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Chapter 30
Medical Nutrition
Therapy for
Lower
Gastrointestinal
Tract Disorders
Common Intestinal Symptoms

Intestinal gas and flatulence

Constipation

Diarrhea

Steatorrhea

Gastrointestinal strictures and obstruction
© 2004, 2002 Elsevier Inc. All rights reserved.
Diarrhea

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
© 2004, 2002 Elsevier Inc. All rights reserved.
Steatorrhea
Dietary 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Steatorrhea
MCT 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Celiac Disease
Gluten-Sensitive Enteropathy

Adverse reaction to gluten—gliadin fraction

Intestinal mucosa damaged
—Malabsorption of nutrients
—Iron deficiency
—Osteomalacia
—Growth failure
—Projectile vomiting
© 2004, 2002 Elsevier Inc. All rights reserved.
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.)
© 2004, 2002 Elsevier Inc. All rights reserved.
Celiac Disease−Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Celiac 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.)
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Celiac Disease−Medical and Nutritional
Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Celiac Disease
Gluten-Sensitive Enteropathy

Treatment
Remove gluten from the diet:
—Wheat
—Rye
—Buckwheat
—Barley
© 2004, 2002 Elsevier Inc. All rights reserved.
Celiac Disease
Gluten-Sensitive Enteropathy—cont’d

Gluten/gliadin-containing foods
Used to thicken many processed foods
See Tables 30-3 and 30-4
© 2004, 2002 Elsevier Inc. All rights reserved.
Tropical 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Intestinal Brush Border Enzyme
Deficiencies

Lactose intolerance

Causes: genetic or secondary deficiency of milk
sugar 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Inflammatory 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Inflammatory Bowel Disease−Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Inflammatory Bowel Disease−
Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Inflammatory Bowel Disease−Medical and
Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Inflammatory Bowel Diseases

Rx:
Diet depends on patient’s status
Nutrition assessment
Select route of feeding
Fiber is beneficial except during flareups.
© 2004, 2002 Elsevier Inc. All rights reserved.
Disorders 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
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Disorders 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
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Disorders 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.
© 2004, 2002 Elsevier Inc. All rights reserved.
Short 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
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Short 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
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Short Bowel Syndrome —cont’d
Factors Affecting Severity of Malabsorption, Number
of Complications, and Dependence on Parenteral
Nutrition








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
© 2004, 2002 Elsevier Inc. All rights reserved.
Short Bowel Syndrome
Nutritional 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.
© 2004, 2002 Elsevier Inc. All rights reserved.
Short Bowel Syndrome

Eventually the remaining bowel increases
absorptive surface, and problems
decrease.

Nutrition support is designed to meet
each patient’s needs.
© 2004, 2002 Elsevier Inc. All rights reserved.
Other 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Blind 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Diet 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Causes of Constipation—
Gastrointestinal





Diseases of the upper gastrointestinal tract
—Celiac disease
—Gastric cancer
—Duodenal ulcer
—Cystic fibrosis
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
© 2004, 2002 Elsevier Inc. All rights reserved.
Causes 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
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Fistula
Abnormal Opening Between Organs

Causes: birth defects; trauma; inflammatory
disease; malignant disease

Rx:
For fluid loss
For electrolyte loss
Aggressive nutritional support
© 2004, 2002 Elsevier Inc. All rights reserved.
Ileostomy or Colostomy
Surgical 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Hemorrhoidectomy

Delay stool formation until healing can
take place

Rx:
Minimal-residue diet or elemental diet

After recovery
High-fiber diet to prevent
© 2004, 2002 Elsevier Inc. All rights reserved.
Summary

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
© 2004, 2002 Elsevier Inc. All rights reserved.