Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders Chapter 29

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Esophagus 1. Gastroesophageal reflux disease (GERD) —Backward flow of the stomach and/or duodenal contents into the esophagus —Burning sensation after meals; heartburn —Possible discomfort during and after eating, change in eating habits, especially in the evening 1. Gastroesophageal reflux disease (GERD) —Backward flow of the stomach and/or duodenal contents into the esophagus —Burning sensation after meals; heartburn —Possible discomfort during and after eating, change in eating habits, especially in the evening

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Esophagus—cont’d 2. Hiatal hernia —An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm —Heartburn after heavy meals or with reclining after meals —May worsen GERD symptoms 2. Hiatal hernia —An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm —Heartburn after heavy meals or with reclining after meals —May worsen GERD symptoms

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Esophagus—cont’d 3. Cancer of the oral cavity, pharynx, and esophagus —Existing nutritional problems and eating difficulties caused by the tumor mass, obstruction, oral infection and ulceration, or alcoholism —Chewing, swallowing, salivation, and taste acuity are often affected. —Weight loss is common. 3. Cancer of the oral cavity, pharynx, and esophagus —Existing nutritional problems and eating difficulties caused by the tumor mass, obstruction, oral infection and ulceration, or alcoholism —Chewing, swallowing, salivation, and taste acuity are often affected. —Weight loss is common.

© 2004, 2002 Elsevier Inc. All rights reserved. Common Symptoms of Gastrointestinal Disease

© 2004, 2002 Elsevier Inc. All rights reserved. Nutritional Care Guidelines for Patients with Reflux and Esophagitis (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.)

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Stomach 1. Indigestion/dysphagia —Epigastric discomfort following meals —Abdominal pain, bloating, nausea, regurgitation, and belching —Eat slowly, chew thoroughly, and do not eat or drink excessively. 1. Indigestion/dysphagia —Epigastric discomfort following meals —Abdominal pain, bloating, nausea, regurgitation, and belching —Eat slowly, chew thoroughly, and do not eat or drink excessively.

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Stomach—cont’d 2. Gastritis —Helicobacter pylori —Infection and inflammation —Acute gastritis: rapid onset of inflammation and symptoms —Chronic gastritis: occurs over period of time —Symptoms: nausea, vomiting, malaise, anorexia, hemorrhage, and epigastric pain 2. Gastritis —Helicobacter pylori —Infection and inflammation —Acute gastritis: rapid onset of inflammation and symptoms —Chronic gastritis: occurs over period of time —Symptoms: nausea, vomiting, malaise, anorexia, hemorrhage, and epigastric pain

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Stomach—cont’d 3. Peptic ulcer disease — Primary causes: H. pylori infection, gastritis, use of NSAIDs, corticosteroids, and so-called stress ulcers —Involves gastric and duodenal regions —Gastric ulcers: in stomach; normal or low acid secretion —Duodenal ulcers: in duodenum; high acid secretion 3. Peptic ulcer disease — Primary causes: H. pylori infection, gastritis, use of NSAIDs, corticosteroids, and so-called stress ulcers —Involves gastric and duodenal regions —Gastric ulcers: in stomach; normal or low acid secretion —Duodenal ulcers: in duodenum; high acid secretion

© 2004, 2002 Elsevier Inc. All rights reserved. Characteristics and Comparisons Between Gastric and Duodenal Ulcers n Gastric ulcer formation involves inflammatory involvement of acid-producing cells but usually occurs with low acid secretion. n Duodenal ulcers are associated with high acid and low bicarbonate secretion. n Increased mortality and hemorrhage are associated with gastric ulcers. n Gastric ulcer formation involves inflammatory involvement of acid-producing cells but usually occurs with low acid secretion. n Duodenal ulcers are associated with high acid and low bicarbonate secretion. n Increased mortality and hemorrhage are associated with gastric ulcers.

© 2004, 2002 Elsevier Inc. All rights reserved. Peptic Ulcer–Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

© 2004, 2002 Elsevier Inc. All rights reserved. Peptic Ulcer—Pathophysiology Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

© 2004, 2002 Elsevier Inc. All rights reserved. Peptic Ulcer—Medical and Nutritional Management Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Peter L. Beyer, 2002.

© 2004, 2002 Elsevier Inc. All rights reserved. Gastric and Duodenal Ulcers

© 2004, 2002 Elsevier Inc. All rights reserved. Factors That Affect Gastric Acidity

© 2004, 2002 Elsevier Inc. All rights reserved. Gastric Surgical Procedures

© 2004, 2002 Elsevier Inc. All rights reserved. Gastric Surgical Procedures—cont’d

© 2004, 2002 Elsevier Inc. All rights reserved. Dumping Syndrome n Complex physiologic response to the rapid emptying of hypertonic contents into the duodenum and jejunum n Dumping syndrome occurs as a result of total or subtotal gastrectomy and is associated with mild to severe symptoms including abdominal distention, systemic systems (bloating, flatulence, pain, diarrhea), and reactive hypoglycemia. n Complex physiologic response to the rapid emptying of hypertonic contents into the duodenum and jejunum n Dumping syndrome occurs as a result of total or subtotal gastrectomy and is associated with mild to severe symptoms including abdominal distention, systemic systems (bloating, flatulence, pain, diarrhea), and reactive hypoglycemia.

© 2004, 2002 Elsevier Inc. All rights reserved. Nutritional Care Guidelines for Patients with Dumping Syndrome and Alimentary Hypoglycemia

© 2004, 2002 Elsevier Inc. All rights reserved. Drugs Commonly Used to Treat Gastrointestinal Disorders n Antacids: lower acidity n Cimetidine (Tagamet), ranitidine (Zantac): block acid secretion by blocking histamine H 2 receptors n Prostaglandins n Sucralfate: coats and protects surface n Colloidal bismuth: coats and protects surface n Carbenoxolone: strengthens mucosal barrier n Tinidazole: antibiotic n Antacids: lower acidity n Cimetidine (Tagamet), ranitidine (Zantac): block acid secretion by blocking histamine H 2 receptors n Prostaglandins n Sucralfate: coats and protects surface n Colloidal bismuth: coats and protects surface n Carbenoxolone: strengthens mucosal barrier n Tinidazole: antibiotic

© 2004, 2002 Elsevier Inc. All rights reserved. Dysphagia n Oral phase problems Pocketing food Drinking from cup or straw Drooling n Pharyngeal phase Gagging Choking Nasal regurgitation n Esophageal phase Obstruction n Oral phase problems Pocketing food Drinking from cup or straw Drooling n Pharyngeal phase Gagging Choking Nasal regurgitation n Esophageal phase Obstruction

© 2004, 2002 Elsevier Inc. All rights reserved. Diagnosis of Swallowing Difficulties 1. Barium swallow 2. Cookie swallow —Record your observations during meals —Treatment —Adapt consistency of food: thickened liquids puddings, custards, pureed; chopped or diced foods 1. Barium swallow 2. Cookie swallow —Record your observations during meals —Treatment —Adapt consistency of food: thickened liquids puddings, custards, pureed; chopped or diced foods

© 2004, 2002 Elsevier Inc. All rights reserved. Diseases of Stomach n Indigestion n Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: —Alcohol —Aspirin —Nonsteroidal antiinflammatory agents n Indigestion n Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: —Alcohol —Aspirin —Nonsteroidal antiinflammatory agents

© 2004, 2002 Elsevier Inc. All rights reserved. Diseases of Stomach—cont’d n Chronic gastritis Precedes gastric lesion like cancer or ulcer H. pylori infection may cause Sx—Indigestion, loss of appetite, feeling full, belching, epigastric pain, nausea, vomiting n Chronic gastritis Precedes gastric lesion like cancer or ulcer H. pylori infection may cause Sx—Indigestion, loss of appetite, feeling full, belching, epigastric pain, nausea, vomiting

© 2004, 2002 Elsevier Inc. All rights reserved. Diseases of Stomach—cont’d Rx: Avoid foods not tolerated; soft consistency; regular meals; chew foods —Avoid highly seasoned foods; avoid excess liquid at meals n Atrophic gastritis: —Stomach cells atrophy —Loss of parietal cells—achlorhydria —Lose IF for B 12 absorption Rx: Avoid foods not tolerated; soft consistency; regular meals; chew foods —Avoid highly seasoned foods; avoid excess liquid at meals n Atrophic gastritis: —Stomach cells atrophy —Loss of parietal cells—achlorhydria —Lose IF for B 12 absorption

© 2004, 2002 Elsevier Inc. All rights reserved. Peptic Ulcer Disease Treatment with Diet n Reduce decaffeinated and regular coffee, cocoa, and tea intake n No alcohol or pepper n Avoid low-pH juices if they cause problems n Avoid irritating foods n Avoid food right before bedtime n Eat at least 3 small meals per day, 6 better n Reduce decaffeinated and regular coffee, cocoa, and tea intake n No alcohol or pepper n Avoid low-pH juices if they cause problems n Avoid irritating foods n Avoid food right before bedtime n Eat at least 3 small meals per day, 6 better

© 2004, 2002 Elsevier Inc. All rights reserved. Disorders of the Stomach— Nutritional Care n Lifestyle changes are an important component of the nutrition care plan. n Patients with dyspepsia should avoid high-fat foods, sugar, caffeine, spices, and alcohol. n Lifestyle changes are an important component of the nutrition care plan. n Patients with dyspepsia should avoid high-fat foods, sugar, caffeine, spices, and alcohol.

© 2004, 2002 Elsevier Inc. All rights reserved. Diabetic Gastroparesis (Gastroparesis Diabeticorum) n Delayed stomach emptying of solids n Etiology—autonomic neuropathy n Nausea, vomiting, bloating, pain n Insulin action and absorption of food not synchronized n Prescribe small frequent meals (may need liquid diet) n Adjust insulin n Delayed stomach emptying of solids n Etiology—autonomic neuropathy n Nausea, vomiting, bloating, pain n Insulin action and absorption of food not synchronized n Prescribe small frequent meals (may need liquid diet) n Adjust insulin

© 2004, 2002 Elsevier Inc. All rights reserved. Summary n Upper GI disorders—H. pylori plays an important role n Maintain individual tolerances as much as possible. n Upper GI disorders—H. pylori plays an important role n Maintain individual tolerances as much as possible.