medical nutrition therapy . lower gi
TRANSCRIPT
MNT in Lower GI tract disorders
Dr. Louay Labban
© 2006 Thomson-Wadsworth
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
Pancreatitis - Acute
• Begins with premature activation of digestive enzymes within pancreatic tissue –leading to the destruction of pancreatic cells and the inflammatory process
Pancreatitis - Acute
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
© 2006 Thomson-Wadsworth
Inflammatory Bowel Disease
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
Inflammatory Bowel Disease
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
Inflammatory Bowel Disease
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
Irritable Bowel Syndrome
Characterized by alterations in:
• Flatulence
• Bloating
• Distention
• Abdominal pain relieved by defecation
• Occurs more frequently in women
Irritable Bowel Syndrome
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
© 2006 Thomson-Wadsworth
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)