrence
 Total gastrectomy
o Removal of entire stomach
o Rarely done = negative impact on digestion, nutritional status
o In extensive gastric cancer & Zollinger-Ellison syndrome not responding to
medical management
o Anastomosis from esophagus to duodenum or jejunum
 Zollinger-Ellison Syndrome
o PUD caused by “gastrinoma”
o Gastrin producing tumor in pancreas
o Gastrin = hormone stimulates HCl prod
o Causes mucosal ulceration
o 50 – 70% are malignant
o Any part of esoph., stomach, duod., jejun.
o Removal of tumor, gastrectomy
 Pyloroplasty
o Surgical enlargement of pylorus or gastric outlet
o To improve gastric emptying with obstructions or when vagatomy interferes with
gastric emptying
o May contribute to Dumping Syndrome
o Ulcer recurrence is common
  Roux-en-Y
o Gastric partitioning – distal ileum, proximal jejunum
o Often for “bariatric” purposes (wt. loss)
o Wt loss for 12 – 18 wks with 50 – 60% excess wt. Loss

Nutritional Goals:
o Prevent deficiencies
o Promote eating, lifestyle changes to maintain losses
o Mechanical soft diet ~ 3 mo., then solid foods
o Small amounts – 1 oz. To 1 cup
o 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.
 Rapid movement of hypertonic chyme into jejunum
 Fluid drawn into bowel by osmosis to dilute concentrated mass of food
 Volume of circulating blood decreases
o Tachycardia (rapid heart rate)
o Dizziness, flushing
o Diaphoresis (profuse sweating)
o Orthostatic hypotension

Dietary Treatment
 Small meals spread throughout day
 High protein (20%), moderate fat (30 – 40%), complex CHO as tolerated
 Very small amts of concentrated sweets
 Food and drink should be moderate in temperature
 Use caution with high fiber foods – use pectin to decrease transit time, glucose absorption
  Take liquids between meals in small amounts (1/2 to 1 cup)
 Lactose  transit – poorly tolerated
 Medium-chain triglycerides-steatorrhea
 Eat slowly, chew food thoroughly
 If dumping is a problem, have patient lie down 20-30 minutes after meals to retard transit
to small bowel
Malabsorption, steatorrhea
 Post-surgical complications affecting nutrition:
o Fat soluble vitamins, calcium
o Folate, B12 (loss of intrinsic factor)
o Iron – better absorbed with  acid
o 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

Chronic gastritis
 Precedes gastric lesion like cancer or ulcer
 H. pylori infection may cause
Sx: Indigestion, loss of appetite, feeling full, belching, epigastric pain, nausea, vomiting
Rx: Avoid foods not tolerated; soft consistency; regular meals; chew foods
o Avoid highly seasoned foods; avoid excess liquid at meals

Atrophic gastritis:
o Stomach cells atrophy
o Loss of parietal cells—achlorhydria
o Lose IF for B12 absorption
Disorders of the Stomach— Nutritional Care
 Lifestyle changes are an important component of the nutrition care plan.
 Patients with dyspepsia should avoid high-fat foods, sugar, caffeine, spices, and alcohol.

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.