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GI Learning Activity
Name: Dawn Ortiz
Fiber
1. What is the difference between dietary fiber and dietary residue?
Dietary residue refers to the roughage left in the digestive tract from fiber rich
foods that the human body is unable to digest. These indigestible fiber
compounds include; cellulose, hemi cellulose, lignin and pectin. As water binds
to the residue, it helps keep the digestive tract healthy by promoting movement
and increasing bulk of stool. A high-residue diet is the same as a high-fiber diet,
which helps prevent constipation, hemorrhoids and diverticulitis.
2. List the physiological function and food sources of both water-soluble and waterinsoluble fiber.
a. Soluble fiber:
This type of fiber dissolves in water to form a gel-like material. Soluble fiber
helps lower LDL cholesterol and glucose levels, which may help reduce blood
pressure and inflammation and potentially decrease the risk of heart disease.
Soluble fiber is found in foods that slow transit time such as oats, flaxseed,
peas, beans, apples, citrus fruits, carrots, barley and psyllium.
b. Insoluble fiber:
Insoluble fiber promotes the movement of material through your digestive
system and increases stool bulk. It helps speed up transit time, which
reduces constipation. Regular bowel movements help prevent hemorrhoids
and colon diseases. Some good sources of insoluble fiber include; wholewheat flour, wheat bran, nuts, beans and vegetables.
3. When counseling an individual regarding increasing the fiber in their diet, what
recommendations would you make to assure better tolerance?
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I would recommend to start increasing fiber intake gradually until reaching a
final goal of 25g for women and 38g for men. Consuming too much soluble fiber
too fast may lead to cramping, as food gets stuck in the digestive tract.
Increasing insoluble fiber too much/too fast may cause diarrhea, as it may move
too quickly through the digestive tract. In order to prevent constipation it is
important to increase fluid intake, to at least 8 glasses of water a day (because
fiber absorbs water). Gradually increasing fiber intake over a few weeks gives
the body time to build up the healthy bacteria in the gut necessary to prevent
gastrointestinal complications.
4. How may a higher fiber diet help prevent the development of diverticulosis?
Diverticulosis develops over time from consistent pressure build up in the colon
causing small pouches to form in the colon wall. Fiber helps decrease this
pressure by softening waste material and reducing transit time.
5. Bulking agents are often used to control the symptoms of irritable bowel
syndrome (IBS) and to help prevent constipation. Explain the rationale for this
treatment and list common bulking agents available.
Bulking agents are helpful because they increase the volume of stool, by
attracting water, making it easier to move through the digestive tract. Types of
bulking agents include; bran, polycarbophil (Fiberlax), methyl cellulose (Citrucel),
psyllium (Metamucil), guar gum (Benefiber).
6. After a thorough work-up by a physician, an individual was diagnosed with IBS.
What diet and lifestyle modifications should be considered when counseling this
individual?
When counseling a newly diagnosed IBS patient, the key lifestyle modifications
include:
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Maintaining a food record to help identify problem foods
Eliminating potential foods that aggravate symptoms, such as; milk,
caffeinated beverages, alcohol, fruit, spicy food, fast food, Chinese food,
broccoli, cabbage, cauliflower, corn, legumes and beans, preservatives
and artificial flavoring and baked goods
Restricting foods containing lactose as needed
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Eating small, frequent meals
Consuming at least 6-8 cups of water daily
Exercise regularly
Gradually increasing fiber intake to reach a goal of 25-38 gm/day
Adding probiotic supplements
7. List the common causes of diarrhea.
There are many clinical and medical causes of diarrhea, which must be identified
to determine the underlying cause when treating:
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Fever
Dehydration
Infection (bacterial or viral)
Contaminated food or water
Hospital/community borne illness (C-DIFF)
Secretory (laxatives, bile acids)
Medications (antibiotics)
Electrolyte repletion (MagOx, Neutraphos)
GI disorders/malabsorption (IBS, IBD, Celiac Disease, etc.)
Malnutrition/Hypoalbuminemia
Post-op lactose intolerance
Clear liquid diets
Partial small bowel obstruction
8. Diarrhea can cause dehydration. What are the symptoms of dehydration and
how should it be treated?
Symptoms of Dehydration:
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Dry, sticky mouth
Lethargic; lack of energy
Excessive thirst
Decreased urine output
Few/no tears when crying
Dry skin
Headache
Hypotension
Rapid heartbeat
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Rapid breathing
Constipation
Dizziness/lightheadedness
Treatment:
Typically, dehydration from diarrhea, vomiting or fever is treated by simply
drinking plenty of water. Sports drinks are also a good treatment for
dehydration because they are rich in electrolytes, which are usually depleted.
Certain liquids, such as fruit juices, carbonated beverages or coffee should be
avoided because they may act as a diuretic, prolonging dehydration. If diarrhea
is severe, hospitalization and IV fluids may be necessary for treatment.
9. List the common causes of constipation.
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Low fiber diet
Inadequate fluid/calorie intake
Medication (pain meds tend to slow GI tract motility)
Vitamin/mineral supplementation
Food sensitivities
Treatment:
Constipation may be treated naturally by increasing dietary fiber along with
increased fluids is helpful to improve motility. Daily exercise also helps improve
motility. Probiotics such as, Lactobacillus acidophilus, also provide the healthy
gut bacteria which help facilitate the digestion process and reduce constipation.
Medications to relieve constipation include; laxatives, bulking agents, lubricants,
stool softeners, osmotics, fiber supplements and stimulants.
GERD / Hiatal Hernia
Mrs. Y is a 69 year old female, 5'2", 195 pounds, who has frequent complaints of
heartburn and indigestion. Her diagnosis is gastrointestinal reflux disease (GERD). Her
usual dietary intake is as follows:
Breakfast:
2 donuts
2 cups coffee with sugar and half & half
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Salad with low calorie Italian dressing
Coffee with sugar and half & half
Lunch:
Dinner:
Meat
Potato with gravy
Carrots with butter
Ice cream
Coffee with sugar and half & half
Evening:
Potato chips
Coke Classic
1. What Medical Nutrition Therapy is recommended for GERD?
The MNT for GERD should begin with testing and limiting the foods that increase
symptoms. Some potential foods to limit/avoid include; peppermint, spearmint,
chocolate, and alcoholic, caffeinated and carbonated beverages. It may also
help to limit or avoid high fat foods because they remain in the stomach for
longer than the other macronutrients. GERD patients should wait at least three
hours before lying down after eating and keep their head raised 6-9 inches while
sleeping. Patients should try eating small, frequent meals throughout the day.
2. What changes would you recommend the patient make to her usual daily
intake?
Mrs. Y needs to change her current dietary intake in order to reduce GERD
symptoms. She needs to reduce her fat intake, along with the carbonated and
caffeinated beverages. She should replace her breakfast of donuts with egg
whites and wheat toast, or oatmeal, raisins and walnuts with a glass on non-fat
milk. Her lunch looks good, but she should drink herbal tea instead of coffee at
lunch. At dinner she should replace the fattening toppings on her potato and
carrots by sautéing her vegetables in olive oil and garlic with a shake of salt and
pepper. She could switch her ice cream dessert to a non-fat Greek yogurt with
berries. Mrs. Y should snack on pretzels and hummus with a sparkling water
instead of chips and soda in the evening. In general, Mrs. Y should make
different food choices and eat small meals and snacks throughout the day to
help reduce her GERD symptoms.
3. Define the types of medications a physician might prescribe as listed below. List
the reason for being prescribed, potential side effects, and names of drugs
within the classification.
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a. Antacids: Neutralize gastric acid, reducing the amount of acid available to
be refluxed into the esophagus. Antacids also restrict the production of
pepsin, an acidic digestive enzyme. Common antacid side effects include;
dose-dependent rebound hyperacidity, magnesium containing antacids
may cause diarrhea, aluminum hydroxide containing antacids may cause
constipation, aluminum-intoxication, osteomalacia, and
hypophosphatemia. Common antacids include; Maalox, Tums and
Mylanta.
b. H-2 blockers: Histamine blockers, block the action of histamine, inhibiting
the secretion of stomach acid. Potential side effects include; headache,
rash, fatigue, diarrhea, muscle cramps and dizziness. Common H-2
blockers include; Pepcid, Zantac and Tagamet.
c. Proton-pump inhibitors: Prescribed to decrease gastric acid secretion by
an irreversible inhibition of the H+/K+ ATPase, in the parietal cells of the
stomach. Possible side effects include; rash, itch, flatulence, constipation
and decreased vitamin B12 absorption. Common PPIs include; Prevacid,
Protonix and Prilosec.
d. Motility altering: Promotility drugs enhance gastric emptying by
increasing gastric, plyoric, and small bowel motor functions. Common
motility altering drugs include; Reglan and Motilium. Side effects include;
fatigue, agitation and abnormal muscle movements.
Inflammatory Bowel Disease
1. Differentiate between Crohn’s Disease and Ulcerative Colitis. Include the area(s)
affected, degree of inflammation, complications, age of onset and treatment in
your answer. (Setting this up as a table may be helpful.)
Ulcerative Colitis: Ulcerative disease of the colon
Crohn’s Disease: Inflammatory disease in the terminal ileum
DISEASE
AFFECTED AREAS
DEGREE OF
INFLAMMATION
DISTRIBUTION
AGE OF ONSET
UC
Rectum and colon
Mucosa and submucosa
CROHN’S
Mouth to anus
Transmural
Continuous
50-70 years old
Segmental
15-30 years old
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SYMPTOMS
Bloody diarrhea, weight Weigt loss, anorexia,
loss, anorexia
diarrhea
TREATMENT
Diet: Soft, bland foods,
Diet: Soft, bland foods,
multivitamin with
multivitamin with
minerals to prevent
minerals to prevent
deficiencies.
deficiencies.
Medications:
Medications: Antibiotics,
Mesalamine,
Sulfasalazine,
Corticosteroids,
Cholestyramine,
antidiarrheals,
Corticosteroids,
antibiotics.
antibiotics.
Surgery: removal of the
Surgery: removal of the
entire colon and rectum, diseased segment of
with the creation of an
bowel (resection), the
ileostomy or external
two ends of healthy
stoma (an opening on
bowel are then joined
together (anastomosis).
the abdomen through
which wastes are
emptied into a pouch,
which is attached to the
skin with adhesive.
DEFECTS FOR BOTH
Macronutrient malabsorption, iron and zinc
DISEASES
deficiency from diarrhea, meds may cause folate
and B12 deficiency and long term steroids may
cause vitamin D and Ca deficiency.
2. Listed below are common medications to treat inflammatory bowel disease.
State the rationale for their use, potential food and drug interaction and any
other significant side effects.
Prednisone: Corticosteroids help reduce inflammation, but have many side
effects so they are not usually administered long term. Side effects include;
puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. Moreserious side effects include hypertension, diabetes, osteoporosis, bone fractures,
cataracts, glaucoma and increased chance of infection. Prednisone may also
decrease the absorption of calcium, vitamin D and phosphorus requiring
supplementation. Prednisone increases sodium and water retention and the
breakdown of protein, possibly requiring a fluid restricted, low sodium, high
protein diet. Magnesium, potassium, zinc and vitamin C may also be depleted,
requiring supplementation. Common drug interactions include; aldesleukin,
mifepristone, which may cause bleeding/bruising (including antiplatelet drugs
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such as clopidogrel), as well as the effectiveness of NSAIDs and blood thinners
such as, dabigatran/warfarin.
Sulfasalazine: Used to treat bowel inflammation, diarrhea, rectal bleeding, and
abdominal pain in patients with an inflamed bowel. Side effects include; gastric
distress, nausea/vomiting, anorexia, headache, yellowing of the skin and
infertility in males while on the medication. Sulfasalazine may cause reduced
absorption of folic acid (leading to deficiency and anemia) and digoxin (reducing
effectiveness). It may also increase blood levels of methotrexate, resulting in
toxicity and folic acid deficiency. Sulfasalazine may increase the blood glucose
lowering effect of oral anti-diabetic drugs, resulting in hypoglycemia. Taken in
combination with NSAIDs may cause kidney dysfunction, combining with
azathioprine may increase the likelihood of blood disorders, and taken with
warfarin may increase the blood thinning effect. Alcohol should be limited and
this drug should not be taken while breastfeeding. Folate supplementation
should be included while taking this drug.
Cholestyramine: Commonly used to treat diarrhea resulting from bile acid
malabsorption, especially in Crohn's disease patients after ileal resection.
Cholestyramine prevents an increase in water by making the bile acids insoluble
and osmotically inactive. Side effects include; constipation, increased risk of
developing gallstones and increased plasma TG levels. Cholestyramine may
prevent absorption and therefore effectiveness of the following drugs; digitalis,
estrogens and progestins, diabetes medication, penicillin, Phenobarbital,
Spironolactone, Tetracycline, Thiazide-type diuretic pills, thyroid medication,
warfarin and leflunomide. Cholestyramine may interfere in the absorption of
fat-soluble vitamins, such as vitamins A, D, E, and K, as well as calcium, folate,
B12, calcium and iron.
Antibiotics: Help reduce harmful intestinal bacteria and suppress the intestine's
immune system. Antibiotics may also help reduce the amount of drainage and
heal fistulas and abscesses in people with Crohn's disease, and control for
infection in ulcerative colitis. Side effects of antibiotics include; diarrhea,
constipation, vomiting, abdominal cramps, vaginal itching and allergic reactions.
Antibiotics may reduce the effectiveness of oral contraceptives. Drinking alcohol
with antibiotics may reduce the effect of the antibiotic. Antibiotics may also
reduce healthy, vaginal flora, causing yeast infections. Disruptions in the
intestinal flora may cause vitamin K deficiency and C-DIFF. Long term antibiotic
use may cause resistance to the drug. Lastly, tendon damage may occur if
antibiotics are taken with corticosteroids.
Immunomodulators: Help suppress the immune response that releases
inflammation-inducing chemicals in the intestinal lining. Side effects include;
increasing the risk for infection and damage to the liver, pancreas and kidneys,
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nausea, vomiting, anorexia, fatigue, headache and hair loss. Women who are
pregnant or breast feeding should not take immunomodulators. Combining
alcohol with these medications may increase risk of liver damage.
Immunomodulators may reduce the effectiveness of ACE inhibitor drugs,
chemotherapy drugs, blood thinners, liver medications, and should not be
combined with other drugs that may weaken the immune system.
Antidiarrheals: (Immodium, Lomotil, Paragoric): Help treat IBD by adding bulk to
the stool. Side effects include; fatigue and dizziness. Potential drug interactions
include; Quinidine or Ritonavir (may increase side effects of antidiarrheals) and
Saquinavir (may decrease effectiveness of antidiarrheals). Alcohol may increase
the side effects associated with antidiarrheals. High fiber foods should also be
avoided.
References:
1. Mayoclinic: Diseases and Conditions, Inflammatory Bowel Disease.
http://www.mayoclinic.org/diseases-conditions/inflammatory-boweldisease/basics/treatment/con-20034908. Updated September 27, 2014.
Accessed November 1, 2014.
2. Drugs.com. www.drugs.com. Updated September 26, 2014. Accessed
November 1, 2014.
3. Medicinenet. www.medicinenet.com. Updated June 20, 2013. Accessed on
November 1, 2014.
3. Patients with IBD are at the greatest risk for deficiencies of the following
nutrients. List the reason(s) why the deficiency may occur in patients with IBD
Iron: Lost in bloody diarrhea; depleted from medications
Zinc: Not absorbed due to diarrhea; depleted from medications
Folate: Medications cause depletion
Vitamin B12: Ilium may be too inflamed for absorption, especially in Crohn’s
Disease; medication depletion
Protein: Malabsorption; broken down from corticosteroids
Fat-Soluble vitamins: Malsbsorption; medication depletion
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Calories: Malabsorption in the GI tract; loss of appetite from meds and disease
In general, patients should follow a low residue, low fiber diet to avoid
malabsorption and nutrient deficiencies during IBD flare ups.
4. What dietary considerations are necessary with an ileostomy?
In an ileostomy the Iloscal valve is removed, which increases the risk of diarrhea
and nutrient malabsorption. Diet considerations include early PO intake to retrain and recondition the bowel, tpn and PO (overlapping feeding modalities),
and a diet high in soluble fiber, low fat and lactose free.
5. What is Short Bowel Syndrome?
SBS usually occurs in patients that have had IBD, especially after extensive small
bowel recession. It is also likely to occur in patients who have had radiation
enteritis and elective weight loss surgery. The inadequate absorptive capacity of
decreased length or decreased amount of functional bowel leads to fluid and
substrate load in the digestive tract exceeding the absorptive capacity remaining
viable mucosa in the intestine. Therefore, cardinal symptoms of SBS usually
result in diarrhea and steatorrhea since 70-75% of small bowel lost.
6. What is the minimal length of functional bowel believed to be necessary for
provision of enteral nutrition?
A normal adult small bowel is 400 cm. A minimum of 120 cm of small bowel
without a colon, or 50 cm with a colon, with the ileocecal valve intact, is
necessary for sufficient absorption of nutrients in the GI tract. If greater than
100 cm of terminal ilium in lost, then bile salt pool cannot be maintained
resulting in steatorrhea and fat soluble vitamin loss.
Celiac Disease
1. Define Celiac Disease, including the frequency of the condition and
causes.
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Celiac disease is an autoimmune response to the exposure of gluten,
which results in an inflammatory process that damages the lining of the
small intestine. The etiology is genetic susceptibility, or it may be
environmentally triggered during pregnancy or infection. Celiac disease
effects 1 out of 141 people.
2. What types of foods must be avoided by patients with Celiac Disease?
Foods containing gluten must be avoided in order for the intestines to
heal. Gluten is a protein common in wheat, rye and barley. Patients with
Celiac Disease should avoid foods such as, pasta, bread, pizza, flour
tortillas and baked goods; as well as less obvious gluten-containing foods
such as, beer, sauces, gravies, candy and supplements. Crosscontamination must also be considered when following a strict glutenfree diet.
3. What nutrients might be deficient in this diet?
Most gluten-containing pastas, cereals, and breads are made from flour
that has been enriched or fortified with iron and B vitamins (especially
B12 and folate). Also, a common source of fiber is whole grains, which
contain gluten. Therefore, eating whole foods (fresh fruits and
vegetables) and supplementing these nutrients while following a gluten
free diet may help prevent deficiencies.
4. Write a one-day menu for a patient on a gluten-free diet.
Breakfast—Vegetable and cheese omelet, gluten free toast, orange juice
and coffee.
Snack—Apple slices
Lunch—2 corn tortillas with grilled chicken, black beans, fresh salsa and
cabbage and unsweetened iced tea with lemon.
Snack—1/4 cup mixed nuts and raisins
Dinner—Grilled salmon with brown rice and broccoli and sparking water.
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Dessert—Yogurt with berries
Gallbladder Disease
1. Define the following terms:
Cholecystitis: Inflammation of the gallbladder, usually caused by bile
build up and gall stones.
Cholelithiasis: The presence of gall stones in the gallbladder.
Cholecystectomy: Surgical removal of the gallbladder.
2. You are asked to counsel an individual regarding a diet post cholecystectomy.
What diet modifications would you recommend both short and long term?
Immediately post-surgery, patients should only consume clear liquids and very
low fat. Patients should transition gradually to a low fat (40g per day), bland
solid foods diet and eat small, frequent meals rich in lean protein, whole grains,
fruits and vegetables. Over time, patients may gradually add more fat to the diet
as the body adjusts to not having a gallbladder, while maintaining a healthy
weight.