mdicalnutrther-gi disorder '10-'11 (kuliah git s1)
TRANSCRIPT
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Victor TambunanJohana Titus
Department of NutritionFaculty of Medicine Universitas Indonesia
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References
Krauses Food & Nutrition Therapy 12th ed.,
2008 ---- L.K. Mahan & S. Escott-Stump
Modern Nutrition in Health and Disease
10th ed., 2006 ---- M.E. Shils et al
Nutrition and Diagnosis-Related Care6th ed., 2008 ---- S. Escott-Stump
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Upper Gastrointestinal (GI) Tract
Esophagus
Stomach
Duodenum
Lower GI Tract
Small intestine
Large intestine
Rectum
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Gastroesophageal Diseases
Gastroesophageal reflux disease (GERD)
Achalasia
Gastritis and peptic ulcer disease
Dumping syndrome
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GERD consists of irritation & inflammation of
the esophagus in response to reflux of
gastric acid into the esophagus
Symptom:
heartburn (pyrosis)
Factors that contribute to GERD:Excessive volume of acidic contents in the stomach
Looseness of lower esophageal sphincter (LES)
Motility disorders in the esophagus
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Medical Nutrition Therapy
Objectives:
1. Prevent esophageal reflux
2. Prevent pain & irritation of theinflamed esophageal mucosa
3. the erosive capacity or acidity ofgastric secretion
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Nutrition Care Guidelines for ReducingGastroesophageal Reflux:
1. Avoid large, high-fat meals
2. Not eating within 34 hours before retiring
3. Avoid tobacco smoking, alcoholic beverages, and
caffeine containing foods & beverages
4. Stay upright & avoid vigorous activity immediatelyafter eating
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Nutrition Care Guidelines (contd)
5. Avoid tight-fitting clothing, especially after a meal
6. Consume a healthy, nutritionally complete diet with
adequate fibre
7. Avoid acidic & highly spiced foods when inflammation
exists
8. Reduce weight if overweight
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Alcohol
Chocolate
Fatty foods
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relaxing the LES & inducing GERD
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Failure of the cardiac sphincter to relax,with obstruction of food passage into thestomach
Nutrition management:
Objective:
Individualized diet according to patient
tolerances & preferences
Monitor chronic dysphagia
Avoid aspiration
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Provide large volumes of fluids with each meal,unless dysphagia prevents appropriate swallowingof liquids. Tube feeding if needed
Emphasize the importance of spacing meals &
achieving relaxation. Recommend intake of food atmoderate temperature only
Elevate head of bed for 3045 minutes after meals& at bedtime
Encourage fluids at mealtimes Avoid foods that aggravate dysphagia
Bland foods are not clearly beneficial & not required
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Medical Nutrition Therapy
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Gastritis & peptic ulcers may resultwhen
infectious
chemical
neural abnormalities
disrupt mucosal integrity ofthe stomach or duodenum
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The most common cause:
Helicobacter pylori infection
H. pylori infection is responsible for:
Most cases of chronic inflammation of gastricmucosa
Peptic ulcer
Atrophic gastritis
Gastric cancer
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Acute gastritis:refers to rapid onset of inflammation& symptoms
Chronic gastritis:may occur over a period of months
to decades, w/ waxing & waning(increasing & decreasing) of symptoms
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Symptoms
Nausea
Vomiting
Malaise
Anorexia
Hemorrhage
Epigastric pain
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Factors that may also compromise
mucosal integrity and
the chanceof acquiring acute & chronic gastritis
Chronic use of aspirin or other NSAIDs
Steroids
Alcohol
Erosive substances
Tobacco
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Medical Nutrition Therapy
Sameas for peptic ulcers
In chronic gastritis: absorption of Fe, Ca, & other nutrients
occurs because gastric acid can their
bioavailability
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Primary causes:
H. pylori infection
Gastritis
Aspirin & other NSAIDsCorticosteroids
Stress-induced ulcer
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Involve two major regions:- Stomach- Duodenum
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Excessive use or high concentration drinks(alcohol) can:
damage gastric mucosa
worsen symptoms of peptic ulcers
interfere w/ ulcer healing
Beers & wines: gastric secretion
Coffee & caffeine:
Stimulate acid secretion
LES pressure19
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Symptoms
Abdominal pain
or
Discomfort
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characteristic ofboth gastric &duodenal ulcers
Anorexia
Weight loss
Nausea & vomitingHeartburn
slightly more often in gastric ulcers
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Medical Nutrition Therapy
Avoid alcohol consumption of spices, esp. chili, cayenne, &black peppers.
Turmeric may inhibit adhesion ofH. pylori to the
gastric wallAvoid coffee & caffeine
intake of n-3 & n-6 fatty acids
Use probiotics as complementary therapy
Regular use ofcranberries which contain phenolicantioxidants may have the capacity to help
eradicate H. pylori
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Frequent small meals may:
comfort
the chance for acid reflux
stimulate gastric blood flow
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persons w/ peptic ulcers should avoid
consuming large meals, esp. beforeretiring, to reduce latent increases
in acid secretion
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Dumping syndrome:
a complex physiologic response to the
rapid emptying of hypertonic contents
into the duodenum & jejunum
May occur as a result of:
total or subtotal gastrectomy
manipulation of the pylorus after fundoplication
after some gastric bypass procedures forobesity
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Symptoms
Abdominal distention & pain
Diarrhea
Tachycardia
Symptoms associated w/ hypoglycemia:
Diaphoresis (profuse sweating)
Palpitations
Weakness
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3060 min.after eating
occur later
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Nutrition care:
Frequent small mealsHigh-protein, moderate-fat foods w/ sufficientcalories. Complex CHOs (starches) can beincluded. Simple CHO (lactose, sucrose,
& dextrose) should be limitedSufficient fibres (pectin in fruits, or guar gums)
beneficial because they upper GI transit
time & the rate of glucose absorption
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Medical Nutrition Therapy
Prime objective:to restore nutrition status & quality of life
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Nutrition care: .. (contd)
Limit the amount of liquids taken w/ meals, butadequate amounts should be consumed duringthe day, small amounts at a time
Lie down immediately after meals & avoid activityan hour after eating
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Nutrition care: .. (contd)
Very small quantities of hypertonic, concentratedsweets (soft drinks, juices, pies, cakes, cookies,and frozen desserts) can be ingested
Lactose, especially in milk & ice cream, are poorlytolerated, but cheeses & yogurt are better
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Diet for preventing symptoms of dumping syndrome:
Moderate fat (30% of calories intake)
High protein (20% of calories intake)
Low in simple CHO
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helps the patient achieve & maintainoptimal weight & nutritional status
When intake is inadequate vit. D & Ca supplements
may be needed
When steatorrhea (+) give oil or fat which high inmedium-chain triglycerides (MCTs)
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Intestinal gas & flatulence
Constipation
Diarrhea
Steatorrhea
Gastrointestinal stricture & obstruction
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Instestinal Gas & Flatulence
Causes:
Inactivity
GI motility
Aerophagia
Dietary components GI disorders
Medical nutrition therapy:
Reduce intake of CHO that are likely to bemalabsorbed & fermented
e.g. legumes, soluble fibre, resistant starches,& simple CHO such as fructose & alcohol sugars
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Constipation
Most common causes:
Ignoring the urge to defecate
Lack of fibre in the dietInsufficient fluid intake
Inactivity
Chronic use of laxatives
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Medical Nutrition Therapy
Consumption of adequate amounts ofboth soluble & insoluble dietary fibre
F i b r e :
colonic fecal fluidmicrobial mass
stool weight & frequency
the rate of colonic transit
softens feces & makes them easier to pass
Adequate water
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Recommended amount of dietary fibre
about 14 g/1000 kcal
Fibre can be provided in the form of:
Whole grainsFruits
Vegetables
LegumesSeeds
Nuts
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Diarrhea
Causes of diarrhea may be related to:
Inflammatory disease
Infections with fungal, bacterial, or viral
agentsMedications
Overconsumption of sugars
Insufficient or damaged mucosal absorptive
surfaceGI resections
Malnutrition
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Medical Nutrition Therapy
First step in managing diarrhea:replacement of necessary fluids & electrolytes,
using:
electrolyte solutions
soups & broths vegetable juices
other isotonic liquids
Later:
starchy CHOs (cereals, breads)
low-fat meats added small amounts of vegetables & fruits,
followed by lipids36
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Probiotics
Modestly successful in:
Antibiotic-related diarrheaTravelers diarrhea
Bacterial overgrowth
Several types of pediatric diarrhea
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Steatorrhea
Steatorrhea:
excessive fat in the stool caused by
disease or surgical resection of organs
involved in the digestion & absorption
oflipid
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Medical Nutrition Therapy
Steatorrhea can result in chronic weight loss may require calorie intake, mainly in theform of protein & complex CHOs
MCTs can be given because:able to enter the portal vein for transport to theliver without micelle formation digestion &absoprtion, & resynthesis into triglycerides in
intestinal cell
easier to be absorbed in the abscense of
bile acids
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Food source of MCTs:
coconut oil
Micronutriens supplementation:
Fat-soluble vitamins
Ca
Zn
Mg
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because losses are as a result ofthe formation of insoluble soaps
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Gastrointestinal Strictures &Obstruction
Causes (partially or completely obstruction):
Instestinal tumors
Scarring from GI surgeries
Inflammatory bowel disease (IBD)
Peptic ulcer
Radiation enteritis
If parts of the GI are partially obstructed
obstructions from foods may occur
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The most common foods that may cause
obstructions are fibrous plant foods
Phytobezoars:
obstructions in the stomach that resultfrom the ingestion of plant foods
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Restricted-fibre diet limit fruits, vegetables, &coarse grains
Provide
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Some Diseases and ConditionsAssociated with Malabsorption
Inadequate digestion Pancreatic insufficiency
Gastric resection
Altered bile salt metabolism withimpaired micelle formation Hepatobiliary disease
Bacterial overgrowth
Abnormalities of mucosal cell transport Biochemical or genetic abnormalities
- Disaccharidase deficiency e.g. lactase deficiency
- Celiac disease (gluten-sensitive enteropathy)
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Some Diseases and (contd)
Inflammatory or infiltitative disorders
- Crohns disease
- Ulcerative colitis
- Radiation enteritis
- Short-bowel syndrome
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Abnormalities of intestinal lymphatics
& vascular system Instestinal lymphangiectasia
Chronic congestive heart failure
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Two major forms of IBD:
Crohns disease
Ulcerative colitis
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Clinical characteristics:
Diarrhea Fever
Weight loss
Anemia Food intolerances
Malnutrition
Growth failure Extraintestinal manifestations (arthritic,
dermatologic, & hepatic)
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S f i fl d b l
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Crohns disease Ulcerative colitis
Segments of inflamed bowel
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Abnormal activationof the mucosal
immune response Secondary systemic
response
Unknown irritantViral? Bacterial?Autoimmune?
Geneticpredisposition
Damage to the cells of the small and/or large intestinewith malabsorption, ulceration, or stricture
- Diarrhea- Weight loss- Poor growth
Pathophysiology of inflammatory bowel disease
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Medical Nutrition Therapy
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IBD patients are at risk ofmalnutrition
Some potential nutrition-related problems
with IBD:
Anemias related to blood loss & poor intake
GI narrowing & strictures leading to bloating,nausea, bacterial overgrowth, & diarrhea
MalabsorptionFood aversion, anxiety, & fear of eating relatedto abdominal pain, bloating, nausea, or diarrhea
Drug-nutrient interactions
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Primary goal of medical nutrition therapy(MNT) to restore & maintain the
nutrition status of patients w/ IBD
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Energy:energy requirements are not greatly
Protein:protein needs may but rarely >50% thannormal needs
Vitamins & minerals supplementation: folic acid, vitamins B6, and B12 Zn, K, and Se
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Small, frequent feedings may be toleratedbetter
Small amounts ofisotonic, liquid, oralsupplements may be valuable
If fat malabsorption (+)
foods made with MCTs
useful to calories intake & for theabsorption of fat-soluble nutrients
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n-3 fatty acids intakeantiinflammatory effect
Probiotics can modify the microbial flora
Prebiotics (such as oligosaccharides): alter the mixture of microorganisms in the
colonic flora favoring lactobacillus & bifidobacteria
suppressing pathogenic or opportunisticmicroflora
production of SCFAs
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Risk factors associated with the onset ofexacerbations of IBD include:
sucrose intakelack of fruits & vegetables
dietary fibre >
alcoholaltered n-6/n-3 fatty acid ratios
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Cirrhosis of liver
a group of chronic liver diseasescharacterized by loss of normal lobulararchitecture with fibrosis, and bydestruction of parenchymal cells andtheir regeneration to form nodules
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56Clinical manifestations external symptoms
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Energy Patients without ascites:
120140% of the resting energy expenditure
(REE)
Patients with ascites, infection, malabsorption,or if nutritional repletion is necessary:
150175% of the REE
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Liver.. (contd)
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Carbohydrate (CHO) Cirrhotic patients are prone to develop diabetes
Insulin resistance seems to be the etiology
Recommendation:
6070% of total calories, preferably as
complex CHO effective in reducing insulinrequirements. Complex CHO intake insoluble fibre >> colonic pH prevent hepatic encephalopathy
Lipid2530% of total calories
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Liver.. (contd)
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Prote in Uncomplicated cirrhosis: 0.81 g/kg dry BW
To promote positive N balance: 1.21.3 g/kg BW
Complicated cirrhosis, including GI bleeding,
severe ascites, infection: 1.5 g/kg BW
Vitamins & Minera ls
Fat-soluble (A, D, E, K) & water-soluble vitamins
(thiamin, B6, B12, niacin, folic acid) Minerals: Fe, Zn, Mg, & Ca
If ascites & edema (+) Na &water restriction
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Liver.. (contd)
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