Special topics Topic 7 and 8:

1. Special topicsTopic 7 and 8: Upper and Lower Gastrointestinal Disorders Reference: understanding normal and clinical nutrition, 9th ed, chapter:23 and 24

2. Dysphagia • (difficulty swallowing) • The main symptom is the sensation of food “sticking” in the esophagus after it is swallowed. • An obstruction can be caused by a stricture (abnormal narrowing), tumor, or compression of the esophagus by surrounding tissues • Achalasia, the most common motility disorder, is a degenerative nerve condition affecting the esophagus; it is characterized by impaired peristalsis and incomplete relaxation of the lower esophageal sphincter when swallowing.

4. Complications of Dysphagia • malnutrition and weight loss • increased risk of dehydration • If aspiration occurs, it may cause choking, airway obstruction, or respiratory infections, including pneumonia

5. Food Properties and Preparation • diets should have easy-to-manage textures and consistencies. Soft, cohesive foods are easier to handle than hard or crumbly foods. Moist foods are better tolerated than dry foods. • Level 1: Dysphagia Pureed: Foods should be pureed or well mashed, homogeneous, and cohesive. This diet is for patients with moderate to severe dysphagia and poor oral or chewing ability.

6. Level 2: Dysphagia Mechanically Altered: Foods should be moist, cohesive, and soft textured and should easily form a bolus. This diet is for patients with mild to moderate dysphagia; some chewing ability is required. • Level 3: Dysphagia Advanced: Foods should be moist and be in bite-sized pieces when swallowed; foods with mixed textures are included. This diet is for patients with mild dysphagia and adequate chewing ability

7. Liquid Consistencies (only those tolerated are allowed in the diet) • Thin: Watery fluids; may include milk, coffee, tea, juices, carbonated beverages. • Nectarlike: Fluids thicker than water that can be sipped through a straw; may include buttermilk, eggnog, tomato juice. • Honeylike: Fluids that can be eaten with a spoon but do not hold their shape; may include honey, tomato sauce, yogurt. • Spoon-thick: Thick fluids that must be eaten with a spoon and can hold their shape; may include milk pudding, thickened applesauce.

8. To increase viscosity, commercial starch thickeners can be stirred into beverages and other liquid foods • Alternative Feeding Strategies for Dysphagia • Some changing the position of the head and neck while eating and drinking can minimize some swallowing difficulties • Individuals with oropharyngealdysphagia can be taught exercises that strengthen the jaws, tongue, or larynx, or they can learn new methods of swallowing that allow them to consume a normal diet.

9. Gastroesophageal Reflux Disease • Causes: pregnancy, obesity, asthma, and hiatal hernia, a condition in which a portion of the stomach protrudes above the diaphragm. • Consequences :esophageal ulcers, with consequent bleeding, Healing and scarring of ulcerated tissue may narrow the inner diameter of the esophagus, causing esophageal stricture. Pulmonary disease may develop if gastric contents are aspirated into the lungs.

10. Chronic reflux is also associated with Barrett’s esophagus, a condition in which damaged esophageal cells are gradually replaced by cells that resemble those in gastric or intestinal tissue; such cellular changes increase the risk of developing esophageal cancer. • GERD can also damage tissues in the mouth, pharynx, and larynx, resulting in eroded tooth enamel, sore throat, and laryngitis

11. Manage Gastroesophageal Reflux Disease • Avoid eating bedtime snacks or lying down after meals. Meals should be consumed at least three hours before bedtime. • Reduce nighttime reflux by elevating the head of the bed on 6-inch blocks, inserting a foam wedge under the mattress, or propping pillows under the head and upper torso. • Consume only small meals, and drink liquids between meals so that the stomach does not become overly distended, which can exert pressure on the lower esophageal sphincter.

12. Limit foods that weaken lower esophageal sphincter pressure or increase gastric acid secretion; these include chocolate, fried and fatty foods, spearmint and peppermint, coffee (both caffeinated and decaffeinated), and tea. • Avoid cigarettes and alcohol; both relax the lower esophageal sphincter. • Avoid bending over and wearing tight-fitting garments; both can cause pressure in the stomach to increase, heightening the risk of reflux.

13. During periods of esophagitis, avoid foods and beverages that may irritate the esophagus, such as citrus fruits and juices, tomato products, garlic, onions, pepper, spicy foods, carbonated beverages, and very hot or very cold foods (depending on individual tolerances). • Avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen, and ibuprofen, which can damage the esophageal mucosa.

14. Conditions Affecting the Stomach • Nausea and Vomiting: • the main goal is to find and correct the underlying disorder. Restoring hydration and electrolyte balance may also be necessary in some individuals. If a medication is the cause, taking it with food may help. • If the cause is unknown or the underlying disorder cannot be corrected, medications that suppress nausea and vomiting can be prescribed

15. To minimize stomach distention, patients should consume small meals and drink beverages between meals rather than during a meal. Dry, starchy foods such as toast, crackers, and pretzels may help to reduce nausea, whereas fatty or spicy foods and foods with strong odors may worsen symptoms. • Foods that are cold or at room temperature may be better tolerated than hot foods. Individuals often have strong food aversions when nauseated, and tolerances vary greatly

16. Peptic Ulcer Disease • Patients should avoid dietary substances that increase acid secretion or irritate the GI lining; examples include alcohol, coffee and other caffeine- containing beverages, chocolate • Small meals may be better tolerated than large ones. • Patients should avoid food consumption for at least two hours before bedtime.

17. Cigarette smoking should be discouraged, as it can delay healing and increase the risk of ulcer recurrence. • There is no evidence that dietary adjustments can alter the rate of healing.

18. Dietary Guidelines after Bariatric Surgery • Only sugar-free, noncarbonated clear liquids and low-fat broths are given during the first two days following bariatric surgery. Afterward, patients consume a liquid diet (low in sugars) at first, followed by pureed foods and then solid foods; the diet is advanced as tolerated. • Once the diet progresses to solid foods, patients may consume between three and six small meals per day.

19. Only small portions of food can be consumed at each meal because overeating can stretch the gastric pouch or result in vomiting or regurgitation. Similarly, fluids must be consumed separately from meals to avoid excessive distention. • Protein intake: Recommendations range from 1.0 to 1.5 grams of protein per kilogram of ideal body weight per day • Vitamin and mineral deficiencies: Supplemental vitamin B12, vitamin D, iron, and calcium are recommended after surgery. A daily multivitamin/mineral supplement ensures that patients meet their needs for other nutrients.

20. Foods to avoid. Some foods may obstruct the gastric outlet; these include doughy or sticky breads, pasta products, and rice; fibrous vegetables such as asparagus; foods with seeds, peels, or skins; nuts; popcorn; and tough, dry meats.

21. Lower Gastrointestinal Disorders • Constipation: • The primary treatment for constipation is a gradual increase in fiber intake to about 25 grams per day. High-fiber diets increase stool weight and fecal water content and promote a more rapid transit of materials through the colon. Foods that increase stool weight the most are wheat bran, fruits, and vegetables. • Bran intake can be increased by adding bran cereals and whole-wheat bread to the diet or by mixing bran powder with beverages or foods. The transition to a high-fiber diet may be difficult for some people because it can increase intestinal gas, so high-fiber foods should be added gradually, as tolerated.

22. Fiber supplements such as methylcellulose (Citrucel), psyllium (Metamucil, Fiberall), and polycarbophil (a synthetic fiber) are also effective; these supplements can be mixed with beverages and taken several times daily. Unlike other fibers, methylcellulose and polycarbophil do not increase intestinal gas. • Consuming adequate fluid (usually 1.5 to 2 liters daily) helps to increase stool frequency in people who are already consuming a high-fiber diet

23. Diarrhea: • Because diarrhea can develop for numerous reasons, the nutrition prescription depends on the medical diagnosis and severity of the condition. • The dietary treatment often recommended is a low-fiber, low-fat, lactose-free diet. • The diet limits foods that contribute to colonic residue, such as those with significant amounts of fiber, resistant starch, fructose, sugar alcohols, and lactose (in lactose-intolerant individuals)

24. Fructose and sugar alcohols, which are poorly absorbed, retain fluids in the colon and contribute to osmotic diarrhea. • milk products may worsen osmotic diarrhea in persons who are lactose intolerant. • Avoidance of fatty foods is recommended because they can sometimes aggravate diarrhea. Gas-producing foods (those with poorly digested or absorbed carbohydrates) can increase intestinal distention and cause additional discomfort.

25. Patients should avoid caffeinated coffee and tea because caffeine stimulates GI motility and can thereby reduce water reabsorption. In the treatment of formulafed infants, apple pectin or banana flakes are sometimes added to formulas to help.

26. Pancreatitis • Pancreatitis is an inflammatory disease of the pancreas. Although mild cases may subside in a few days, other cases can persist for weeks or months. Chronic pancreatitis can lead to irreversible damage to pancreatic tissue and permanent loss of function. • Nutrition Therapy for Acute Pancreatitis • The initial treatment for acute pancreatitis is supportive and includes pain control, intravenous hydration, and supplementary oxygen, if necessary

27. Oral fluids and food are withheld until the patient is pain free and experiences no nausea or vomiting. • Afterward, patients may consume a liquid diet or small low-fat meals, as tolerated (fat stimulates the pancreas more than other nutrients). • In severe pancreatitis, tube feedings may be necessary; either standard formulas or elemental formulas may be used, depending on patient tolerance.

28. Protein and energy needs are high in severe cases due to the catabolic and hypermetabolic effects of inflammation. Patients with acute pancreatitis require nutrient supplementation until food intake can meet nutritional needs. • Nutrition Therapy for Chronic Pancreatitis • The objectives of nutrition therapy are to correct malnutrition, reduce malabsorption, and prevent symptom recurrence.

29. Dietary supplements are used to correct nutrient deficiencies, which may be due to malabsorption or to the alcohol abuse that caused the disease. To improve food tolerance, patients should consume small, low-fat meals. • They should also avoid alcohol completely and quit smoking cigarettes, as these substances can exacerbate illness and interfere with healing. • Steatorrhea is usually treated with pancreatic enzyme replacement.

30. Pancreatic enzymes are often enteric coated to resist the acidity of the stomach and do not dissolve until the pH is above 5.5. • If nonenteric-coated preparations are used, acid-suppressing drugs are also required. Fecal fat concentrations must be monitored to determine if the enzyme treatment has been effective. • In some cases fat- controlled diet may help to reduce symptoms, and MCT oil can be used as an alternative source of fat kcalories.

31. Conditions Affecting the Small Intestine • Celiac disease and inflammatory bowel diseases are intestinal conditions that can impair mucosal function. • Celiac disease is an immune disorder characterized by an abnormal immune response to a protein fraction in wheat gluten • The reaction to gluten causes severe damage to the intestinal mucosa and subsequent malabsorption

32. Nutrition Therapy for Celiac Disease • The treatment for celiac disease is lifelong adherence to a gluten-free diet. • Improvement in symptoms is often evident within several weeks, although mucosal healing can sometimes take years. • If lactase deficiency is suspected, patients should avoid lactose-containing foods until the intestine has recovered. • Dietary supplements can be used to meet micronutrient needs and reverse deficiencies.

33. The gluten-free diet eliminates foods that contain wheat, barley, and rye • Gluten-containing products that may be overlooked include beer, caramel coloring, coffee substitutes, communion wafers, imitation meats, malt syrup, medications, salad dressings, and soy sauce. • A gluten-free diet may become monotonous unless care is taken to diversify food choices. The diet can also be a social liability by restricting food choices when individuals eat in restaurants, visit friends, or travel

34. Conditions Affecting the Large Intestine • Irritable Bowel Syndrome • experience chronic and recurring intestinal symptoms that cannot be explained by specific physical abnormalities. • The symptoms usually include disturbed defecation (diarrhea and/or constipation), flatulence, and abdominal discomfort or pain; • the pain is often aggravated by eating and relieved by defecation.

35. In some patients, symptoms are mild; in others, the disturbances in colonic function can interfere with work and social activities enough to dramatically alter the person’s lifestyle and sense of well-being. • Nutrition Therapy for Irritable Bowel Syndrome: • is to gradually increase fiber intake from food or supplements to relieve constipation and improve stool bulk • clinical studies suggest that additional fiber has only marginal effectiveness in improving symptoms and may worsen flatulence

36. Psyllium supplementation may be helpful for individuals with constipation. • Some individuals have fewer symptoms when they consume small, frequent meals instead of larger ones. • Foods that aggravate symptoms may include fried or fatty foods, gas-producing foods, milk Products, wheat products, coffee.

37. Treatments under investigation for irritable bowel syndrome include peppermint oil, which relaxes smooth muscle within the GI tract, and various types of probiotics • Medical treatment of irritable bowel • syndrome often includes dietary adjustments, stress management, and behavioral therapies.

38. Medications may be prescribed to manage symptoms, although they are not always helpful. The drugs prescribed may include antidiarrheal drugs, anticholinergics (which affect GI motility), antidepressants, and laxatives