1. Upper Gastrointestinal Tract
KNH 411
Chewing, swallowing, etc.

2. 4 basic functions – motility, secretion, digestion, absorption
Mouth, pharynx, esophagus, stomach
Accessory: pancreas, biliary system, liver

3. 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

4. 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

5. 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]

6. 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

7. 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

8. 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)

9. 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)

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

12. 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

13. 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

14. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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

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

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

28. 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

29. © 2007 Thomson - Wadsworth