CHAPTER 18 1. 2 Identify problems of the upper gastrointestinal tract Identify problems of the lower gastrointestinal tract Identify food allergies and.

CHAPTER 18

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Chapter 18Gastrointestinal and Accessory Organ Problems

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Objectives:Identify problems of the upper

gastrointestinal tractIdentify problems of the lower

gastrointestinal tractIdentify food allergies and intolerancesIdentify problems of the gastrointestinal

accessory organs

Key Concepts3

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.

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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

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Gingivitis/TMJ problems

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Problems of the MouthOral 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

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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

8Salivary 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

Problems of the Mouth9

Swallowing disordersDysphagia (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

Problems of the Mouth10

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

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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

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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

Problems of the Esophagus13

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

GI Cocktail14

Mixture of liquid antacid

Viscous lidocaineDonnatol

Useful as part of the diagnostic protocol for patients complaining of chest pain

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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

Problems of the Esophagus16

GERD cont.Treatment:

Weight management

Acid control Low-fat diet Sleep with HOB

elevated

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Normal Stomach

Hiatal hernia

Hiatal hernia Portion of

upper stomach protrudes through opening in the diaphragm membrane (hiatus)

Especially common in obese adults

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Peptic Ulcer DiseaseIncidence:

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 cancerTobacco smoking linked to PUD

Peptic Ulcer Disease 20

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

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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

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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

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Peptic Ulcer Disease

Peptic Ulcer Disease 24

Medical Management:

4 basic goals: Alleviate the

symptoms Promote healing Prevent

recurrences by eliminating the cause

Prevent complications

Peptic Ulcer Disease 25

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

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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

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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

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Small Intestine Diseases

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

Small Intestine Diseases29

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

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Small Intestine DiseasesMalabsorption -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

Small Intestine Diseases31

3 common malabsorption conditions:

Cystic FibrosisInflammatory

Bowel DiseaseDiarrhea

Small Intestine Disease32

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

Small Intestine Disease33

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

Cystic Fibrosis

Symptoms of CF35

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

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Small Intestine DiseasesCystic 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

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Intestine DiseasesInflammatory 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

Intestinal Diseases39

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

Intestinal Diseases40

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

Intestinal Disease41

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

Intestinal Disease42

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

Small Intestine Diseases43

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

Large Intestine Diseases44

Diverticular diseaseDiverticulosis: lower intestinal conditionFormation 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

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Large Intestine Diseases46

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

Large Intestine Diseases47

Irritable bowel syndromeMulticomponent 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

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Irritable Bowel Syndrome

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Large Intestine DiseasesIrritable 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

Large Intestine Diseases 50

ConstipationCommon short-term

problem Nervous tension

and worry Changes in routines Constant laxative

use Low-fiber diets Lack of exercise

Dietary management rather than laxatives

Food Allergies and Intolerances51

Allergic reaction is body’s immune system reacting to a protein as a threatening foreign object

“Allergy”: from 2 Grk. words meaning “altered reactivity” and refers to the abnormal reactions of the immune system to a number of substances in the environment.

Food Allergies and Intolerances52

Most common food allergens include proteins in: Cow’s milk Eggs Peanuts Wheat Soy Fish/shellfish Tree nuts

Food Allergies and Intolerances53

If a child is showing signs of allergic reaction, a process of food elimination is sometimes used to identify disagreeable foods.If a given food causes an allergic

reaction, the food is identified as an allergen and eliminated from use. The food may be tried again later to see if it still causes the same reaction, validating the initial response.

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Food AllergiesRecognizing s/sx of

allergic reactions may save a life

Anaphylaxis is the most severe response to an allergen Swelling of the face and

throat Respiratory distress Decreased blood pressure Death

Food Allergies and Intolerances55

Most common symptoms of food allergies are: Hives, nausea, diarrhea,

and abdominal pain

Dietitian can provide guidance on food substitutions or special food products

Recipes modified to maintain nutritional needs for growth

Large Intestine Diseases56

Celiac Sprue/Celiac Disease The cause:

Hypersensitivity to the protein gluten in certain grains – wheat, barley, rye

GI tract has damaged mucosal surface villi and microvilli that are malformed and deficient in number

Steatorrhea (approx. 80% of fat appears in the stool) and progressive malnutrition are secondary effects to gluten reaction

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Small Intestine Diseases Celiac Sprue cont.Nutrition management:

Goal: to control dietary gluten intake and prevent malnutrition

Avoid wheat, rye, oats, barley Adhering to a low-gluten or gluten-free

diet is the only effective tx. in maintaining a healthy mucosa

Must be followed for life Possible vitamin supplementation

Problems of the GI Accessory Organs58

3 major accessory organs: Liver Gallbladder Pancreas

Produce digestive agents

Diseases of these organs affect GI function and cause problems with the handling of specific foods

Liver Function59

Essential functions: Bile production Synthesis of proteins and blood clotting

factors Metabolism of hormones, medications,

macronutrients and micronutrients Regulation of blood glucose levels Urea production to remove the waste

products of normal metabolism

Liver Disease60

Steatohepatitis “the silent liver disease” – inflammation

and fat accumulation Exact cause is unknown Most often associated with alcohol abuse However, approx. 2-5% of Americans who

drink little are also affected. “Nonalcoholic steatohepatitis”. Higher incidence for individuals with

diabetes or obesity.

Liver Disease61

HepatitisAcute Hepatitis is an

inflammatory condition caused by viruses, alcohol, drugs, or toxins

Virus often transmitted via the oral-fecal route

The carrier is usually contaminated food or water

Other modes of transmission: blood transfusion, contaminated syringes, needles

Liver Disease62

Hepatitis cont.Symptoms: anorexia, jaundice, underlying

malnutritionTreatment : rest, nutrition therapyNutritional Therapy:

Adequate protein, high CHO, low fat, high kcals;

Progress from liquid feedings full diet

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Liver Diseases Cirrhosis

Often a chronic state Fatty cirrhosis associated with

malnutrition and alcoholism Fatty infiltration kills liver cells, leaving

nonfunctioning scar tissue Low plasma protein levels ascites (fluid

collection in the abdomen) Scar tissue impairs blood circulation

elevated venous pressure esophageal varices

Rupture of varices massive hemorrhage

Liver Disease64

Nutritional Therapy Protein according to

tolerance If no s/sx hepatic

coma, 80-100 g of protein per day to correct severe malnutrition, heal liver tissue, and restore plasma protein

Low sodium Soft texture Optimal general

nutrition : No alcohol

Liver Disease65

Hepatitis cont. Treatment based

on bed rest and nutrition therapy: High protein,

high CHO, moderate fat, high energy; liquid diet full diet as tolerated

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Liver Diseases Hepatic Encephalopathy

As cirrhosis continues, the blood, carrying its ammonia load, cannot get to the liver for its normal removal of the ammonia and nitrogen

Ammonia intoxication and coma occur Blood by passes the liver through

collateral circulation and goes brain Hepatic encephalopathy apathy,

confusion, inappropriate behavior, drowsiness, and coma

Treatment focuses on removing sources of excess ammonia – reduce protein intake

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Advanced Liver Disease

Gall Bladder Disease68

Basic function of the Gall bladder: to concentrate and store bile

Releases concentrated bile into small intestine in response to fat

Bile emulsifies fat and then carries it into the cells of the intestinal wall for continued metabolism

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Gallbladder DiseaseCholecystitis – inflammation of the GB

Usually results from low-grade chronic infection

Continued infection alters solubility of bile ingredients, cholesterol separated out, and forms gallstones cholelithiasis

When infection, stones or both are present, the normal contraction of the GB (triggered by fat entering the intestine) causes pain

May need surgery for treatment: Cholecystectomy

Diet therapy centers on controlling fat intake

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Gallstones

Pancreatic Disease71

Pancreas:Key organ in normal

digestion and metabolism

Digestive enzymes and bicarbonates Breakdown

carbohydrates, proteins, and fats

Blood glucose regulation Glucagon Insulin

Pancreatic Diseases72

Diabetes mellitus Acute

pancreatitis Chronic

pancreatitis Pancreatic

enzyme deficiency

Pancreas tumor

Pancreatic Disease73

Pancreatitis – acute inflammation of the pancreas occurs when the very enzyme that the pancreas produces (trypsin) digests the organ tissue Symptoms:

Severe pain Recurrent episodes Excessive alcohol

and gallstones are the major causes

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Pancreatic DiseasePancreatitis cont.Obstruction of common duct causes

enzymes and bile to back up into pancreasResults in acute inflammation as enzymes

digest organ tissueCaused by gallstones and excessive alcohol

consumptionTreatment includes: fluid and electrolyte

replacement, antibiotics, pain med, sometimes gastric suctioning

Avoid alcohol and caffeine