1. Lower Gastrointestinal Tract KNH 411

3. © 2007 Thomson - Wadsworth

6. Pathophysiology: Lower GI Tract Malabsorption - maldigestion of fat, CHO, Protein Diarrhea may result Concerned with: Celiac’s, Crohn’s, Diverticulitous May concern accessory organs due to cancer Decreased villious height, enzyme production Decreased transit time—surgery or resecting of a certain area may stress/compromise a part of the the GI

7. Pathophysiology: Lower GI Tract Malabsorption - fat Steatorrhea (excretion of abnormal quantities of fat) Fat-soluble vitamins malabsorbed—A,D,E,K (=diarrhea) Potential for excess oxalate (“kidney stones”) Signs/Conerns: Abdominal pain, cramping, diarrhea Diagnoses from: fecal fat test or D-xylose (type of sugar in the blood/urine & tells how well body is absorbing simple sugars) absorption test, or small bowel x-ray

8. Pathophysiology: Lower GI Tract Malabsorption - Fat – Nutrition 1. Restrict fat 25-50 g/day (would have to write up menu/plan) 2. 2. Use of MCT supplements (short chain triglycerides used; chemically made—helps absorb fat directly in the system (enzymes won’t need to be utilized so gut doesn’t have to work as hard yet body gets the nutrients it needs Elemental product 3. Pancreatic enzymes

9. Pathophysiology: Lower GI Tract Malabsorption - CHO Lactose malabsorption Increased gas, abdominal cramping, diarrhea—similar to signs with fat Restrict milk and dairy products Diagnosed by a lactose tolerance test Products such as Lactaid can be rec.

10. Pathophysiology: Lower GI Tract Malabsorption - protein Protein-losing enteropathy (excess protein loss) Reduced serum protein Use albumin for long term stays Use pre-albumin for short term (2 day turnover) Both aids in protein status Peripheral edema System/cells can’t hold in the water (bleeding it out) and you’re fluid overloaded since fluids aren’t being held in their cells

11. Pathophysiology: Lower GI Tract Malabsorption - Nutrition Therapy Results in weight loss Loss of vit/ minerals Protein Energy Malnutrition (PEM_ Treat underlying disease/ nutrient being malabsorbed Fat: you could used a shorter chain triglycerides Protein: use elemental formula that has protein broken down into simplest form Carbs: elemental formula with simple sugars

12. Pathophysiology: Lower GI Tract Celiac disease Inflammatory state that create antibodies Inflammation of the abdomen due to inability to break down gluten Genetic and autoimmune that occurs when alphaglaten from wheat, rye, malt, oats, or barley is eaten Occurs when alpha-gliadin from wheat, rye, malt, barley are eaten Infiltration of WBC, production of IgA antibodies

13. Pathophysiology: Lower GI Tract Celiac disease - pathophysiology Damage to villi Surface area compromised Decreased enzyme function Maldigestion and malabsorption Occurs with other autoimmune disorders Type 1 diabetes Rheumatoid arthritis

15. Pathophysiology: Lower GI Tract Celiac disease - clinical manifestations Sense of touch affected (something neuropathy) Diarrhea, abdominal pain, cramping, bloating, gas Muscle cramping, fatigue Skin rash Higher risk for lymphoma and osteoporosis

16. Pathophysiology: Lower GI Tract Celiac Disease - Diagnosis/Treatment/Prognosis Biopsy of small intestinal mucosa Reversal of symptoms following gluten-free diet Refractory CD (clinical disease); d/t coexisting disease

17. Pathophysiology: Lower GI Tract Celiac Disease - Nutrition Intervention Low-residue (to minimize diarrhea), low-fat (45-50 g/day), lactose-free, gluten-free diet (for life) Oats are controversial (max: ½ c./day) because of cross contamination Identify hidden sources of gluten Specialty products

19. Pathophysiology: Lower GI Tract Irritable Bowel Syndrome (IBS) Pain relieved with defecation Onset associated with change in frequency of stool Onset associated with change in form of stool Eliminate “red flag” symptoms: difficulty with elimination

20. Pathophysiology: Lower GI Tract IBS (irritable bowel syndrome) Most common GI complaint: pain with defication More common in women than men Etiology unknown in most cases Increased serotonin, inflammatory response, abnormal GI motility, pain Stressed, anxiety, depression, emotional trauma can trigger IBS (if predisposed)

21. Pathophysiology: Lower GI Tract IBS - clinical manifestations Abdominal pain, alterations in bowel habits, gas, flatulence Increased sensitivity to certain foods (lactose, wheat, high fiber foods specifically) Concurrent dg: fibro mialga, chronic fatigue syndrome, food allergies

22. Pathophysiology: Lower GI Tract IBS - Treatment Guided by symptoms Antidiarrheal agents Tricyclic antidepressants, SSRIs (selected serotonin reuptake inhibitors—another depressant) Bulking agents, laxatives Behavioral therapies (to help relieve the stress) Antidepressents

23. Pathophysiology: Lower GI Tract IBS - Nutrition Therapy Can lead to nutrient deficiency, underweight or malnourished due to constant pain or depression Decrease anxiety which leads to normalize dietary patterns: depressed or GI discomfort state

24. Pathophysiology: Lower GI Tract IBS - Nutrition Therapy Assess diet hx (what foods trigger?) Assess nutritional adequacy (24-hr. recall, access macro./micro nutrients) Focus on increasing fiber intake (25 g/day) Adequate fluid (to help with GI motility; 2,000 cc’s/kcal) Pre- and probiotics (trying to rebuild the gut flora) Avoid foods that produce gas & straws (swallowed air)

27. © 2007 Thomson - Wadsworth

31. Pathophysiology: Lower GI Tract IBD - Nutrition Therapy Malnutrition: those who can eat: high calorie, protein, fiber regiment Look at micronutrients Iron, Zinc, Magnesium, Electrolytes—Na, K, Cl—replaced because of fluid loss May need to increase kcal, protein, micronutrients

32. Pathophysiology: Lower GI Tract IBD - Nutrition Interventions During exacerbation Supplement (use enteral products such as Ensure to keep GI functioning) Supplement (glutamine, argenine help glutamine, argenine help decrease inflammation Assess energy needs + stress factor (200-500 extra calories/day) May need to increase protein (1.5-1.7 g/kilo) Low-residue, lactose-free diet Small, frequent meals that are high calorie, high protein (key!)

33. Pathophysiology: Lower GI Tract IBD - Nutrition Interventions May use MCT oil (if problems with steatorrhea) Restrict gas-producing foods Increase fiber and lactose as tolerated once they’ve stabilized and out of crises stage –individual bases Advancement of oral diet –individual basis Multivitamin (make sure patient has these; B12, Iron, zinc, calcium, magnesium, copper need to be present, specifically)

34. Pathophysiology: Lower GI Tract IBD - Nutrition Interventions During remission/rehabilitation Maximize energy & protein Weight gain and physical activity Food sources of antioxidants, Omega-3s specifically Pro- and prebiotics (to keep flora)

35. Pathophysiology: Lower GI Tract Diverticulosis—when inflammed/diverticulitis – abnormal presence of outpockets or pouches on surface of SI or colon/inflammation of these Low fiber intake (concern during crises); history of constipation Increases inflammatory response Other risks: obesity, sedentary lifestyle, on steroids for other health concerns, high alcohol/caffeine intake, history of smoking

37. Pathophysiology: Lower GI Tract Diverticulosis/diverticulitis – pathophysiology Fecal matter trapped creates excessive pressure against wall of colon and how pouches are developed Development of pouches Diverticulitis—inflammation of those pouches and concern is they could burst Food stuff Bleeding abscess, obstruction, fistula (bleeding area of the gut & need resection, perforation

38. Pathophysiology: Lower GI Tract Diverticulosis/-itis – Treatment/ Nutrition Therapy Specific focus on fiber Pro- and prebiotic supplementation (to increase gut flora) Acute Antibiotics

39. Pathophysiology: Lower GI Tract Diverticulosis/-itis – Nutrition Therapy -osis Avoid nuts, seeds, hulls (? May not get trapped in the pouch so may not be of concern) Fiber supplement ( in order to reach 40 g per day) -itis Low fiber diet (area is inflamed and you don’t want to exacerbate it) Bowel rest (may be on clear liquids) Avoid nuts, seeds, fibrous vegetables (because of fiber content not their shape)