g.i. disorders lower g.i. and accessory organs. irritable bowel syndrome approximately 5 million...

G.I. DisordersG.I. Disorders

Lower G.I. Lower G.I. and and

accessory accessory organsorgans

Irritable Bowel SyndromeIrritable Bowel Syndrome Approximately 5 million Approximately 5 million

people in the U.S. suffer people in the U.S. suffer with the syndromewith the syndrome

Also known as:Also known as:– ColitisColitis

Does not always include Does not always include inflammationinflammation

– Spastic colonSpastic colon Does not always occur in Does not always occur in

the Colonthe Colon

– Not to be confused with Not to be confused with Ulcerative ColitisUlcerative Colitis

Irritable Bowel SyndromeIrritable Bowel Syndrome

Characterized by:Characterized by:– Pain (duration > 3 months)Pain (duration > 3 months)

SymptomsSymptoms– Diarrhea, constipation or alternating Diarrhea, constipation or alternating

episodes of bothepisodes of both– Flatulence, bloating, Flatulence, bloating, – Indigestion, belching, heartburn, nauseaIndigestion, belching, heartburn, nausea– Mucus in the stoolMucus in the stool

Irritable Bowel SyndromeIrritable Bowel Syndrome

Medical Nutrition TherapyMedical Nutrition Therapy– Elemental diet, for persons with acute IBSElemental diet, for persons with acute IBS– Low fat Diet, with liberal fruits and veggiesLow fat Diet, with liberal fruits and veggies

Soluble fiberSoluble fiber

– Avoid milk Avoid milk (lactose intolerance common) (lactose intolerance common)

– Liberal lactose free liquidsLiberal lactose free liquids– Avoid spicy foodsAvoid spicy foods– Avoid gas-forming foodsAvoid gas-forming foods– Avoid caffeine, alcohol, sorbitolAvoid caffeine, alcohol, sorbitol

Client EducationClient Education Vitamin B-complex supplement may be Vitamin B-complex supplement may be

necessarynecessary Encourage regular bowel evacuationEncourage regular bowel evacuation Stress and coping mechanismsStress and coping mechanisms Regular exerciseRegular exercise Food diaries may help identify food Food diaries may help identify food

sensitivitiessensitivities Products that reduce intestinal gas Products that reduce intestinal gas

(Bean-O)(Bean-O)

Diverticular DiseaseDiverticular Disease Diverticula – the Diverticula – the

presence of presence of outpouchings in the outpouchings in the intestinal wallintestinal wall– Diverticulum Diverticulum

Diverticulitis – Diverticulitis – inflammation of inflammation of diverticuladiverticula

Diverticulosis – the Diverticulosis – the presence of presence of diverticuladiverticula

Medical Nutrition Medical Nutrition therapytherapy

DiverticulitisDiverticulitis (Inflamed state) (Inflamed state) Bowel rest – NPOBowel rest – NPO ( (nil per os)nil per os) Clear liquidsClear liquids Progress to Soft, Low fat dietProgress to Soft, Low fat diet No excess spices or fiberNo excess spices or fiber Gradually progress to normal fiber Gradually progress to normal fiber

intake as inflammation decreasesintake as inflammation decreases


Diverticulosis (Convalescent state)Diverticulosis (Convalescent state) High fiber - >30grams per day High fiber - >30grams per day

desirabledesirable– Start with small amount and increase Start with small amount and increase

graduallygradually– Add whole grains, raw fruits and vegetablesAdd whole grains, raw fruits and vegetables

Increase fluid intakeIncrease fluid intake Low fatLow fat


In both conditions, In both conditions, AVOIDAVOID::

Small seeds Small seeds (strawberries, poppy)(strawberries, poppy)

Nuts, chunky peanut Nuts, chunky peanut butterbutter

PopcornPopcorn CornCorn Fibrous vegetablesFibrous vegetables

Ulcerative ColitisUlcerative Colitis Inflammatory bowel Inflammatory bowel

diseasedisease Symptoms:Symptoms:

– Diarrhea (resulting in Diarrhea (resulting in malabsorption)malabsorption)

– Rectal bleeding (resulting Rectal bleeding (resulting in anemia)in anemia)

– Cramping, abdominal Cramping, abdominal painpain

– Anorexia, weight lossAnorexia, weight loss


Dietary interventions do not Dietary interventions do not lessen diseaselessen disease– Low fiberLow fiber– Lactose freeLactose free– Vitamin and mineral Vitamin and mineral

supplementationsupplementation

Regional Enteritis Regional Enteritis (Crohn’s)(Crohn’s)

Inflammation and Inflammation and ulceration of the G.I. ulceration of the G.I. tract.tract.

Nutrition consequencesNutrition consequences– Protein malnutritionProtein malnutrition

hypoalbuminemiahypoalbuminemia

– Vitamin deficienciesVitamin deficiencies Vitamin BVitamin B1212, Folate, C and fat , Folate, C and fat

solublessolubles

– Mineral deficienciesMineral deficiencies Calcium, Magnesium, Zinc, Calcium, Magnesium, Zinc,

IronIron

– Anemia Anemia


High kcal, High kcal, High protein, (1-1.5g/kg)High protein, (1-1.5g/kg) Fat restricted Fat restricted (if steatorrhea is present)(if steatorrhea is present) Low fiberLow fiber Vitamin and mineral supplementationVitamin and mineral supplementation Avoid foods not well tolerated Avoid foods not well tolerated (i.e. (i.e.

lactose)lactose) Small, frequent meals recommended Small, frequent meals recommended

Celiac DiseaseCeliac Disease Also known as Celiac SprueAlso known as Celiac Sprue Inflammatory condition of the G.I. tract that Inflammatory condition of the G.I. tract that

affects the small intestines.affects the small intestines. Malabsorption due to a sensitivity to GliadinMalabsorption due to a sensitivity to Gliadin Gliadin = part of the protein Gluten found in:Gliadin = part of the protein Gluten found in:

wheat, buckwheat, Rye, barleywheat, buckwheat, Rye, barley Oats Oats (can usually be taken in small amounts)(can usually be taken in small amounts)

Celiac DiseaseCeliac Disease

ConsequencesConsequences Protein malnutrition Protein malnutrition (low serum protein (low serum protein

levels)levels)

Anemia – iron, folate and Vit B12 Anemia – iron, folate and Vit B12 deficiencydeficiency

Steatorrhea, diarrhea Steatorrhea, diarrhea (resulting in weight(resulting in weight loss)loss)

Calcium deficiency Calcium deficiency (resulting in bone pain)(resulting in bone pain)

Vitamin and mineral deficiencies Vitamin and mineral deficiencies (fat (fat soluble vitamins lost with steatorrhea)soluble vitamins lost with steatorrhea)


Gliadin-free/ gluten restricted dietGliadin-free/ gluten restricted diet– No wheat, buckwheat, rye,barleyNo wheat, buckwheat, rye,barley– Small amount of oats Small amount of oats (may be contaminated (may be contaminated

with wheat during processing)with wheat during processing)

May have: corn, rice, tapioca, potato, May have: corn, rice, tapioca, potato, arrowroot, cassava (yuca) gluten-free arrowroot, cassava (yuca) gluten-free flourflour

Lactose restrictedLactose restricted Vitamin and mineral supplementationVitamin and mineral supplementation

Accessory Accessory OrgansOrgans

PancreatitisPancreatitis Inflammation of the Inflammation of the

PancreasPancreas Acute – due to organ Acute – due to organ

autodigestionautodigestion

- Usually as a result of duct - Usually as a result of duct obstructionobstruction

- Enzymes become activated - Enzymes become activated in duct instead of in duct instead of duodenumduodenum

Alcohol abuseAlcohol abuse Gallstones (~45% of all Gallstones (~45% of all

cases)cases)

Acute PancreatitisAcute Pancreatitis

Symptoms of Acute Symptoms of Acute PancreatitisPancreatitis

Sudden, severe abdominal painSudden, severe abdominal pain– May be constant and disablingMay be constant and disabling

Nausea, vomitingNausea, vomiting DiarrheaDiarrhea Approximately 25% develop Approximately 25% develop

chronic pancreatitischronic pancreatitis


NPO with IV feedings ~ 48 hoursNPO with IV feedings ~ 48 hours Jejunostomy feedings if longerJejunostomy feedings if longer

Clear liquid progress to Low fat dietClear liquid progress to Low fat diet Provide pancreatic enzyme Provide pancreatic enzyme

replacementreplacement Small frequent mealsSmall frequent meals No alcohol, caffeineNo alcohol, caffeine

Chronic PancreatitisChronic Pancreatitis Fibrotic, necrotic disease Fibrotic, necrotic disease

where cells suffer where cells suffer permanent damage.permanent damage.

Decreased enzyme Decreased enzyme productionproduction

Nausea, vomiting, Nausea, vomiting, abdominal painabdominal pain

Most common cause is Most common cause is alcohol abuse (~70%) alcohol abuse (~70%)

Other causes: pancreatic Other causes: pancreatic cancer, Cystic Fibrosiscancer, Cystic Fibrosis


High calorie, semi-elemental tube High calorie, semi-elemental tube feedingfeeding

Low fat, high calorie, moderate proteinLow fat, high calorie, moderate protein Low fiberLow fiber Six small mealsSix small meals No alcohol, caffeine or gastric stimulantsNo alcohol, caffeine or gastric stimulants Vitamin and mineral supplementationVitamin and mineral supplementation

Cystic FibrosisCystic Fibrosis

ConsequencesConsequences Pancreatic insufficiency (80-90%)Pancreatic insufficiency (80-90%)

– May require enzyme replacement, insulinMay require enzyme replacement, insulin Chronic lung diseaseChronic lung disease

– Lung infections – major cause of deathLung infections – major cause of death Growth retardation (85%)Growth retardation (85%) Decreased bone densityDecreased bone density Abnormally high electrolytes in sweatAbnormally high electrolytes in sweat


High kcal, high High kcal, high proteinprotein– 20 – 50% above 20 – 50% above

normal needsnormal needs Pancreatic enzymesPancreatic enzymes

– To control To control steatorrheasteatorrhea

Multivitamin Multivitamin supplementationsupplementation

Liberal salt useLiberal salt use Encourage fluidsEncourage fluids


When body weight When body weight falls below 85% std, falls below 85% std, alternate feedings alternate feedings are indicated.are indicated.

Infant feeding:Infant feeding:– Enzyme replacement Enzyme replacement

with breast feedingwith breast feeding– Up to ¼ tsp salt daily Up to ¼ tsp salt daily

given to replace given to replace losseslosses

Liver: HepatitisLiver: Hepatitis

Definition: Inflammation of the LiverDefinition: Inflammation of the Liver 5 types5 types Hepatitis A associated with Hepatitis A associated with

food/water contamination – highly food/water contamination – highly contagious.contagious.

HepatitisHepatitis SymptomsSymptoms- JaundiceJaundice- Dark urineDark urine- Elevated liver Elevated liver

enzymesenzymes- Tender, enlarged Tender, enlarged

liverliver Hepatitis is mainly Hepatitis is mainly

acute, but sometimes acute, but sometimes chronicchronic– May lead to cancer, May lead to cancer,

liver failure, hepatic liver failure, hepatic coma, deathcoma, death

Medical Nutrition Medical Nutrition TherapyTherapy

Regular dietRegular diet High protein, high kcal (if High protein, high kcal (if

malnourished)malnourished) Small, frequent feedingsSmall, frequent feedings

– Anorexia, nausea is commonAnorexia, nausea is common Nutritional supplement (Ensure, Nutritional supplement (Ensure,

Boost)Boost)

CirrhosisCirrhosis Definition:Definition: Chronic Chronic

liver failure where liver failure where scar tissue replace scar tissue replace liver cells and there liver cells and there is a permanent loss is a permanent loss of function. of function.

Causes: Causes: Alcohol Alcohol abuseabuse

Biliary tract Biliary tract obstructionobstruction

InfectionInfection

Consequence of CirrhosisConsequence of Cirrhosis Portal hypertensionPortal hypertension Esophageal varicesEsophageal varices AscitesAscites Elevated blood Ammonia levelsElevated blood Ammonia levels

Hepatic ComaHepatic Coma Changes in judgment, mood, Changes in judgment, mood,

personalitypersonality Sweet, musky or pungent (fecal) odorSweet, musky or pungent (fecal) odor Flapping tremor of outstretched handFlapping tremor of outstretched hand


Energy: Energy: adequate carbohydrate and fat adequate carbohydrate and fat to spare protein (35-45kcal/kg BW)to spare protein (35-45kcal/kg BW)

Protein (1.0 – 1.5 gm/kg BW)Protein (1.0 – 1.5 gm/kg BW)– Enough to regenerate cells, but not Enough to regenerate cells, but not

increase ammoniaincrease ammonia– Impending coma (40 – 60 gm/day)Impending coma (40 – 60 gm/day)– ComaComa

Vegetable protein and Branch Chain Amino Vegetable protein and Branch Chain Amino AcidAcid

Medical Medical Nutrition Nutrition TherapyTherapy

Sodium (2 grams)Sodium (2 grams)– To control ascitesTo control ascites

Fluids (1.0 – 1.5 Fluids (1.0 – 1.5 liters/ day)liters/ day)– Restricted to Restricted to

control ascitescontrol ascites Vitamin and Vitamin and

mineralmineral

Drug Drug TherapyTherapy

AntibioticsAntibiotics– To limit growth of To limit growth of

intestinal bacteriaintestinal bacteria LaxativesLaxatives

– to decrease transit to decrease transit timetime

DiureticsDiuretics– To reduce fluid To reduce fluid

retentionretention

CholelithiasisCholelithiasis GallstonesGallstones: solid masses that form in : solid masses that form in

the gallbladder from bilethe gallbladder from bile BileBile: fat emulsifier produced in the liver : fat emulsifier produced in the liver

and stored in the gallbladderand stored in the gallbladder Gallstones are:Gallstones are:

– Cholesterol stonesCholesterol stones– Pigment stonesPigment stones

Risk FactorsRisk Factors

Body weight (obesity)Body weight (obesity) Gender (female)Gender (female) Age (~40 yrs)Age (~40 yrs) EthnicityEthnicity Type II diabetesType II diabetes Short bowel syndrome, gastric Short bowel syndrome, gastric

bypassbypass Certain medicationsCertain medications


Low fatLow fat– Weight reduction if appropriateWeight reduction if appropriate

High fiberHigh fiber– Soluble fibers bind bile acidsSoluble fibers bind bile acids

Avoid gas formersAvoid gas formers– Prevent distentionPrevent distention

Water-based fat soluble vitaminsWater-based fat soluble vitamins

Renal Diseases:Renal Diseases:Nephrotic SyndromeNephrotic Syndrome

Definition: Cluster of symptoms Definition: Cluster of symptoms which result in protein in the urine which result in protein in the urine (albuminuria)(albuminuria)

Consequences:Consequences:– Protein calorie malnutritionProtein calorie malnutrition– AnemiaAnemia– InfectionInfection– AtherosclerosisAtherosclerosis

For unknown reasons, blood lipid levels riseFor unknown reasons, blood lipid levels rise


Adequate non-protein caloriesAdequate non-protein calories Normal protein intake (0.8 – 1.0 Normal protein intake (0.8 – 1.0

gm/kg)gm/kg) Low saturated fat/ low cholesterolLow saturated fat/ low cholesterol Sodium restriction (~2 grams)Sodium restriction (~2 grams)

Renal FailureRenal Failure Definition: Loss of the Definition: Loss of the

kidney’s ability to kidney’s ability to functionfunction

May be acute or chronicMay be acute or chronic Consequences:Consequences:

– Uremia (azotemia)Uremia (azotemia)– Electrolyte imbalance Electrolyte imbalance

(Hyperkalemia)(Hyperkalemia)– Changes in fluid balanceChanges in fluid balance


Consider:Consider:– Energy needs (non-protein kcalories)Energy needs (non-protein kcalories)– Protein restrictionProtein restriction

Depending on kidney functionDepending on kidney function

– Electrolyte restriction`Electrolyte restriction` Sodium, potassium, phosphorusSodium, potassium, phosphorus

– Fluid restrictionFluid restriction Monitor intake and outputMonitor intake and output

– SupplementsSupplements Calcium, folate, Vitamin BCalcium, folate, Vitamin B66, Vitamin D, Vitamin D

Renal Calculi Renal Calculi (kidney (kidney stones)stones)

Calcium stones (>75%)Calcium stones (>75%)– Causes: Hypercalciuria (idiopathic)Causes: Hypercalciuria (idiopathic)– ImmobilizationImmobilization– hyperoxaluriahyperoxaluria

Medical Nutrition TherapyMedical Nutrition Therapy– Calcium managementCalcium management– Increased fluidsIncreased fluids– Limit oxalate intakeLimit oxalate intake

Renal Calculi Renal Calculi (kidney (kidney stones)stones)

Uric Acid StonesUric Acid Stones– Common in goutCommon in gout

Medical Nutrition TherapyMedical Nutrition Therapy– Low Purine dietLow Purine diet– Increase fluidsIncrease fluids

Cystine stonesCystine stones– Genetically linkedGenetically linked

Medical Nutrition TherapyMedical Nutrition Therapy– Low Methionine dietLow Methionine diet– Increased fluidsIncreased fluids

g.i. disorders lower g.i. and accessory organs. irritable bowel syndrome approximately 5 million...

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