1. Upper GI NFSC 370 - Clinical Nutrition McCafferty

3. Anatomy: Review Mouth –Salivary glands –Food chewed and mixed w/saliva. Bolus is moved toward pharynx and swallowing is stimulated Esophagus: Extends from pharynx to stomach –Protected by mucus –Empty and collapsed at rest

4. –Esophagus is maintained empty by 2 sphincters UES - Upper Esophageal Sphincter – first 2-3 cm of the esophagus. Thickening of circular muscle layer which allows food to move from the mouth to the esophagus LES - Lower Esophageal Sphincter – (AKA Cardiac sphincter) Between esophagus and stomach. No structural difference (no thickening) but high intraluminal pressure that keeps it closed until food needs to be dumped into the stomach. This prevents gastric reflux.

5. Stomach –Upper portion (fundus/orad region) Storage occurs here. Little muscle tone so it can bulge outward: “active relaxation.” Little contractile activity. –Lower portion (body, antrum) Mixing moves contents toward antrum. With each wave, a few ml of chyme move into duodenum, but most is pushed back for more mixing w/gastric secretion (retropulsion). –As the stomach empties, contractions begin further up the body to bring down stomach contents. –Pyloric Sphincter connects stomach to duodenum

6. Small Intestine (duodenum, jejunum, ileum) bulk of nutrient absorption –structural folds in lining (less in ileum), including villi and microvilli (brush border) –ileocecal sphincter (ileocecal valve) connects s.i. to large intestine. Large Intestine (colon) bulk of fluid and electrolyte absorption Rectum/Anus – holding/excretion of fecal matter.

7. Pyloric sphincter LES

8. Disorders of the Mouth and Esophagus Difficulties Chewing (masticating) can lead to wt. loss and compromised nutritional status. Depending on the problem (individualized!) soft or pureed foods may be used. (remember this is just a regular diet that’s mechanically modified). –keep as wide a variety of foods as possible, and use appropriate temperatures/variety of colors

9. Conditions that may interfere w/chewing and swallowing: 1. Mouth ulcers (2’ viruses, drugs, radiation therapy) – –

10. 2. Inadequate Saliva Production – –Encourage good oral hygiene Encourage sucking on sugarless candy/chewing sugarless gum

11. Difficulties Swallowing – DYSPHAGIA Causes: Diagnosis: ____________________________, x-ray, measurement of UES pressure, fluoroscopy.

12. Dangerous and often undiagnosed: –“food gets stuck in my throat” – – – – –

13. Watch for:    aspiration  food caught in trachea/lungs   “Silent” aspiration:

14. Nutrition Therapy Individualized according to pt.’s particular swallowing problem Mechanical soft “solids” and smooth or thickened liquids are easiest to handle – Tube feedings may be necessary –TF into stomach still risks aspiration pneumonia –Safer:

15. Nutrition Therapy Monitor patient for – – – – –

16. Disorders of the Esophagus and Stomach Indigestion and Reflux Esophagitis (GERD) Indigestion (dyspepsia) = vague term for epigastric pain, fullness, early satiety, belching, hiccups, heartburn and regurgitation of stomach acid into the esophagus.

17. Recurrent acid reflux  irritation of esophageal mucosa  Severe inflammation may cause:

18. Causes – – – – – – –

19. Nutrition Therapy Alleviate reflux and irritation by – – “CAPA-free diet” (peptic ulcer diet) Foods that decrease LES pressure or increase acid secretion: – –

20. Small meals w/ fluids between meals Eat slowly, relax, chew food thoroughly Elevate head of bed and/or refrain from lying down after eating. Avoid tight clothing that increases abdominal pressure.

21. Drug Therapy Antacids Antiulcer agents Cholinergics –

22. Protrusion of stomach into the chest cavity through the esophageal hiatus of the diaphragm Normally, the LES sits right in the hiatus of the diaphragm and is reinforced by it. Hiatal Hernia –

23. Cause: hiatus weakens allowing a portion of the stomach to protrude above the diaphragm. Most common: “sliding” hiatal hernia. Pressure generated by the hernia is sufficient to force acidic stomach contents into the esophagus. Nutrition Therapy Same as for reflux esophagitis.

24. Gastritis Inflammation of the stomach mucosa – pain, n/v. Acute Gastritis: –asprin/alcohol use, food allergies, food poisoning, radiation therapy, metabolic stress, bacterial infection –n/v:

25. Chronic Gastritis (atrophic gastritis): –May be associated w/ chronic disease or no known etiology. – – –

26. Peptic Ulcer Disease (PUD) Erosion of cells of the top layer of mucosa (gastric, duodenal, esophageal). –Underlying layers exposed to stomach acid/peptidases. –If  –

28. Causes: – – –Disorders that cause excessive gastric acid production (less common) –Zollinger-Ellison syndrome: tumor in pancreas secretes excessive amts. of gastrin, causing hypersecretion of gastric acid,  ulcers

29. Nutrition Therapy –Minimizing pain/irritation, promoting healing. –

30. Drugs – decrease gastric secretions or otherwise protect mucosa from further erosion.

31. Gastric Surgery Gastrectomy –

32. Pyloroplasty –

33. Gastric partitioning –

34. Gastric Bypass

35. Nutritional consequences –If duodenum is bypassed:  absorption of: Patients are required to take nutritional supplements that usually prevent these deficiencies. –Dumping Syndrome: Mr. C had extensive gastric resection 1 wk ago, and has just begun to eat solids. About 15 minutes after eating he begins to feel weak and dizzy. He looks pale, his heart beats rapidly, and he breaks out into a sweat. Shortly thereafter, he develops diarrhea. What has happened?

36. Pylorus removed Partially digested food is “dumped” into the jejunum – – Fluid from body (capillaries) enters jejunum – – Result:

38. The pt. may experience the same symptoms again a few hours later… why? Most people who experience dumping gradually adapt to a fairly regular diet.

39. Nutrition Therapy: The Post-Gastrectomy Diet –NPO post-surgically for several days. Advanced to liquids, then solids. – – – –High protein, moderate fat –ADAT (close monitoring of tolerances) –Monitor fluid and lytes/hydration

40. –Gastric bypass patients: 1 week 2 weeks

41. Nutrition-related Gastrectomy Complications Weight loss, malabsorption, nutrient deficiencies. –Limited intake 2  early satiety, post-surgical pain, & dumping –Reflux esophagitis –Prot and fat malabsorption Normally, food entering the duodenum triggers the release of hormones such as CCK  secretion of digestive enzymes & bile. Duodenum bypassed: fat D&A interrupted. Accelerated transit of food   absorption

42. –Anemia – Fe-deficiency common after gastric surgery. (may take time to show up)

43. –B12 def from  IF prod? –Bone disease –