chapter 18 nutrition and lower gastrointestinal disorders
TRANSCRIPT
1818Nutrition and
Lower Gastrointestinal
Disorders
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Common Intestinal Problems
• Constipation– Fewer than three bowel movements per week– Hard stools and excessive straining– More prevalent in women and older adults– Causes of constipation
• Low-fiber diet, low food intake, inadequate fluid intake, or low level of physical activity
• Some medical conditions and medications
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Common Intestinal Problems: Constipation (cont’d.)
• Treatment of constipation– Fiber intake: gradual increase to 20-25 g/day
• Foods that increase stool weight: wheat bran, fruits, and vegetables
• Fiber supplements– Adequate fluids: 1.5 to 2 liters per day– Prunes or prune juice– Increase physical activity if inactive
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Common Intestinal Problems: Constipation (cont’d.)
• Laxatives– Action: increase stool weight, increase stool
water content, or stimulate peristaltic contractions
– Enemas and suppositories: distend and stimulate the rectum or lubricate the stool
• Medical interventions• What medical interventions may be taken for
patients who do not respond to dietary or laxative treatments?
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Common Intestinal Problems (cont’d.)
• Intestinal gas (flatulence)– Nutrition therapy: restrict FODMAPs
• Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols
– Foods associated with flatulence• Corn, carbonated beverages• FODMAPs sources: apples, broccoli, cabbage,
dried beans and peas, fructose-sweetened products, pears, etc.
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Common Intestinal Problems (cont’d.)
• Diarrhea– Passage of frequent, watery stools– Severe or persistent: dehydration and
electrolyte imbalances– Chronic cases: weight loss and malnutrition– Causes of diarrhea
• Various GI disorders, infections, medications, or dietary substances
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Common Intestinal Problems: Diarrhea (cont’d.)
• Causes of diarrhea– Osmotic diarrhea
• Unabsorbed nutrients or other substances attract water to the colon and increase fecal water content
– Secretory diarrhea • Fluid secreted by the intestines exceeds the
amount that can be reabsorbed by intestinal cells– Motility disorders may result in diarrhea
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Common Intestinal Problems: Diarrhea (cont’d.)
• Causes of diarrhea– Acute cases
• Start abruptly and may persist for several weeks• What are some typical causes of acute cases of
diarrhea?– Chronic cases
• Persist for about four weeks or longer• Result from malabsorption disorders, inflammatory
diseases, motility disorders, infections, etc.
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Common Intestinal Problems: Diarrhea (cont’d.)
• Medical treatment of diarrhea– Correct the underlying problem
• Antibiotics for intestinal infections; eliminating responsible foods; prescribing a different medication; etc.
– Bulk-forming agents– Antidiarrheal drugs– Probiotics– Intractable diarrhea: parenteral nutrition
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Common Intestinal Problems: Diarrhea (cont’d.)
• Oral rehydration therapy– Replace lost fluid and electrolytes– Rehydration solutions: water, salts, glucose
(Box 18-3)– Why are commercial sport drinks not ideal
fluids for rehydration?
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Common Intestinal Problems: Diarrhea (cont’d.)
• Nutrition therapy for diarrhea– Depends on cause, severity, duration– Initially recommended: low-fiber, low-fat, and
lactose-free diet– Fluid intakes increased to replace fluid losses– Formula-fed infants: apple pectin or banana
flakes added to formulas
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Malabsorption
• Causes– Pancreatic disorders leading to enzyme or
bicarbonate deficiencies– Disorders leading to bile deficiency– Inflammatory diseases or medical treatments
damaging intestinal tissue
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Malabsorption (cont’d.)
• Fat malabsorption– Fat = nutrient most frequently malabsorbed
• Requires both digestive enzymes and bile for its digestion
– Steatorrhea: excessive fat in the stools• Evidence of fat malabsorption
– Consequences of fat malabsorption• Losses of food energy, essential fatty acids,
fat-soluble vitamins, and some minerals
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The Consequences of Fat Malabsorption
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Malabsorption: Fat Malabsorption (cont’d.)
• Nutrition therapy for fat malabsorption– Fat-restricted diet (Table 18-5)
• Fat restricted no more than necessary– Medium-chain triglycerides (MCT): alternative
dietary fat source• Lacks essential fatty acids
– Box 18-5 provides tips for adhering to a fat-restricted diet and using MCT oil
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Sample Menu—Fat-Restricted Diet
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Malabsorption (cont’d.)
• Bacterial overgrowth– Excessive bacterial colonization of the
stomach and small intestine– May result in fat malabsorption
• Deficiencies of fat-soluble vitamins may develop
– May reduce absorption of vitamin B12
– Causes of bacterial overgrowth• Impaired intestinal motility, reduced gastric
secretions
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Malabsorption (cont’d.)
• Bacterial overgrowth– Treatment for bacterial overgrowth
• Antibiotics• Surgical correction of anatomical defects• Medications to stimulate peristalsis• Discontinuation of acid-suppressing medications• Lactose-restricted diet• Dietary supplements to correct nutrient
deficiencies
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Malabsorption (cont’d.)
• Lactose intolerance– Prevalence: 75% of people worldwide– Primary symptoms:
• Diarrhea • Increased intestinal gas
– What dietary adjustments are recommended for people with lactose intolerance?
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Disorders of the Pancreas
• Pancreatitis: an inflammatory disease– Acute pancreatitis
• Digestive enzymes within pancreatic cells become prematurely activated, causing pancreatic tissue destruction and subsequent inflammation
• 70% to 80% of cases are caused by gallstones or alcohol abuse
• What are common symptoms of acute pancreatitis?
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Disorders of the Pancreas: Pancreatitis (cont’d.)
• Nutrition therapy for acute pancreatitis– Initial treatment: pain control and intravenous
hydration; oral fluids and food withheld– Usually progress to regular diet
• Fat-restricted diet if malabsorption symptoms occur
• Continuous tube feedings (started within 48 hours) for severe disease
• Protein: 1.2 to 1.5 g/kg/day
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Disorders of the Pancreas: Pancreatitis (cont’d.)
• Chronic pancreatitis– Progressive, permanent damage
• Impaired secretion of digestive enzymes and bicarbonate
– 70% to 80% of cases due to excessive alcohol consumption
• Nutrition therapy for chronic pancreatitis– Objectives: reduce malabsorption, correct
malnutrition
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Disorders of the Pancreas: Pancreatitis (cont’d.)
• Nutrition therapy for chronic pancreatitis– Pancreatic enzyme replacement for
steatorrhea/malabsorption– Daily needs: 1.0-1.5 g/kg protein, 35 kcal/kg– Dietary supplements to correct nutrient
deficiencies– Avoid alcohol completely; quit smoking
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Disorders of the Pancreas (cont’d.)
• Cystic fibrosis– Genetic disorder that alters the ion
concentration and/or viscosity of exocrine secretions
– Consequences of cystic fibrosis• Lung disease: chronic respiratory infections,
progressive inflammation, airway obstruction• Pancreatic disease: obstructed pancreatic ducts
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Disorders of the Pancreas: Cystic Fibrosis (cont’d.)
• Consequences of cystic fibrosis– Excessive salt losses in sweat– Others: intestinal obstruction; gallbladder and
liver diseases; abnormalities in genital tissues• Nutrition therapy for cystic fibrosis
– High-kcal, high-protein diet; liberal fat intake– Oral supplements and/or tube feedings– Pancreatic enzyme therapy
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Disorders of the Small Intestine
• Celiac disease– Immune disorder; abnormal response to
wheat gluten and related proteins– Causes severe damage to the intestinal
mucosa• Subsequent malabsorption
– Consequences of celiac disease• GI disturbances: diarrhea, steatorrhea, and
flatulence
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Disorders of the Small Intestine (cont’d.)
• Celiac disease– Nutrition therapy for celiac disease
• Gluten-free diet (Table 18-6) • Avoid lactose until recovered if lactase deficiency
suspected• Dietary supplements
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Sample Menu—Gluten-Free Diet
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Disorders of the Small Intestine (cont’d.)
• Inflammatory bowel diseases– Chronic inflammatory illnesses characterized
by abnormal immune responses to microbes that inhabit the GI tract
– Major forms:• Crohn’s disease• Ulcerative colitis
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Disorders of the Small Intestine: Inflammatory Bowel Diseases (cont’d.)
• Complications of Crohn’s disease– Ulcerations, fissures, fistulas, strictures– 40% require surgery within 10 y of diagnosis– Increased risk of intestinal cancer– Malnutrition
• Poor food intake, malabsorption, diarrhea, bleeding, nutrient losses, increased needs
– B12 deficiency, anemia, and anorexia
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Disorders of the Small Intestine: Inflammatory Bowel Diseases (cont’d.)
• Complications of ulcerative colitis– Mucosal atrophy, thin walls, colon dilation– Varying symptoms: diarrhea, constipation,
rectal bleeding, and abdominal pain– Weight loss, fever, and weakness– Severe cases: anemia, dehydration, and
electrolyte imbalances– Colon cancer risk substantially increased
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Disorders of the Small Intestine: Inflammatory Bowel Diseases (cont’d.)
• Drug treatment for inflammatory bowel diseases– Purpose: control symptoms, reduce
inflammation, and minimize complications• Nutrition therapy for Crohn’s disease
– Aggressive dietary management• Specific measures: depend on functional status of
the GI tract; symptoms and complications that develop
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Disorders of the Small Intestine: Inflammatory Bowel Diseases (cont’d.)
• Nutrition therapy for ulcerative colitis– In most cases: few adjustments to diet– Manage symptoms as needed
• Restore fluid and electrolyte balances• Correct deficiencies• Low-fiber diet may reduce irritation
– Severely impaired colon function• NPO, intravenous fluids and electrolytes
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Disorders of the Small Intestine (cont’d.)
• Short bowel syndrome– Malabsorption syndrome following resection
of a major portion of small intestine– Intestinal adaptation
• What changes occur during intestinal adaptation?– Nutrition therapy for short bowel syndrome
• Initially following resection: fluids and electrolytes must be supplied intravenously
• First few weeks: rehydration therapy
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Disorders of the Small Intestine (cont’d.)
• Short bowel syndrome– Nutrition therapy for short bowel syndrome
• Gradual transition: parenteral nutrition to tube feedings and/or oral feedings
• What factors determine the exact diet prescribed for short bowel syndrome?
• Dietary choices tailored according to individual symptoms and tolerances
• Example: Box 18-12 (case study)
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Nutrient Absorption and Consequences of Intestinal Surgeries
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Disorders of the Large Intestine
• Irritable bowel syndrome– Chronic and recurring intestinal symptoms
• Not explained by specific physical abnormalities– Symptoms
• Disturbed defecation, bloating, abdominal discomfort or pain
– Treatment of irritable bowel syndrome• Dietary adjustments, stress management, and
behavioral therapies; medications
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Disorders of the Large Intestine: Irritable Bowel Syndrome (cont’d.)
– Nutrition therapy for irritable bowel syndrome– Responses among patients vary considerably
• Avoid foods that aggravate symptoms: fried or fatty foods, gas-producing foods, milk products, etc.
• Low-FODMAP diet• Small, frequent meals• Psyllium supplementation (for constipation)• Under investigation: peppermint oil, probiotics
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Disorders of the Large Intestine (cont’d.)
• Diverticular disease of the colon– Diverticulosis
• Presence of small herniations (diverticula) in the intestinal mucosa
• Usually asymptomatic– Diverticulitis
• Inflammation or infection involving diverticula• Persistent abdominal pain, tenderness in the
affected area, fever, constipation, and diarrhea
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Disorders of the Large Intestine: Diverticular Disease (cont’d.)
• Treatment for diverticular disease– Increased fiber intakes often recommended
but not shown to reverse the disease or prevent its progression
– Diverticulitis treatment• May need antibiotics and pain-control drugs• NPO, intravenous fluids in severe cases• Surgical interventions for complications
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Disorders the Large Intestine (cont’d.)
• Colostomies and ileostomies– Ostomy: surgically created opening (stoma) in
the abdominal wall• For dietary waste elimination
– Colostomy: stoma formed from a section of the colon
– Ileostomy: stoma formed from a section of the ileum
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Colostomy and Ileostomy
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Disorders of the Large Intestine: Colostomies and Ileostomies (cont’d.)
• Nutrition care for patients with ostomies– Individualized dietary adjustments
• Depends on surgical procedure and symptoms– Recommendations with ileostomies
• Chew foods thoroughly• Avoid foods high in insoluble fibers• Use salt liberally and drink beverages with added
electrolytes
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Disorders of the Large Intestine: Colostomies and Ileostomies (cont’d.)
• Nutrition care for patients with ostomies– Recommendations with colostomies
• Most patients return to a regular diet
• Obstructions– Primary concern of ileostomy patients– What are examples of foods that may cause
difficulty?
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Disorders of the Large Intestine: Colostomies and Ileostomies (cont’d.)
• Reducing gas and odors – Foods that may reduce odors: buttermilk,
cranberry juice, parsley, and yogurt• Diarrhea
– Table 18-3: foods that may worsen diarrhea– Foods that may thicken stool: applesauce,
banana, cheese, pasta, potatoes, smooth peanut butter, tapioca, white rice
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Nutrition in Practice:Probiotics and Intestinal Health
• Roles of nonpathogenic intestinal bacteria• Probiotics
– Research on uses in medical treatment• Infectious diarrhea• Pouchitis following ileostomy or colostomy
– Dietary sources (mainly fermented foods)• Adverse effects
– Bacterial translocation
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