medical nutrition therapy for lower gastrointestinal tract disorders chapter 30

Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders

Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders

Chapter 30Chapter 30

© 2004, 2002 Elsevier Inc. All rights reserved.

Common Intestinal SymptomsCommon Intestinal Symptoms

Intestinal gas and flatulence

Constipation

Diarrhea

Steatorrhea

Gastrointestinal strictures and obstruction

Intestinal gas and flatulence

Constipation

Diarrhea

Steatorrhea

Gastrointestinal strictures and obstruction


DiarrheaDiarrhea

Need to solidify stools

Pectin (apples, bananas) is helpful

World Health Organization provides guidance on fluid and electrolyte replacements—set formula works best

Gatorade also useful

Need to solidify stools

Pectin (apples, bananas) is helpful

World Health Organization provides guidance on fluid and electrolyte replacements—set formula works best

Gatorade also useful


SteatorrheaDietary Modification

SteatorrheaDietary Modification

Increase kcal to meet needs, especially protein and carbohydrate

Control fat level

Give only level tolerated

Use MCT oil to meet kcal needs with caution

Vitamin and mineral supplements

Use fat-soluble vitamins; add extra Ca, Mg, Zn, Fe

Increase kcal to meet needs, especially protein and carbohydrate

Control fat level

Give only level tolerated

Use MCT oil to meet kcal needs with caution

Vitamin and mineral supplements

Use fat-soluble vitamins; add extra Ca, Mg, Zn, Fe


SteatorrheaMCT OilSteatorrheaMCT Oil

8 to 10 carbons long

Bile not needed for absorption

Delivered to liver via blood

8.3 kcal/g

1 T = 116 kcal

Expensive

Increases osmolality of tube feedings

8 to 10 carbons long

Bile not needed for absorption

Delivered to liver via blood

8.3 kcal/g

1 T = 116 kcal

Expensive

Increases osmolality of tube feedings


Celiac DiseaseGluten-Sensitive EnteropathyCeliac DiseaseGluten-Sensitive Enteropathy

Adverse reaction to gluten—gliadin fraction

Intestinal mucosa damaged

—Malabsorption of nutrients

—Iron deficiency

—Osteomalacia

—Growth failure

—Projectile vomiting

Adverse reaction to gluten—gliadin fraction

Intestinal mucosa damaged

—Malabsorption of nutrients

—Iron deficiency

—Osteomalacia

—Growth failure

—Projectile vomiting


Normal Human Duodenal Mucosa (A) and Peroral Small Bowel Biopsy Specimen (B) from a Patient with Gluten Enteropathy

Normal Human Duodenal Mucosa (A) and Peroral Small Bowel Biopsy Specimen (B) from a Patient with Gluten Enteropathy

(From Floch MH. Nutrition and Diet Therapy in Gastrointestinal Disease. New York: Menum Medical Book Co., 1981.)


Celiac Disease−CauseCeliac Disease−Cause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.


Celiac Disease−PathophysiologyCeliac Disease−Pathophysiology

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenisis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)



Celiac Disease−Medical and Nutritional ManagementCeliac Disease−Medical and Nutritional Management



Celiac DiseaseGluten-Sensitive EnteropathyCeliac DiseaseGluten-Sensitive Enteropathy

Treatment

Remove gluten from the diet:

—Wheat

—Rye

—Buckwheat

—Barley

Treatment

Remove gluten from the diet:

—Wheat

—Rye

—Buckwheat

—Barley


Celiac DiseaseGluten-Sensitive Enteropathy—cont’dCeliac DiseaseGluten-Sensitive Enteropathy—cont’d

Gluten/gliadin-containing foods

Used to thicken many processed foods

See Tables 30-3 and 30-4

Gluten/gliadin-containing foods

Used to thicken many processed foods

See Tables 30-3 and 30-4


Tropical SprueTropical Sprue

Cause unknown; imitates celiac disease

Results in atrophy and inflammation of villi

Sx: diarrhea, anorexia, abdominal distention

Rx: tetracycline, folate 5 mg/d, B12 IM

Cause unknown; imitates celiac disease

Results in atrophy and inflammation of villi

Sx: diarrhea, anorexia, abdominal distention

Rx: tetracycline, folate 5 mg/d, B12 IM


Intestinal Brush Border Enzyme DeficienciesIntestinal Brush Border Enzyme Deficiencies Lactose intolerance

Causes: genetic or secondary deficiency of milksugar enzyme, lactase

—Blacks, Asians, Native Americans

—Aging: damage to GI tract

Dx: lactose tolerance test or breath hydrogen test

Rx: avoid large amounts of lactose

(milk protein allergy requires milk-free diet); take lactase enzyme; processed dairy sometimes OK

Lactose intolerance

Causes: genetic or secondary deficiency of milksugar enzyme, lactase

—Blacks, Asians, Native Americans

—Aging: damage to GI tract

Dx: lactose tolerance test or breath hydrogen test

Rx: avoid large amounts of lactose

(milk protein allergy requires milk-free diet); take lactase enzyme; processed dairy sometimes OK


Inflammatory Bowel DiseaseInflammatory Bowel Disease

Crohn’s disease or ulcerative colitis

Both involve damage to the intestine

Crohn’s: may damage either small or large intestine

Disease progression varies

Ulcerative colitis: begins at rectum and progresses up the large intestine

Crohn’s disease or ulcerative colitis

Both involve damage to the intestine

Crohn’s: may damage either small or large intestine

Disease progression varies

Ulcerative colitis: begins at rectum and progresses up the large intestine


Inflammatory Bowel Disease−CauseInflammatory Bowel Disease−Cause



Inflammatory Bowel Disease−PathophysiologyInflammatory Bowel Disease−Pathophysiology



Inflammatory Bowel Disease−Medical and Nutritional ManagementInflammatory Bowel Disease−Medical and Nutritional Management



Inflammatory Bowel DiseasesInflammatory Bowel Diseases

Rx:

Diet depends on patient’s status

Nutrition assessment

Select route of feeding

Fiber is beneficial except during flareups.

Rx:

Diet depends on patient’s status

Nutrition assessment

Select route of feeding

Fiber is beneficial except during flareups.


Disorders of the Large IntestineDisorders of the Large Intestine

1. Irritable bowel syndrome

—Common syndrome involving altered intestinal motility, increased sensitivity of the GI tract, and increased awareness and responsiveness of the viscera to internal and external stimuli

—Alternating constipation and diarrhea, abdominal pain, and bloating

1. Irritable bowel syndrome

—Common syndrome involving altered intestinal motility, increased sensitivity of the GI tract, and increased awareness and responsiveness of the viscera to internal and external stimuli

—Alternating constipation and diarrhea, abdominal pain, and bloating


Disorders of the Large Intestine —cont’dDisorders of the Large Intestine —cont’d

2. Diverticular disease

—Herniations of the colon, chronic diverticulosis, acute diverticulitis

—Diverticulosis

High-fiber diet: fruits, vegetables, whole grains (2 tsp bran daily)

—Diverticulitis

Low-residue or elemental diet Possibly low-fat diet

2. Diverticular disease

—Herniations of the colon, chronic diverticulosis, acute diverticulitis

—Diverticulosis

High-fiber diet: fruits, vegetables, whole grains (2 tsp bran daily)

—Diverticulitis

Low-residue or elemental diet Possibly low-fat diet


Disorders of the Large Intestine —cont’dDisorders of the Large Intestine —cont’d

3. Colon cancer and polyps

—Colon cancer is the second most common cancer among US adults

—Polyps are considered precursors of colon cancer.

3. Colon cancer and polyps

—Colon cancer is the second most common cancer among US adults

—Polyps are considered precursors of colon cancer.


Short Bowel SyndromeShort Bowel Syndrome

Follows removal of more than two thirds of small intestine

Causes weight loss; diarrhea; decreased transit time; malabsorption; dehydration; loss of electrolytes; hypokalemia

Follows removal of more than two thirds of small intestine

Causes weight loss; diarrhea; decreased transit time; malabsorption; dehydration; loss of electrolytes; hypokalemia


Short Bowel Syndrome —cont’dShort Bowel Syndrome —cont’d

Removal of ileocecal valve causes more complications.

Fat malabsorption frequent

Steatorrhea

Saponify calcium, zinc, and magnesium

Remove ileum and lose B12 and bile salt absorption

Removal of ileocecal valve causes more complications.

Fat malabsorption frequent

Steatorrhea

Saponify calcium, zinc, and magnesium

Remove ileum and lose B12 and bile salt absorption


Short Bowel Syndrome —cont’dShort Bowel Syndrome —cont’d

Length of remaining small intestine Loss of ileum, especially distal one third Loss of ileocecal valve Loss of colon Disease in remaining segments(s) of

gastrointestinal tract Radiation enteritis Coexisting malnutrition Older age surgery

Length of remaining small intestine Loss of ileum, especially distal one third Loss of ileocecal valve Loss of colon Disease in remaining segments(s) of

gastrointestinal tract Radiation enteritis Coexisting malnutrition Older age surgery

Factors Affecting Severity of Malabsorption, Number of Complications, and Dependence on Parenteral Nutrition

Factors Affecting Severity of Malabsorption, Number of Complications, and Dependence on Parenteral Nutrition


Short Bowel SyndromeNutritional CareShort Bowel SyndromeNutritional Care

Step 1

Parenteral only for most patients

Step 2

Gradually introduce enteral nutrition.

Glutamine is an important nutrient for the gut.

Narcotic drugs for pain cause GI problems and should be evaluated.

Step 1

Parenteral only for most patients

Step 2

Gradually introduce enteral nutrition.

Glutamine is an important nutrient for the gut.

Narcotic drugs for pain cause GI problems and should be evaluated.


Short Bowel SyndromeShort Bowel Syndrome

Eventually the remaining bowel increases absorptive surface, and problems decrease.

Nutrition support is designed to meet each patient’s needs.

Eventually the remaining bowel increases absorptive surface, and problems decrease.

Nutrition support is designed to meet each patient’s needs.


Other Bowel DiseasesOther Bowel Diseases

Irritable bowel syndrome

Alternating diarrhea and constipation

Rx:

High-fiber diet: be careful with wheat bran

Elimination of stimulants

Evaluate for food allergies or intolerances

Irritable bowel syndrome

Alternating diarrhea and constipation

Rx:

High-fiber diet: be careful with wheat bran

Elimination of stimulants

Evaluate for food allergies or intolerances


Blind Loop SyndromeBlind Loop Syndrome

Bacterial overgrowth from stasis in intestine, obstruction, radiation enteritis, fistula, or surgical repair

Treatment (Rx):

Appropriate meds for malabsorption

Antibiotics for bacterial overgrowth

Bacterial overgrowth from stasis in intestine, obstruction, radiation enteritis, fistula, or surgical repair

Treatment (Rx):

Appropriate meds for malabsorption

Antibiotics for bacterial overgrowth


Diet Modification of Fiber in DietsDiet Modification of Fiber in Diets

Restricted-fiber diet

5 to 10 g/day

High-fiber diet

25 to 35 g/day

Minimal-residue diet or elemental formulas

Restricted-fiber diet

5 to 10 g/day

High-fiber diet

25 to 35 g/day

Minimal-residue diet or elemental formulas


Causes of Constipation— GastrointestinalCauses of Constipation— Gastrointestinal Diseases of the upper gastrointestinal tract

—Celiac disease

—Duodenal ulcer Diseases of the large bowel resulting in:

—Failure of propulsion along the colon (colonic inertia)

—Failure of passage though anorectal structures (outlet obstruction)

Irritable bowel syndrome Anal fissures or hemorrhoids Laxative abuse

Diseases of the upper gastrointestinal tract

—Celiac disease

—Duodenal ulcer Diseases of the large bowel resulting in:

—Failure of propulsion along the colon (colonic inertia)

—Failure of passage though anorectal structures (outlet obstruction)

Irritable bowel syndrome Anal fissures or hemorrhoids Laxative abuse

—Gastric cancer

—Cystic fibrosis

—Gastric cancer

—Cystic fibrosis


Causes of Constipation—SystemicCauses of Constipation—Systemic

Side effect of medication Metabolic endocrine abnormalities, such as

hypothyroidism, uremia, and hypercalcemia Lack of exercise Ignoring the urge to defecate Vascular disease of the large bowel Systemic neuromuscular disease leading to

deficiency of voluntary muscles Poor diet, low in fiber Pregnancy

Side effect of medication Metabolic endocrine abnormalities, such as

hypothyroidism, uremia, and hypercalcemia Lack of exercise Ignoring the urge to defecate Vascular disease of the large bowel Systemic neuromuscular disease leading to

deficiency of voluntary muscles Poor diet, low in fiber Pregnancy


FistulaAbnormal Opening Between OrgansFistulaAbnormal Opening Between Organs

Causes: birth defects; trauma; inflammatory disease; malignant disease

Rx:

For fluid loss

For electrolyte loss

Aggressive nutritional support

Causes: birth defects; trauma; inflammatory disease; malignant disease

Rx:

For fluid loss

For electrolyte loss

Aggressive nutritional support


Ileostomy or ColostomySurgical Opening of Intestine to OutsideIleostomy or ColostomySurgical Opening of Intestine to Outside

Causes: ulcerative colitis; Crohn’s disease; colon cancer; trauma

Rx:

Nutrition needs vary with location and individual

Avoid gas- or odor-forming foods

Fluid and electrolyte needs

Causes: ulcerative colitis; Crohn’s disease; colon cancer; trauma

Rx:

Nutrition needs vary with location and individual

Avoid gas- or odor-forming foods

Fluid and electrolyte needs


HemorrhoidectomyHemorrhoidectomy

Delay stool formation until healing can take place

Rx:

Minimal-residue diet or elemental diet

After recovery

High-fiber diet to prevent

Delay stool formation until healing can take place

Rx:

Minimal-residue diet or elemental diet

After recovery

High-fiber diet to prevent


SummarySummary

Lower GI conditions—important for nutritional consequences

Important to note where obstruction or surgery has taken place to determine impact on specific nutrients

Most dramatic: short bowel syndrome, which may require long-term TPN

Lower GI conditions—important for nutritional consequences

Important to note where obstruction or surgery has taken place to determine impact on specific nutrients

Most dramatic: short bowel syndrome, which may require long-term TPN

medical nutrition therapy for lower gastrointestinal tract disorders chapter 30

Documents

absorption n

blood n

diarrhea n need

best n gatorade

useful n need

caution n vitamin

fe n increase kcal

steatorrhea mct oil