Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders

1. Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders

3. 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

4. Common Symptoms of Gastrointestinal Disease

5. 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.

6. 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

7. Head and Neck Cancers

8. 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.

9. 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, soft-textured foods and small, frequent meals • Artificial saliva solutions, increased fluids, topical anaesthetics to relieve pain • Aggressive oral hygiene, fluoride, treatment of fungal infections

10. 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

11. 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

12. Anatomy of Esophagus and Hiatal Hernia

13. Complications of GERD • Esophagitis, stricture or ulcer • Barrett’s Esophagus (premalignant state)

14. 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

15. Ambulatory Reflux Monitoring

16. 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

17. 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

18. 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

19. Nutrition Prescription for GERD • Spicy, acidic foods may be irritating if esophagitis is present • Limitation of these foods should be based on individual tolerance

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Medications Used to Tx GERD Promotility Agents (enhance esophageal clearing and gastric emptying) • Cisapride, bethanechol

27. Surgical Treatment of GERD • Fundoplication: Fundus of stomach is wrapped around lower esophagus to limit reflux

28. Illustration of Fundoplication Source: http://www.medformation.com/ac/adamsurg.nsf/page/100181#

29. MNT in NAUSEA/VOMITING

30. Nausea & Vomiting • Prolonged vomiting = hyperemesis • Loss of nutrients, fluids, electrolytes • Dehydration, electrolyte imbalance, wt. loss • Medications: • Antinauseants • Antiemetics

31. 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

32. 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

33. 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

34. 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

35. 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

36. Diseases of Stomach • Indigestion • Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: —Alcohol —Aspirin —Nonsteroidal antiinflammatory agents

37. Indigestion (Dyspepsia) Symptoms • Abdominal pain • Bloating • Nausea • Regurgitation • Belching

38. Dyspepsia Treatment • Avoid offending foods • Eat slowly • Chew thoroughly • Do not overindulge

39. Gastritis • Normally gastric & duodenal mucosa protected by: • Mucus • Bicarbonate (acid neutralized) • Rapid removal of excess acid • Rapid repair of tissue

40. Gastritis • Erosion of mucosal layer • Exposure of cells to gastric secretions, bacteria • Inflammation & tissue damage

41. Gastritis • Helicobacter Pylori (H. pylori) • Bacteria, resistant to acid • Damages mucosa • Treat with bismuth, antibiotics, antisecretory agents • Causes ~92% duodenal ulcers; 70% gastric ulcers

42. 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

43. Endoscopy

44. 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

45. Characteristics and Comparisons Between Gastric and Duodenal Ulcers • Gastric ulcer formation involves inflammatory involvement of acid-producing 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.

46. Gastric and Duodenal Ulcers

47. 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

48. 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

49. 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

50. 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