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Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders Esophagus Tube from pharynx to stomach Upper esophageal sphincter (UES or cardiac sphincter) closed except when swallowing Lower esophageal sphincter (LES) closes entrance to stomach; prevents reflux of stomach contents back into esophagus Common Symptoms of Gastrointestinal Disease Cancer of the Oral Cavity, Pharynx, Esophagus Existing nutritional problems and eating difficulties caused by the tumor mass, obstruction, oral infection and ulceration, or alcoholism Chewing, swallowing, salivation, and taste acuity are often affected. Weight loss is common. Head and Neck Cancers Can affect any part of the head and neck area Surgical treatment can have profound effect on ability to take food orally Often feeding tubes are placed at the time of surgery Head and Neck Cancers MNT in Head and Neck Cancers Address nutritional consequences of disease and treatments (radiation therapy, surgery) Radiation therapy can alter taste sensation, result in dry mouth, loss of appetite, mucositis and dysphagia Malnutrition is reported to affect 30 to 50% of patients with head and neck cancers. MNT in Head and Neck Cancers Goal is to maintain adequate intake to promote healing and allow aggressive treatment May involve enteral feedings, liquid oral supplements, dietary changes (liquid, moist, softtextured foods and small, frequent meals Artificial saliva solutions, increased fluids, topical anaesthetics to relieve pain Aggressive oral hygiene, fluoride, treatment of fungal infections Gastroesophageal Reflux Disease (GERD) Defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Symptoms: Burning sensation after meals; heartburn, regurgitation or both, especially after meals Symptoms often aggravated by recumbency or bending over and are relieved by antacids DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200 Hiatal Hernia An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm Heartburn after heavy meals or with reclining after meals May worsen GERD symptoms Anatomy of Esophagus and Hiatal Hernia Complications of GERD Esophagitis, stricture or ulcer Barrett’s Esophagus (premalignant state) Diagnosis of GERD Empirically, via symptoms (symptoms don’t always correlate with the degree of damage) Endoscopy – to confirm Barrett’s Esophagus and dysplasia (a negative endoscopy does not rule out the presence of GERD) Ambulatory reflux monitoring DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200 Ambulatory Reflux Monitoring Goals of Nutrition Intervention in GERD Increasing lower esophageal sphincter competence Decreasing gastric acidity, which results in decreasing severity of symptoms Improving clearance of contents from the esophagus Identification of drug-nutrient interaction Prevention of obstruction if esophageal stricture present Improvement of nutritional intake if appropriate ADA Nutrition Care Manual, accessed 4-06 Nutrition Prescription for GERD Initiate weight-reduction program if overweight Initiate smoking cessation (lowers LES pressure) Improve clearing of materials from esophagus Remain upright after eating Avoid eating within 3 hours of bedtime Wear loose-fitting clothing Raise the head of bed for sleeping ADA Nutrition Care Manual, accessed 4-06 Nutrition Prescription for GERD Reduce gastric acidity by eliminating the following: Black and red pepper Coffee (caffeinated and decaffeinated) Alcohol Substitute smaller more frequent meals Restrict foods that lessen lower esophageal sphincter pressure by eliminating the following: Chocolate Mint Foods with a high fat content. ADA Nutrition Care Manual, accessed 4-06 Nutrition Prescription for GERD Spicy, acidic foods may be irritating if esophagitis is present Limitation of these foods should be based on individual tolerance Nutritional Care for Patients with Reflux and Esophagitis Evidence reflecting the true efficacy of these maneuvers in patients is almost completely lacking – American College of Gastroenterology Guidelines, 2005 Drugs Commonly Used to Treat Gastrointestinal Disorders Antibiotics: eradicate Helicobacter pylori, prevent or treat infection after abdominal wounds or surgery Antacids: neutralize gastric acid in acid reflux, peptic ulcer Proton pump inhibitors (omeprazole, lansoprazole): decrease gastric acid secretion Histamine-2 receptor antagonists (cimetidine, ranitidine): inhibit gastric acid secretion Sucralfate (sulfated disaccharide): protects stomach lining and may increase mucosal resistance to acid or enzyme damage Medications Used to Tx GERD Antacids: Mylanta, Maalox: neutralize acids Gaviscon: barrier between gastric contents and esophageal mucosa H2 receptor antagonists available over the counter and by prescription (reduce acid secretion): cimetadine, ranitidine, famotidine, nizatidine Medications Used to Treat GERD Proton Pump Inhibitors (PPIs) Omeprazole (Prilosec), lansoprazole, rabeprazole, pantoprazole, esomeprazole Some available over the counter now Decrease gastric acid secretion Medications Used to Treat GERD Acid suppression is the mainstay of therapy for GERD. Proton pump inhibitors provide the most rapid symptomatic relief and heal esophagitis in the highest percentage of patients. Although less effective than PPIs, Histamine-2 receptor blockers given in divided doses may be effective in persons with less severe GERD DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200 Medications Used to Treat GERD Promotility agents may be used in selected patients, especially as an adjunct to acid suppression. Currently available promotility agents are not ideal monotherapy for most patients with GERD DeVault KR and Castell DO. Updated guidelines for the diagnosis and treatment of Gastroesophageal Reflux disease. Am J. Gastroenterol 2005;100:190-200 Medications Used to Tx GERD Promotility Agents (enhance esophageal clearing and gastric emptying) Cisapride, bethanechol Surgical Treatment of GERD Fundoplication: Fundus of stomach is wrapped around lower esophagus to limit reflux Illustration of Fundoplication Source: http://www.medformation.c om/ac/adamsurg.nsf/page/1 00181# MNT in NAUSEA/VOMITING Nausea & Vomiting Prolonged vomiting = hyperemesis – Loss of nutrients, fluids, electrolytes – Dehydration, electrolyte imbalance, wt. loss Medications: – Antinauseants – Antiemetics Goals of MNT in Nausea/Vomiting Decrease the frequency and severity of nausea and/or vomiting Maintain optimal fluid balance and nutritional status Prevent development of anticipatory nausea, vomiting, and learned food aversions ADA Nutrition Care Manual, accessed 4-06 MNT for Nausea/Vomiting When vomiting stops, introduce ice chips if older than 3 years of age. If tolerated, start with rehydration beverage or clear liquids, 1 tsp every 10 minutes. Increase to 1 Tbsp every 20 minutes. Double amount of fluid every hour. If diarrhea is present, use only rehydration beverage. Apple juice Sports drink Warm or cold tea Lemonade ADA Nutrition Care Manual, accessed 4-06 MNT for Nausea/Vomiting When there has been no vomiting for at least 8 hours, initiate oral intake slowly with adding one solid food at a time in very small increments. Choose the following types of foods: Without odor Low in fat Low in fiber (see Client Education - Detailed, Foods Recommended). Take prescribed antiemetics and other medications on a regular schedule to assist in prevention of nausea and vomiting. Take all other medications after eating. ADA Nutrition Care Manual, accessed 4-06 Nausea/Vomiting: Food and Feeding Issues Keep patient away from strong food odors Provide assistance in food preparation so as to avoid cooking odors Eat foods at room temperature Keep patient's mouth clean and perform oral hygiene tasks after each episode of vomiting Offer fluids between meals Patient should sip liquids throughout the day Cold beverages may be more easily tolerated Keep low-fat crackers or dry cereal by the bed to eat before getting out of bed Nausea/Vomiting: Lifestyle Issues Relax after meals instead of moving around Sit up for 1 hour after eating Wear loose-fitting clothes Provide fresh air with a fan or open window Limit sounds, sights, and smells that may trigger nausea and vomiting Other complementary and alternative medicine interventions that have anecdotal evidence (though clinical trials have not been conducted): Relaxation techniques Acupuncture Hypnosis ADA Nutrition Care Manual, accessed 4-06 Diseases of Stomach Indigestion Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: —Alcohol —Aspirin —Nonsteroidal antiinflammatory agents Indigestion (Dyspepsia) Symptoms Abdominal pain Bloating Nausea Regurgitation Belching 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 Gastritis Erosion of mucosal layer Exposure of cells to gastric secretions, bacteria Inflammation & tissue damage Gastritis Helicobacter Pylori (H. pylori) – Bacteria, resistant to acid – Damages mucosa – Treat with bismuth, antibiotics, antisecretory agents – Causes ~92% duodenal ulcers; 70% gastric ulcers Atrophic Gastritis Loss of parietal cells in stomach – Hypochloria = in HCl production – Achlorhydria = loss of HCl production – Decrease or loss of intrinsic factor production • Malabsorption of vitamin B12 • Pernicious anemia • vitamin B12 injections or nasal spray Endoscopy 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 – Melena = black, tarry stools from GI bleeding Characteristics and Comparisons Between Gastric and Duodenal Ulcers Gastric ulcer formation involves inflammatory involvement of acidproducing 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. Copyright © 2000 by W. B. Saunders Company. All rights reserved. Gastric and Duodenal Ulcers Peptic Ulcer Disease (PUD) Definition and Etiology Erosion through mucosa into submucosa – H. pylori – Aspirin, NSAIDs – Stress: • Severe burns, trauma, surgery, shock, renal failure, radiation Peptic Ulcer Disease (PUD) Medical Management Plays a more important role than diet – or stop aspirin, NSAIDs – Use antibiotics, antacids – Use sucralfate (Carafate) = gastric mucosa protectant – forms barrier over ulcer Peptic Ulcer Disease (PUD) Behavioral Management Avoid tobacco • Risk factor for ulcer development • complications – impairs healing, increases incidence of recurrence • Interferes with tx • Risk of recurrence, degree of healing inhibition correlate with number of cigarettes per day MNT for Peptic Ulcer Disease and Gastritis Avoid foods that increase gastric acid secretion, such as the following: Alcohol Pepper Caffeine Tea Coffee (including noncaffeinated) Chocolate ADA Nutrition Care Manual, accessed 4-06 MNT for Peptic Ulcer Disease Identify foods that directly irritate the gastric mucosa or are not generally tolerated Avoid eating at least 2 hours before bedtime Peptic Ulcer Disease Treatment with Diet 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: – Hemorrhage – Perforation – Obstruction – Intractability (difficult to manage, cure) – Pt unable to follow medical regimen Ulcers may recur after medical or surgical tx Gastric Surgery Resective surgical procedures “anastamosis” – connection of two tubular structures Gastrectomy – surgical removal of part or all of stomach – Hemigastrectomy = half – Partial gastrectomy – Subtotal gastrectomy = 30-90% resected Gastric surgical procedures. Fig. 30-7. p. 661. Carcinoma of the Stomach Obstruction and mechanical interference Surgical resection or gastrectomy Prevention of GI cancers: fruits, vegetables, and selenium Increase risk of GI cancers: alcohol, overweight, high salted or pickled foods, inadequate micronutrients Gastric Surgery Billroth I = gastroduodenostomy – Partial gastrectomy – anastomosis to duodenum – To remove ulcers, other lesions (cancer) Billroth II = gastrojejunostomy – Partial gastrectomy - anastomosis to jejunum Allows resection of damaged mucosa Reduces number of acid producing cells Reduces ulcer recurrence Gastric Surgery Total gastrectomy – Removal of entire stomach – Rarely done = negative impact on digestion, nutritional status – In extensive gastric cancer & ZollingerEllison syndrome not responding to medical management – Anastomosis from esophagus to duodenum or jejunum Zollinger-Ellison Syndrome PUD caused by “gastrinoma” – Gastrin producing tumor in pancreas – Gastrin = hormone stimulates HCl prod – Causes mucosal ulceration – 50 – 70% are malignant – Any part of esoph., stomach, duod., jejun. – Removal of tumor, gastrectomy Gastric surgical procedures. (cont.) Fig. 30-7. p. 661. Pyloroplasty Surgical enlargement of pylorus or gastric outlet To improve gastric emptying with obstructions or when vagotomy interferes with gastric emptying May contribute to Dumping Syndrome Ulcer recurrence is common Roux-en-Y Gastric partitioning – distal ileum, proximal jejunum Often for “bariatric” purposes (wt. loss) Wt loss for 12 – 18 wks with 50 – 60% excess wt. Loss Roux-en-Y Nutritional Goals: – Prevent deficiencies – Promote eating, lifestyle changes to maintain losses – Mechanical soft diet ~ 3 mo., then solid foods – Small amounts – 1 oz. To 1 cup – 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. Dumping Syndrome Rapid movement of hypertonic chyme into jejunum Fluid drawn into bowel by osmosis to dilute concentrated mass of food Volume of circulating blood decreases ADA Nutrition Care Manual, accessed 4-06 Dumping Syndrome Symptoms Cramping Abdominal pain Hypermotility Diarrhea Dizziness Weakness Tachycardia within 10-20 minutes after eating MNT for Dumping Syndrome Prevent onset of early and late dumping syndromes. Initially avoid all hypertonic, concentrated sweets. Do not start clear liquids as first oral feeding. The first meals should consist of protein, fat, and complex carbohydrate, but with only 1-2 food items at a time. Patients may be initially lactose intolerant. Slowly progress to 5-6 small meals each day. Consume liquids 30 minutes to 1 hour after consuming solid food. Lie down after eating. Consider addition of functional fibers to delay gastric emptying and assist with treatment of diarrhea. MNT for Dumping Syndrome These foods may exacerbate symptoms: Sucrose Fructose Sugar alcohols: – Xylitol – Mannitol – Sorbitol Source: ADA Nutrition Care Manual, accessed 4-06 Malabsorption, steatorrhea Post-surgical complications affecting nutrition: • Fat soluble vitamins, calcium • Folate, B12 (loss of intrinsic factor) • Iron – better absorbed with acid – 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 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 Summary Upper GI disorders—H. pylori plays an important role Maintain individual tolerances as much as possible.