Victor Tambunan Department of Nutrition Faculty of Medicine Universitas Indonesia 1
References Krause s Food & Nutrition Therapy 12th ed., 2008 ---- L.K. Mahan & S. Escott-Stump Modern Nutrition in Health and Disease 10th ed., 2006 ---- M.E. Shils et al 2
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GASTROINTESTINAL TRACT Upper Gastrointestinal (GI) Tract Esophagus Stomach Duodenum Lower GI Tract Small intestine Large intestine Rectum 4
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Gastroesophageal Diseases Gastroesophageal reflux disease (GERD) Gastritis and peptic ulcer disease Gastric cancer Dumping syndrome 6
GERD consists of irritation & inflammation of the esophagus in response to reflux of gastric acid into the esophagus Symptom: heartburn Factors that contribute to GERD: Excessive volume of acidic contents in the stomach Looseness of lower esophageal sphincter (LES) Motility disorders in the esophagus 7
Medical Nutrition Therapy Objectives: 1. Prevent esophageal reflux 2. Prevent pain & irritation of the inflamed esophageal mucosa 1. the erosive capacity or acidity of gastric secretion 8
Nutrition Care Guidelines for Reducing Gastroesophageal Reflux: 1. 2. 3. 4. 5. 6. 7. 8. Avoid large, high-fat meals Not eating within 3 to 4 hours before retiring Avoid tobacco smoking Avoid alcoholic beverages Avoid caffeine containing foods & beverages Stay upright & avoid vigorous activity soon after eating Avoid tight-fitting clothing, esp. after a meal Consume a healthy, nutritionally complete diet with adequate fibre 9. Avoid acidic & highly spiced foods when inflammation exists 10. Reduce weight if overweight 9
Alcohol Chocolate Fatty foods relaxing the LES & inducing GERD 10
Gastritis & peptic ulcers may result when infectious chemical neural abnormalities disrupt mucosal integrity of the stomach or duodenum 11
The most common cause: Helicobacter pylori infection H. pylori infection is responsible for: Most cases of chronic inflammation of gastric mucosa Peptic ulcer Atrophic gastritis Gastric cancer 12
Acute gastritis: refers to rapid onset of inflammation & symptoms Chronic gastritis: may occur over a period of months to decades, w/ increasing & decreasing of symptoms 13
Atrophic gastritis: chronic inflammation w/ deterioration of the mucous membrane & glands, resulting in: achlorhydria (loss of secretion of HCl) loss of intrinsic factor 14
Factors that may also compromise mucosal integrity and the chance of acquiring acute & chronic gastritis Chronic use of aspirin or other NSAIDs Steroids Alcohol Erosive substances Tobacco 15
Medical Nutrition Therapy as for peptic ulcers In patients w/atrophic gastritis: evaluate vitamin B12 status because lack of intrinsic factor & HCl results in malabsorption of vitamin B12 In chronic gastritis: absorption of Fe, Ca, & other nutrients 16
Involve two major regions: - Stomach - Duodenum Primary causes: H. pylori infection Gastritis Aspirin & other NSAIDs Corticosteroids Stress-induced ulcer 17
Excessive use or high concentration drinks (alcohol) can: damage gastric mucosa worsen symptoms of peptic ulcers interfere w/ ulcer healing Beers & wines: gastric secretion Coffee & caffeine: stimulate acid secretion LES pressure 18 18
Medical Nutrition Therapy Avoid alcohol consumption of spices, esp. chili, cayenne, & black peppers. Turmeric may inhibit adhesion of H. pylori to the gastric wall Avoid coffee & caffeine intake of n-3 & n-6 fatty acids Use probiotics as complementary therapy Regular use of cranberries which contain phenolic antioxidants may have the capacity to help eradicate H. pylori 19
Frequent small meals may: comfort the chance for acid reflux stimulate gastric blood flow persons w/ peptic ulcers should avoid consuming large meals, esp. before retiring, to reduce latent increases in acid secretion 20
Cancer of the stomach can lead to malnutrition because of: Excessive blood & protein losses, or Obstruction & mechanical interference w/ food intake more commonly Consumption of fruits, vegetables, & selenium may have a modest role in the prevention of GI cancers Alcohol & overweight the risk Other factors: - Chronic infection w/ H. pylori Smoking Intake of highly salted or pickled foods Inadequate amounts of micronutrients the risk 21
Medical Nutrition Therapy Dietary regimen is determined by: Location of the cancer Nature of the functional disturbance Stage of the disease Patients w/ advanced, inoperable cancer should receive a diet that is adjusted to their tolerances, preferences, and comfort Anorexia: almost always present from the early stages. In the later stages: - liquid diet or - parenteral nutrition (intravenously) 22
Dumping syndrome: a complex physiologic response to the rapid emptying of hypertonic contents into the duodenum & jejunum May occur as a result of: total or subtotal gastrectomy manipulation of the pylorus after fundoplication after some gastric bypass procedures for obesity 23
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Medical Nutrition Therapy Prime objective: to restore nutrition status & quality of life Nutrition care: Frequent small meals High-protein, moderate-fat foods w/ sufficient calories. Complex CHOs (starches) can be included. Simple CHO (lactose, sucrose, & dextrose) should be limited Sufficient fibres (pectin in fruits, or guar gums) beneficial because they upper GI transit time & the rate of glucose absorption 25
Nutrition care:.. (cont d) Limit the amount of liquids taken w/ meals, but adequate amounts should be consumed during the day, small amounts at a time Lie down immediately after meals & avoid activity an hour after eating Very small quantities of hypertonic, concentrated sweets (soft drinks, juices, pies, cakes, cookies, and frozen desserts) can be ingested Lactose, esp. in milk & ice cream, are poorly tolerated, but cheeses & yogurt are better 26
Diet for preventing symptoms of dumping syndrome: Moderate fat (30% of calories intake) High protein (20% of calories intake) Low in simple CHO helps the patient achieve & maintain optimal weight & nutritional status When intake is inadequate vit. D & Ca supplements may be needed When steatorrhea (+) give oil or fat which high in medium-chain triglycerides (MCTs) 27
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Intestinal gas & flatulence Constipation Diarrhea Steatorrhea Gastrointestinal stricture & obstruction 29
Instestinal Gas & Flatulence Causes: Inactivity GI motility Aerophagia Dietary components GI disorders Medical nutrition therapy: Reduce intake of CHO that are likely to be malabsorbed & fermented e.g. legumes, soluble fibre, resistant starches, & simple CHO such as fructose & alcohol sugars 30
Constipation Most common causes: Ignoring the urge to defecate Lack of fibre in the diet Insufficient fluid intake Inactivity Chronic use of laxatives 31
Medical Nutrition Therapy Consumption of adequate amounts of both soluble & insoluble dietary fibre Fibre: colonic fecal fluid microbial mass stool weight & frequency the rate of colonic transit softens feces & makes them easier to pass Adequate water 32
Recommended amount of dietary fibre about 14 g/1000 kcal Fibre can be provided in the form of: Whole grains Fruits Vegetables Legumes Seeds Nuts 33
Diarrhea Causes may be related to: Inflammatory disease Infections w/ fungal, bacterial, or viral agents Medications Overconsumption of sugars Insufficient or damaged mucosal absorptive surface GI resections Malnutrition 34
Medical Nutrition Therapy First step in managing diarrhea: replacement of necessary fluids & elctrolytes, using: electrolyte solutions soups & broths vegetable juices other isotonic liquids Later: Starchy CHOs (cereals, breads) Low-fat meats Added small amounts of vegetables & fruits, followed by lipids 35
Probiotics Modestly successful in: Antibiotic-related diarrhea Traveler s diarrhea Bacterial overgrowth Several types of pediatric diarrhea 36
Steatorrhea Steatorrhea: excessive fat in the stool caused by disease or surgical resection of organs involved in the digestion & absorption of lipid 37
Medical Nutrition Therapy Steatorrhea can result in chronic weight loss may require calorie intake, mainly in the form of protein & complex CHOs MCTs can be given because: able to enter the portal vein for transport to the liver without micelle formation digestion & absoprtion, & resynthesis into triglycerides in intestinal cell easier to be absorbed in the abscense of bile acids 38
Food source of MCTs: coconut oil Micronutriens supplementation: Fat-soluble vitamins Ca Zn Mg because losses are as a result of insoluble soaps formation 39
Gastrointestinal Strictures & Obstruction Causes (partially or completely obstruction): Instestinal tumors Scarring from GI surgeries Inflammatory bowel disease (IBD) Peptic ulcer Radiation enteritis If parts of the GI are partially obstructed obstructions from foods may occur 40
The most common foods that may cause obstructions are fibrous plant foods Phytobezoars: obstructions in the stomach that result from the ingestion of plant foods 41
Medical Nutrition Therapy Restricted-fiber diet limit fruits, vegetables, & coarse grains Provide <10 15 g of dietary fibre, usually in the form of small particle size such as vegetable & fruit juices, cereals, & breads In distal obstructions or strictures: Keep the feces soft by: including moderate amounts of fibre, but of small particle size (such as juices) adequate water 42
Some Diseases and Conditions Associated with Malabsorption Inadequate digestion Pancreatic insufficiency Gastric resection Altered bile salt metabolism w/ impaired micelle formation Hepatobiliary disease Bacterial overgrowth Abnormalities of mucosal cell transport Biochemical or genetic abnormalities - Disaccharidase deficiency e.g. lactase deficiency - Celiac disease (gluten-sensitive enteropathy) 43
Some Diseases and (cont d) Inflammatory or infiltitative disorders - Crohn s disease - Ulcerative colitis - Radiation enteritis - Short-bowel syndrome Abnormalities of intestinal lymphatics & vascular system Instestinal lymphangiectasia Chronic congestive heart failure 44
Two major forms of IBD: Crohn s disease Ulcerative colitis 45
Clinical characteristics: Diarrhea Fever Weight loss Anemia Food intolerances Malnutrition Growth failure Extraintestinal manifestations (arthritic, dermatologic, & hepatic) 46
Segments of inflamed bowel Crohn s disease Colitis ulcerative 47
Unknown irritant Viral? Bacterial? Autoimmune? Genetic predisposition Abnormal activation of the mucosal immune response Secondary systemic response Damage to the cells of the small and/or large intestine w/ malabsorption, ulceration, or stricture - Diarrhea - Weight loss - Poor growth Pathophysiology of inflammatory bowel disease 48
Medical Nutrition Therapy IBD patients are at risk of malnutrition primary goal of MNT to restore & maintain the nutritional status Energy: energy requirements are not greatly Protein: protein needs may but rarely >50% than normal needs 49
Vitamins & mineral supplementation: folic acid, vitamins B6, and B12 Zn, K, and Se Small, frequent feedings may be tolerated better Small amounts of isotonic, liquid, oral supplements may be valuable If fat malabsorption (+) foods made w/ MCTs useful to calories intake & for absorption of fat-soluble nutrients 50
n-3 fatty acids intake antiinflammatory effect Probiotics can modify the microbial flora Prebiotics (such as oligosaccharides): alter the mixture of microorganisms in the colonic flora favoring lactobacillus & bifidobacteria suppressing pathogenic or opportunistic microflora production of SCFAs 51
Risk factors associated w/ the onset of exacerbations of IBD include: sucrose intake lack of fruits & vegetables dietary fibre << red meat >> alcohol altered n-6/n-3 fatty acid ratios 52
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