Chapter 18 Gastrointestinal and Accessory Organ Problems

1. Chapter 18Gastrointestinal and Accessory Organ Problems Chapter 18

2. Objectives: Identify problems of the upper gastrointestinal tract Identify problems of the lower gastrointestinal tract Identify food allergies and intolerances Identify problems of the gastrointestinal accessory organs

3. Key Concepts Diseases of the gastrointestinal tract and its accessory organs interrupt the body’s normal cycle of digestion, absorption, and metabolism Food allergies result from sensitivity to certain proteins Underlying genetic diseases may cause metabolic defects that block the body’s ability to handle specific food nutrients.

4. Problems of the Mouth • Dental problems • Tooth decay • Ill-fitting dentures, loss of teeth  problems with eating, swallowing, and overall nutrition • Mechanical soft diet helpful • Post Surgical procedures • E.g. fx. Jaw, head/neck surgeries • Healing nutrients administered with high-protein, high-caloric milk shakes

5. Gingivitis/TMJ problems

6. Problems of the Mouth Oral tissue inflammation – malnutrition causes deterioration of oral tissues resulting in local infection or injury  pain and difficulty eating • Gingivitis – inflammation of the gums + the tissues encircling the base of the teeth • Stomatitis –inflammation of the oral mucous lining of the mouth • Glossitis – inflammation of the tongue • Cheilosis – a cracking and dry scaling process at the corners of the mouth affecting the lips and corner angles making opening the mouth to eat painful

7. Mouth ulcers may develop from 3 infections: • Herpes Simplex Virus  mouth sores on the inside mucous lining of the cheeks and lips or on the external portion of the lips (cold sores, blisters) • Candida Albicans – a fungus causing similar sores on the oral mucosa (thrush) • Hemolytic Streptococcus – bacteria causing canker sores • Eating is painful and adequate nutrition becomes a major problem • Nutritionally dense liquids  soft, nonacidic and nonspicy, room temperature foods

8. Salivary gland problems • Infections – e.g. virus that attacks the parotid gland (mumps) • Excess salivation – e.g. Parkinson’s, local mouth infections, injury and drug reactions • Xerostomia (permanent dry mouth) – sometimes in middle-aged and elderly adults often associated with RA, radiation therapy, drug side effect

9. Problems of the Mouth Swallowing disorders • Dysphagia (difficulty swallowing) fairly common problem • Variety of causes: • Insufficient production of saliva • Dry mouth • Abnormal peristaltic motility of the esophagus • Complications of medication • Neurologic problems

10. Problems of the Mouth • Swallowing Disorders cont. • To treat dysphagia, the problem must be identified as either mechanical obstruction or a neuromuscular disorder • Dysfunctional swallowing  aspirate food particles • Swallowing disorders common in trauma, brain injury, and stroke patients • Diet adaptations may be necessary • Special feeding techniques

11. Problems of the Mouth Warning signs of swallowing disorders: • Reluctance to eat certain food consistencies or any food at all • Very slow chewing or eating • Fatigue from eating • Frequent throat clearing • Complaints of food “sticking” in throat • Holding pockets of food in cheeks • Painful swallowing • Regurgitation, coughing, choking

12. Problems of the Esophagus • Central tube (esophagus) – problems interrupt normal swallowing: • Muscle spasms or uncoordinated contractions • Stricture (narrowing) of the tube • Lower esophageal sphincter problems • May come from changes in the smooth muscle itself or from the nerve-muscle hormone control of peristalsis

13. Problems of the Esophagus • Lower Esophageal Sphincter Problems cont. • Achalasia or cardiospasm –spasms occur when the LES muscles maintain an excessively high muscle tone, even while resting, thus failing to open normally when a person swallows • Sx. – swallowing problems, frequent vomiting, feeling of fullness in chest, weight loss from eating difficulty, serious malnutrition, pulmonary complications • Treatment – surgical – dilate the LES or slit the muscle • Diet: oral liquids and progress to regular diet

14. GI Cocktail Mixture of liquid antacid Viscous lidocaine Donnatol Useful as part of the diagnostic protocol for patients complaining of chest pain

15. Problems of the Esophagus Gastroesophageal Reflux Disease (GERD) • Caused by constant regurgitation of acid gastric contents into lower esophagus  esophagitis • Pregnancy, obesity, pernicious vomiting, or nasogastric tubes are factors • Gastric acid and pepsin cause tissue erosion • Stenosis (narrowing or stricture) most common complication + peptic ulcer

16. Problems of the Esophagus • GERD cont. • Treatment: • Weight management • Acid control • Low-fat diet • Sleep with HOB elevated

17. Normal Stomach

18. Hiatal hernia • Hiatal hernia • Portion of upper stomach protrudes through opening in the diaphragm membrane (hiatus) • Especially common in obese adults

19. Peptic Ulcer Disease • Incidence: • Lifetime prevalence of PUD is approx. 10%, occurring simultaneously in men and women • Seen mostly in middle adulthood between the ages of 45-55 • 80-90% caused by Helicobacter pylori (H. pylori) infection (bacteria) • Persons with chronic H. Pylori are at greater risk for gastric cancer • Tobacco smoking linked to PUD

20. Peptic Ulcer Disease Chronic use of nonsteroidal anti-inflammatory (NSAID) drugs may contribute to development in some persons  irritate the gastric mucosa  bleeding, erosion, and ulceration

21. Physical Factors: • Lesion can occur in the lower esophagus, stomach, or the first portion of the duodenum • Most occur in the first portion of the duodenum (duodenal bulb) because the gastric contents emptying there are more concentrated • The lesion results from an imbalance between: • 1. the amount of gastric acid and pepsin secretions plus the extent of H. pylori infection • 2. the degree of tissue resistance to these secretions and infection

22. Psychological Factors: • Stress during young- and middle- adult years may contribute • Stress of emergency trauma and injury • Long term rehab processes • Clinical symptoms: • Increased gastric muscle tone and painful contractions when stomach empty • Hemorrhage • Dx. Confirmed by radiographs and gastroscopy

23. Peptic Ulcer Disease

24. Peptic Ulcer Disease • Medical Management: • 4 basic goals: • Alleviate the symptoms • Promote healing • Prevent recurrences by eliminating the cause • Prevent complications

25. Peptic Ulcer Disease • Treatment: • REST: adequate rest, relaxation, and sleep – enhances the body’s healing process • Anxiety Management: • incorporate positive coping skills into daily life • encourage pts. to talk about anxieties, anger, frustrations • Appropriate physical activity • Smoking, alcohol use should be eliminated • Some common drugs (e.g. ASA, NSAIDS) should be avoided

26. Drug therapy • Blocking agents that control acid secretion • Tagamet, Zantac • Proton Pump Inhibitors – inhibit HCl production • Omeprazole, Pantoprazole • Mucosal protectors inactivate pepsin and produce gel-like substance to cover ulcer • Sucralfate (Carafate) • Antibiotics control H. pylori • Amoxicillin, Tetracycline, Metronidazole • Antacids counteract or neutralize acid

27. Peptic Ulcer Disease Dietary management • Well-balanced, healthy diet • Avoid acid stimulation • Food quantity • Milk intake • Seasonings • Dietary Fiber • Avoid caffeine, citric acid juices, alcohol • Avoid smoking • Bland diets have been proven to be ineffective and lacking in adequate nutrition

28. Small Intestine Diseases Malabsorption syndromes are characterized by a defect in the absorption of fats, proteins, carbohydrate, vitamins, minerals, and/or water.

29. Small Intestine Diseases • Malabsorption results from a disturbance in the normal digestive process and the defect may include any of the following processes: • Digestion of macronutrients (CHO, proteins, fats) • Terminal digestion at the brush border mucosa • Transport • Chronic Diarrhea/Steatorrhea – most common symptom of malabsorption disorders

30. Small Intestine Diseases Malabsorption -Causes: • Maldigestion problems – pancreatic disorders, bacterial overgrowth, Inflammatory bowel disease • Intestinal mucosal changes – mucosal surface alterations; surgery • Genetic disease – e.g. cystic fibrosis (pancreatic insufficiency, lack of pancreatic enzymes • Intestinal enzyme deficiency – e.g. lactose intolerance • Cancer and its treatment – effects of radiation and chemotherapy • Metabolic defects – absorbing surface effects of pernicious anemia and gluten-induced mucosal disease

31. Small Intestine Diseases • 3 common malabsorption conditions: • Cystic Fibrosis • Inflammatory Bowel Disease • Diarrhea

32. Small Intestine Disease • Cystic Fibrosis • Most fatal genetic disease in North America • Metabolic defect characterized as a pulmonary disease with a profound GI impact • Life expectancy now to adulthood • Inhibits movement of chloride and sodium ions in the body tissue fluids • These ions become trapped in cells causing thick mucous to form that clogs ducts and passageways • CF symptoms: • Thick mucous in the lungs  damaged airways  difficulty breathing and lung infections

33. Small Intestine Disease • Cystic Fibrosis symptoms cont. • Pancreatic Insufficiency  lack of normal pancreatic enzymes and progressive loss of insulin-producing beta cells  diabetes mellitus • Malabsorption of undigested food nutrients  malnutrition and stunted growth • Liver disease from progressive degeneration of functional liver tissue d/t clogged bile ducts • Salt concentration increased in body perspiration  salt depletion

34. Cystic Fibrosis

35. Symptoms of CF • Clinical manifestations: • very salty-tasting skin; • persistent coughing, at times with phlegm; • frequent lung infections; • wheezing or shortness of breath; • poor growth/weight gain in spite of a good appetite; and • frequent greasy, bulky stools or difficulty in bowel movements

37. Small Intestine Diseases Cystic fibrosis cont. • Nutrition Management • Treated with pancreatic replacement products • Children with CF require 105% - 150% of recommended nutrients for their age • Nutritionally adequate high-protein, normal-to-high fat diet recommended • Regular Nutritional Assessment, Education, and follow up care

38. Intestine Diseases • Inflammatory Bowel Disease • Applies to both Ulcerative Colitis and Crohn’s disease • Related condition: Short-bowel syndrome - results from repeated surgical removal of parts of the small intestine as disease progresses • Reduces absorption of nutrients because absorbing surfaces are reduced • Considered “idiopathic” diseases because their etiology is unknown

39. Intestinal Diseases • Inflammatory Bowel Disease cont. • Crohn’s Disease: most commonly localized in the ileum and colon • Inflammation may skip sections of the GI tract and affect more than 1 section at a time • Ulcerative Colitis: limited to the colon • Symptoms include: diarrhea with blood and mucous, abdominal pain, cramping • Progressive from the anus

40. Intestinal Diseases All inflammatory bowel conditions can have severe nutritional results as more and more of the absorbing surface area becomes involved.

41. Intestinal Disease • Inflammatory Bowel Disease cont. • Restoring positive nutrition is a basic requirement for tissue healing and health • Elemental Formulas of amino acids, glucose, fat, minerals, and vitamins are more easily absorbed and support initial healing in response to antibacterial and anti-inflammatory medications. • Principles of continuing dietary management: • High protein (omitting milk at first) • High energy 2500-3000 kcal/day • Increased vitamins and minerals

42. Intestinal Disease • Diarrhea • Typically not a disease of the small intestine • A symptom or result of another underlying cause • May result from: • Intolerance to specific foods • Acute food poisoning from a specific food-borne organism or toxin • Viral infections

43. Small Intestine Diseases • Diarrhea cont. • Organisms include: • Parasites: Giardia, Cryptsporidium, Entamoeba • Bacteria: Campylobacter, Clostridium Difficile, E. coli, Listeria Monocytogenes, Salmonella, Shigella • Virus: HIV, rotovirus • Chronic diarrhea can be life-threatening for infants, young children and those with compromised immune systems  dehydration and nutrient loss • Fluid and electrolyte replacement needed

44. Large Intestine Diseases Diverticular disease Diverticulosis: lower intestinal condition Formation of many small pouches (diverticula) along muscular mucosal lining Develop at points of weakened muscles in the bowel wall Diverticulitis caused by pockets becoming infected

46. Large Intestine Diseases • Diverticular Disease cont. • Symptoms: as the inflammatory process advances: • Increase pain localized in LLQ of abdomen • N/V/D, distention, intestinal spasm • Fever • Perforation  surgery • Nutritional Therapy – increase dietary fiber; avoid nuts, seeds

47. Large Intestine Diseases Irritable bowel syndrome • Multicomponent disorder of physiologic, emotional, environmental, psychologic function • 3 major types of symptoms: • Chronic recurrent pain in abdomen • Small-volume bowel dysfunction (constipation, diarrhea, or both) • Excess gas formation

48. Irritable Bowel Syndrome

49. Large Intestine Diseases Irritable bowel syndrome • Individual approach to nutrition care essential • Food Plan Basic Principles: • Increase dietary fiber • Recognize gas formers • Respect food intolerances • Reduce total fat content • Avoid large meals • Decrease air-swallowing habits

50. Large Intestine Diseases Constipation • Common short-term problem • Nervous tension and worry • Changes in routines • Constant laxative use • Low-fiber diets • Lack of exercise • Dietary management rather than laxatives