Upper Gastrointestinal Tract KNH 411 Chewing, swallowing, etc.

4 basic functions – motility, secretion, digestion, absorption Mouth, pharynx, esophagus, stomach Accessory: pancreas, biliary system, liver

Upper GI – A&P Stomach - Motility Filling, storage, mixing, emptying 50 mL empty – stretches to 1000 mL Pyloric sphincter 50 – 120 cc for stomach 1 oz. = 30 cc Stomach holds 2 – 6 oz. but can stretch up to a liter (32 oz) Water, mucus for protection, HCl (pepsinogen denatures protein), enzymes, and intrinsic factor (B12) are secreted by stomach © 2007 Thomson - Wadsworth

G and D cells, endocrine and enterochroma G and D cells, endocrine and enterochroma.. help to control the flow of the secretions Produce gastric juices: exocrine  parietal cells

Main concern is getting adequate calories and protein Chewing problems cause weight loss Want high calorie-high protein dense foods (Ensure, Boost) & high fat foods [semisolid, mechanical soft]

Pathophysiology - Oral Cavity Nutrition Therapy/Evaluation Increase frequency of meals Bland foods served at room temp. Liberal use of fluids Preference for cold and frozen foods (takes away some of the smell; taste fatigue may be less because of numbing) Oral hygiene (may not have dentition to tolerate food stuff; embarrassment) Monitor using food diary, observation, or kcal count Monitor weight gain or maintenance

Pathophysiology - Esophagus GERD - reflux of gastric contents into the esophagus Incompetence of LES Increased secretion of gastrin, estrogen, progesterone Hiatal hernia Cigarette smoking Use of medications (steroids, etc) Foods high in fat, chocolate, spearmint, peppermint, alcohol, caffeine

Pathophysiology - Esophagus GERD - symptoms Dysphagia (difficulty swallowing) Heartburn Increased salivation Belching Pain radiating to back, neck, or jaw Aspiration Ulceration Barrett’s esophagus (change in the epithelial cells and/or the esophageal mucous lining – creates abnormal pH which can result in squamous cell carcinoma)

Pathophysiology - Esophagus GERD - Treatment Medical management (histamine blockers, etc) Modify lifestyle factors Medications – 5 classes Surgery Fundoplication (wrapping of the fundus of the stomach around the esophagus – acts as the LES [tightens the area]) Stretta procedure (radiofrequency energy is delivered to the LES, increasing function)

Magnesium – can cause diarrhea H2 blockers – individuals may have concerns with short term relief, may need medical intervention or medications

Pathophysiology - Esophagus GERD - Nutrition Therapy Identify foods that worsen symptoms Assess food intake esp. those that reduce LES pressure, or increase gastric acidity Assess smoking and physical activity Small, frequent meals (less strain) Weight loss if warranted Peppermints, coffees, cocoa, teal, anything fried, high fat desserts, pepper, alcohol (worsen symptoms) Alcohol, coffee, and pepper can increase gastric acids

Pathophysiology - Esophagus Dysphagia – difficulty swallowing Potential causes – GERD, stroke, Drooling, coughing, choking (long term – predisposed to aspiration when eating) Weight loss, generalized malnutrition Aspiration to aspiration pneumonia Treatment requires health care team dg by bedside swallowing, videofluoroscopy, barium swallow Stop eating or discontinue eating… watch for drop in weight. Stress, dementia, stroke, MS, any type of oral cancer

Pathophysiology - Esophagus Dysphagia – Nutrition Therapy Use acceptable textures to develop adequate menu National Dysphagia Diet 1,2,3 ** Use of thickening agents and specialized products Monitor weight, hydration, and nutritional parameters Dysphagia 1 – pureed (pudding-like) Dysphagia 2 – mechanically altered (moist, soft mechanical foods) Dysphagia 3 – Advanced (no hard foods – fresh fruit, veggies, nuts, seeds) slight difficulty swallowing Monitor weight, hydration, and multivitamins

Hiatal Hernia Same treatment as GERD Repair site, if possible, and remove any nutritional concerns Sliding – portion (stomach) protrudes through esophagus and above diaphragm Rolling – protrudes out but remains below diaphragm Requires surgical procedures if not resolved on its own © 2007 Thomson - Wadsworth

Pathophysiology - Stomach Gastritis Inflammation of the gastric mucosa Primary cause: H. pylori bacteria Alcohol, food poisoning, NSAIDs Symptoms: belching, anorexia, abdominal pain, vomiting Type A - automimmune Type B – H. pylori Increases with age, achlorhydria (lack of HCl) Treat with antibiotics and medications Type B – atrophy of mucosa due to infection (short term while working with client to resolve) BRAT diet (bananas, rice, apples, toast) (bland diet)- to help resolve symptoms Low fat, plain yogurt

Pathophysiology - Stomach Peptic ulcer disease (PUD) - ulcerations of the gastric mucosa that penetrate submucosa Gastric or duodenal H. pylori NSAIDS, alcohol, smoking Certain foods, genetic link Increased risk of gastric cancer PUD – 1 out of 10 Americans develop this Causes – nonsteroidal meds, smoking, alcohol, genetics Look at timing/size of meals (6x per day is better), foods being eaten, do not lie down between meals (30 min to an hour after you have eaten)

Pathophysiology - Stomach Peptic Ulcer Disease - Nutrition Restrict only those foods known to increase acid secretion Black and red pepper, caffeine, coffee, alcohol, individually non- tolerated foods Consider timing and size of meal Do not lie down after meals Small, frequent meals Concerns with protein, denaturation, vitamins/minerals

Gastric bypass – bypasses duodenum to jejunum Watch fat (A,D, E, K) – malabsorption of nutrients Gastroduodenostomy – removed part of stomach and connected to top half of duodenum (ususally with pyloric cancers) B. Concerns with dumping syndrome (Billroth I) Small frequent feedings, break down nutrients (sometimes) C. Gastrojejunostomy (Billroth II) Usually done with ulcer treatments or stomach cancer © 2007 Thomson - Wadsworth

Pathophysiology - Stomach Gastric Surgery - Nutrition Implications Reduced capacity Changes in gastric emptying & transit time Components of digestion altered or lost (maldigest micro/macronutrients) Decreased oral intake, maldigestion, malabsorption

Pathophysiology - Stomach Gastric Surgery - Dumping Syndrome Increased osmolar load enters small intestine too quickly from stomach Release of hormones, enzymes, other secretions altered Food “dumps” into small intestine

Pathophysiology - Stomach Gastric Surgery - Dumping Syndrome Early dumping – 10-20 min.; diarrhea, dizziness, weakness, tachycardia Intermediate - 20-30 min.; fermentation of bacteria produces gas, abdominal pain, etc. Late dumping - 1-3 hrs.; hypoglycemia

Pathophysiology - Stomach Gastric Surgery - Dumping Syndrome Other nutritional concerns: vitamin and mineral deficiencies, lack of intrinsic factor, iron deficiency, osteoporosis

Pathophysiology - Stomach Dumping Syndrome - Nutrition “Anti-dumping” diet Slightly higher in protein & fat Avoid simple sugars & lactose (use complex) Calcium & vitamin D Liquid between meals Small, frequent meals Lie down after meals Assess for weight loss, malabsorption, and steatorrhea

© 2007 Thomson - Wadsworth