Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders

1. Chapter 30 Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders

2. Common Intestinal Symptoms • Intestinal gas and flatulence • Constipation • Diarrhea • Steatorrhea • Gastrointestinal strictures and obstruction

3. 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

4. SteatorrheaDietary 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

5. SteatorrheaMCT 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

6. Celiac DiseaseGluten-Sensitive Enteropathy • Adverse reaction to gluten—gliadin fraction • Intestinal mucosa damaged —Malabsorption of nutrients —Iron deficiency —Osteomalacia —Growth failure —Projectile vomiting

7. 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.)

8. Celiac Disease−Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

9. 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.

10. 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.

11. Celiac DiseaseGluten-Sensitive Enteropathy • Treatment Remove gluten from the diet: —Wheat —Rye —Buckwheat —Barley

12. Celiac DiseaseGluten-Sensitive Enteropathy—cont’d • Gluten/gliadin-containing foods Used to thicken many processed foods See Tables 30-3 and 30-4

13. 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

14. Intestinal Brush Border Enzyme Deficiencies • Lactose intolerance • Causes: genetic or secondary deficiency of milksugar 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

15. 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

16. Inflammatory Bowel Disease−Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

17. Inflammatory Bowel Disease−Pathophysiology Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Peter L. Beyer, 2002.

18. 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.

19. Inflammatory Bowel Diseases • Rx: Diet depends on patient’s status Nutrition assessment Select route of feeding Fiber is beneficial except during flareups.

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. Short Bowel SyndromeNutritional 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.

27. Short Bowel Syndrome • Eventually the remaining bowel increases absorptive surface, and problems decrease. • Nutrition support is designed to meet each patient’s needs.

28. 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

29. 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

30. 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

31. Causes of Constipation— Gastrointestinal • Diseases of the upper gastrointestinal tract —Celiac disease —Duodenal ulcer • 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 • —Gastric cancer • —Cystic fibrosis

32. 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

33. FistulaAbnormal Opening Between Organs • Causes: birth defects; trauma; inflammatory disease; malignant disease • Rx: For fluid loss For electrolyte loss Aggressive nutritional support

34. Ileostomy or ColostomySurgical 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

35. Hemorrhoidectomy • Delay stool formation until healing can take place • Rx: Minimal-residue diet or elemental diet • After recovery High-fiber diet to prevent

36. 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