Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition for Patients with Disorders of the Lower GI Tract and Accessory Organs Chapter 18

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition for Patients With Disorders of the Lower GI Tract Ninety to 95% of nutrient absorption occurs in the first half of the small intestine Large intestine absorbs water and electrolytes and promotes the elimination of solid wastes Accessory organs—liver, gallbladder, and pancreas—play vital roles in nutrient digestion Nutrition therapy is used: –To improve or control symptoms –Replenish losses –Promote healing

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination Constipation –Difficult or infrequent passage of stools that are hard and dry –Can occur secondary to irregular bowel habits, psychogenic factors, lack of activity, chronic laxative use, inadequate intake of fluid and fiber, metabolic and endocrine disorders, and bowel abnormalities (e.g., tumors, hernias, strictures) –Certain medications cause constipation

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Constipation (cont’d) –Nutrition therapy oConstipation is treated by treating the underlying cause oIncreasing fiber and fluid intake effectively relieves and prevents constipation oHigh-fiber diet

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Constipation (cont’d) –Nutrition therapy (cont’d) oAdequate intake set for fiber is 25 g/day for women and 38 g/day for men oCommon practice is to recommend fiber intake be gradually increased oFiber intake should be spread throughout the day oLifestyle changes to promote bowel regularity include drinking more fluid and increasing exercise

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Diarrhea –Characterized by more than 3 bowel movements a day of large amounts of liquid or semi-liquid stool –Potential for dehydration, hyponatremia, hypokalemia, acid–base imbalance, and metabolic acidosis –Chronic diarrhea can lead to malnutrition related to impaired digestion, absorption, and intake

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Diarrhea (cont’d) –Osmotic diarrhea occurs when there is an increase in particles in the intestine, which draws water in to dilute the high concentration oCauses include maldigestion of nutrients (e.g., lactose intolerance), excessive intake of sorbitol or fructose, dumping syndrome, tube feedings, and some laxatives oCured by treating the underlying cause

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Diarrhea (cont’d) –Secretory diarrhea oRelated to an excessive secretion of fluid and electrolytes into the intestines oCaused by infections, some medications, some GI disorders, and an excessive amount of bile acids or unabsorbed fatty acids in the colon oTreatment  Antibiotics if cause is infectious  Symptoms may be treated with medications that decrease GI motility or thicken the consistency of stools

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Nutrition therapy –Primary nutritional concern with diarrhea is maintaining or restoring fluid and electrolyte balance –Mild diarrhea lasting 24 to 48 hours: oUsually requires no nutrition intervention other than encouraging a liberal fluid intake to replace losses oHigh-potassium foods are encouraged; clear liquids are avoided because they have high osmolality related to their high sugar content, which may promote osmotic diarrhea

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Bowel Elimination (cont’d) Nutrition therapy (cont’d) –For more serious cases, commercial (e.g., Pedialyte, Rehydralyte) or homemade oral rehydration solutions, or IV therapy, is used to replace fluid and electrolytes –May improve by avoiding foods that stimulate GI motility –A low-fiber diet that is also low in fat and lactose may help decrease bowel stimulation

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question One cause of osmotic diarrhea is: a. Antibiotics b. Maldigestion c. Some GI disorders d. Unabsorbed fatty acids

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Maldigestion Rationale: The causes of osmotic diarrhea include maldigestion of nutrients (e.g., lactose intolerance), excessive intake of sorbitol or fructose, dumping syndrome, tube feedings, and some laxatives. It is cured by treating the underlying cause.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders Occurs secondary to nutrient maldigestion or from alterations to the absorptive surface of the intestinal mucosa Malabsorption related to maldigestion involves one or few nutrients Malabsorption that stems from an altered mucosa is more generalized, resulting in multiple nutrient deficiencies and weight loss Symptoms vary with the underlying disorder

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Excretion of fat in the stool means that essential fatty acids, fat-soluble vitamins, calcium, and magnesium are also lost through the stool Can cause metabolic complications

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Goal of nutrition therapy for malabsorption syndromes is to: –Control steatorrhea –Promote normal bowel elimination –Restore optimal nutritional status –Promote healing, when applicable Individualized according to symptoms and complications

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Lactose intolerance –Occurs when the level of lactase is absent or deficient –Lactose digestion is impaired –Undigested lactose increase the osmolality of the intestinal contents –May lead to osmotic diarrhea

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Lactose intolerance (cont’d) –Lactose is fermented in the colon –Produces bloating, cramping, and flatulence

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Primary lactose intolerance occurs in “well” people who simply do not secrete adequate lactase –Least common in people of northern European descent –May be asymptomatic when doses less than 4 to 12 g of lactose are consumed (e.g., ⅓ to 1 cup of milk) or when lactose is consumed as part of a meal –Chocolate milk is usually better tolerated than plain milk

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Primary lactose intolerance (cont’d) –Know individual limits –Lactose-reduced milk and lactase enzyme tablets or liquid may be used

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Lactose intolerance secondary to gastrointestinal disorders that alter the integrity and function of intestinal villi cells, where lactase is secreted –Loss of lactase may also develop secondary to malnutrition because the rapidly growing intestinal cells that produce lactase are reduced in number and function –Tends to be more severe than primary lactose intolerance

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Nutrition therapy –Nutrition therapy for lactose intolerance is to reduce lactose to the maximum amount tolerated by the individual –A lactose-free diet is not realistic

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In lactose intolerance, undigested lactose increases the __________ of the intestinal contents. a. Secretions b. Osmolality c. Acidity d. Liquidity

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Osmolality Rationale: Particles of undigested lactose increase the osmolality of the intestinal contents, which may lead to osmotic diarrhea.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Inflammatory bowel disease (IBD) –Primarily refers to 2 chronic inflammatory GI diseases oCrohn’s disease oUlcerative colitis –IBD is believed to be caused by an abnormal immune response to a complex interaction between environmental and genetic factors

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Inflammatory bowel disease (IBD) (cont’d) –Characterized by periods of exacerbation and remission –Share symptoms and treatment

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Inflammatory bowel disease (IBD) (cont’d) –Nutrition therapy oDepends on the presence and severity of symptoms, the presence of complications, and the nutritional status of the patient oDiet restrictions kept to a minimum oPatients are often reluctant to eat oCrohn’s disease is more likely to cause nutritional complications

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Inflammatory bowel disease (IBD) (cont’d) –Nutrition therapy (cont’d) oFocus of therapy for acute exacerbation of IBD is to correct deficiencies by providing nutrients in a form the patient can tolerate oFor patients consuming an oral diet, low fiber is recommended to minimize bowel stimulation oProtein and calorie needs are elevated to facilitate healing oDiet modifications are made according to symptoms

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Celiac disease –A genetic autoimmune disorder characterized by chronic inflammation of the proximal small intestine mucosa –Related to a permanent intolerance to certain proteins found in wheat, barley, and rye –Malabsorption of carbohydrates, protein, fat, vitamins, and minerals may occur, resulting in diarrhea, flatulence, weight loss, and vitamin and mineral deficiencies

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Celiac disease (cont’d) –Symptoms and their severity vary depending on the patient’s age and the duration and extent of the disease –Classic symptoms in children are diarrhea, abdominal distention, and failure to thrive –Adults present with diarrhea, constipation, weight loss, weakness, flatus, abdominal pain, and vomiting

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Celiac disease (cont’d) –Atypical presentations –In 0% to 20% of people with celiac disease, dermatitis herpetiformis is the presenting symptom –Symptoms of dermatitis herpetiformis respond to a gluten-free diet

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Celiac disease (cont’d) –People who have a first-degree relative with celiac disease, people with Down syndrome, and those with an autoimmune disease are at risk for celiac disease –Untreated celiac disease is associated with an increased incidence of small-bowel cancers and enteropathy-associated T-cell lymphoma

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Celiac disease (cont’d) –Nutrition therapy oOnly scientifically proven treatment for celiac disease is to completely and permanently eliminate gluten from the diet oLactose intolerance secondary to celiac disease may be temporary or permanent

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Celiac disease (cont’d) –Nutrition therapy (cont’d) oA gluten-free diet requires a major lifestyle change oExpensive Short-bowel syndrome (SBS) –Occurs when the bowel is surgically shortened to the extent that the remaining bowel is unable to absorb adequate levels of nutrients to meet the individual’s needs

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Who is at risk for celiac disease? a. People with a second-degree relative who has celiac disease b. People who have lactose intolerance c. People who have congenital diseases d. People who have an autoimmune disease

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer d. People who have an autoimmune disease Rationale: People who have a first-degree relative with celiac disease, people with Down syndrome, and those with an autoimmune disease are at risk for celiac disease.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Short-bowel syndrome (SBS) (cont’d) –Most common reasons for extensive intestinal resections that result in SBS oCrohn’s disease oTraumatic abdominal injuries oMalignant tumors oMesenteric infarction

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Short-bowel syndrome (SBS) (cont’d) –Nutrition complications experienced by people with short-bowel syndrome depend on the amount and location of resected and remaining bowel oPatients who have 150 cm or more of remaining small bowel without a colon, or 60 to 90 cm of small bowel with a colon, initially require TPN and may progress to an oral diet over a 1- to 2-year period

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Short-bowel syndrome (SBS) (cont’d) –Factors that influence adaptation oLength of remaining jejunum and/or ileum and whether the colon is present oPatient’s age oWhether the ileocecal value remains oHealth of the remaining bowel oHealth of the stomach, liver, and pancreas

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Short-bowel syndrome (SBS) (cont’d) –Nutrition therapy oIn the early months after bowel surgery, TPN is the major source of nutrition and hydration oConsuming intact nutrients promotes bowel adaptation because they stimulate blood flow to the intestine and the secretion of pancreatic enzymes and bile acids

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Malabsorption Disorders (cont’d) Short-bowel syndrome (SBS) (cont’d) –Nutrition therapy (cont’d) o6 to 8 small meals/day oIf the patient’s colon is intact, fat intake is restricted to avoid steatorrhea and increased fluid losses

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine Irritable bowel syndrome (IBS) –Most frequently diagnosed digestive disorder in the U.S. –Many factors involved in its etiology –Symptoms include lower abdominal pain, constipation, diarrhea, alternating periods of constipation and diarrhea, bloating, and mucus in the stools –Can significantly impair quality of life

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Irritable bowel syndrome (IBS) (cont’d) –Nutrition therapy oInconclusive evidence for any of the current treatments used for IBS oPharmacologic treatment options  Meet with limited success oComplementary therapies oElimination diet

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Irritable bowel syndrome (IBS) (cont’d) –Nutrition therapy (cont’d) oPrebiotics oGrade A level evidence exists for the use of 5 g of guar gum daily  Guar gum is a soluble, non-gelling fiber

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Diverticular disease –Diverticula are caused by increased pressure within the intestinal lumen –Usually asymptomatic –Diverticulitis occurs when diverticula become inflamed

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Diverticular disease (cont’d) –Symptoms of diverticulitis oCramping oAlternating periods of diarrhea and constipation oFlatus oAbdominal distention oLow-grade fever

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Diverticular disease (cont’d) –Potential complications oOccult blood loss and acute rectal bleeding leading to iron-deficiency anemia oAbscesses and bowel perforation leading to peritonitis oFistula formation causing bowel obstruction oBacterial overgrowth (in small-bowel diverticula) that leads to malabsorption of fat and vitamin B12

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Diverticular disease (cont’d) –Nutrition therapy oHigh-fiber intake may prevent and improve symptoms of diverticulosis and prevent diverticulitis oAvoid nuts, seeds, and popcorn

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Diverticular disease (cont’d) –Nutrition therapy (cont’d) oDuring an acute phase of diverticulitis:  Patients are NPO until bleeding and diarrhea subside  Oral intake resumes with clear liquids and progresses to a low-fiber diet until inflammation and bleeding are no longer a risk  A high-fiber diet is recommended unless symptoms of diverticulitis recur

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Pharmacologic treatment options meet with limited success in diverticular disease.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Rationale: Antidiarrheals, antispasmodics, and antidepressants are pharmacologic treatment options that meet with limited success in irritable bowel syndrome.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Ileostomies and colostomies –Performed after part or all the colon, anus, and rectum are removed –Potential nutritional problems –The smaller the length of remaining colon, the greater the potential for nutritional problems –Ileostomies cause a decrease in fat, bile acid, and vitamin B12 absorption

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Ileostomies and colostomies (cont’d) –Effluent from an ileostomy is liquidy, and fluid and electrolyte losses are considerable –Effluent through a colostomy varies from liquid to formed stools –Nutrition therapy oGoals of nutrition therapy for ileostomies and colostomies are to minimize symptoms and replenish losses

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditions of the Large Intestine (cont’d) Ileostomies and colostomies (cont’d) –Nutrition therapy (cont’d) oInitially only clear liquids that are low in simple sugars oAdvanced slowly based on individual tolerance oFear of eating is common oA near-regular diet resumes 6 to 8 weeks post-op oObtaining adequate fluid and electrolytes is a major concern

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs Liver disease –After absorption, almost all nutrients are transported to the liver –Vital for detoxifying drugs, alcohol, ammonia, and other poisonous substances –Liver damage can have profound and devastating effects on the metabolism of almost all nutrients –Failure can occur from chronic liver disease or secondary to critical illnesses

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Liver disease (cont’d) –Early symptoms of hepatitis oAnorexia, nausea and vomiting, fever, fatigue, headache, and weight loss –Later oDark-colored urine, jaundice, liver tenderness, and possibly liver enlargement may develop –Cell damage reversible with proper rest and nutrition

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Liver disease (cont’d) –Acute hepatitis advances to chronic hepatitis, which may lead to cirrhosis, liver cancer, and liver failure –Glucose intolerance is common –Cirrhosis can progress to hepatic encephalopathy and hepatic coma –Liver “fails” when liver cell loss is extensive

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Liver disease (cont’d) –Nutrition therapy oObjectives of nutrition therapy for liver disease are to avoid or minimize permanent liver damage, promote liver cell regeneration, restore optimal nutritional status, alleviate symptoms, and avoid complications oRegeneration may not be possible oPatients with acute hepatitis have difficulty consuming an adequate diet

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Liver disease (cont’d) –Nutrition therapy (cont’d) oMalnutrition is common among patients with cirrhosis oMeeting nutrient and calorie needs is difficult

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs Nutrition therapy for liver transplantation –Treatment option for patients with severe and irreversible liver failure –Moderate to severe malnutrition increases the risk of complications and death after transplantation –Not one specific post-transplant diet –Small frequent meals and commercial supplements may help maximize intake

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Nutrition therapy for liver transplantation (cont’d) –Long-term complications associated with immunosuppressive therapy, such as excessive weight gain, hypertension, hyperlipidemia, osteopenic bone disease, and diabetes, may require nutrition therapy –Use of immunosuppressant drugs elevates the importance of safe food handling practices to avoid foodborne illness

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Pancreatitis –Inflammation of the pancreas –People with pancreatitis may also develop hyperglycemia related to insufficient insulin secretion –Alcohol abuse and gallstones account for 75% to 85% of cases of acute pancreatitis –Acute pancreatitis that is not resolved or recurs frequently can lead to chronic pancreatitis oCharacterized by scarring, fibrosis, and loss of organ function

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Pancreatitis (cont’d) –Seventy percent of cases are caused by alcohol abuse; 20% are idiopathic –Characterized by intermittent pain that is made worse by eating –Malabsorption does not occur until pancreatic enzyme secretion is less than 10% of normal

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Pancreatitis (cont’d) –Nutrition therapy oAcute pancreatitis is treated by reducing pancreatic stimulation oIn mild cases, the patient is given pain medications, IV therapy, and nothing by mouth (NPO) oSmall, frequent meals may be better tolerated initially because they help to reduce the amount of pancreatic stimulation at each meal

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Pancreatitis (cont’d) –Nutrition therapy (cont’d) oIn moderate to severe acute pancreatitis, patients are ordered NPO and a nasogastric tube is inserted to suction gastric contents  Preferred route of delivering nutritional enteral feeding  Jejunal feedings

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Pancreatitis (cont’d) –Nutrition therapy (cont’d) oGoals of nutrition therapy for chronic pancreatitis are to maintain weight, reduce steatorrhea, minimize pain, avoid acute attacks while meeting the patient’s nutrient needs oA mildly low-fat diet that is high in protein is recommended oPancreatic enzyme replacement pills

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Accessory GI Organs (cont’d) Gallbladder disease –Gallstones –Cholelithiasis –Cholecystitis –Dietary limitations