BirgitHumpert-GI_2012-google.doc.docx · Web viewEtiology: An increase in the secretion of gastrin, estrogen, and progesteron, obesity, scleroderma, hiatal hernia (part of the stomach

GI_2012Due: June 22, 2012

GI Clinical Packet Name: Birgit Humpert

Please answer all questions in your own words. list the applicable references at the end of each section.

A.) Medical Terminology 1. Fill in the blanks in the following table:

Body Part Related Root word

Primary Function of the body part

Example: Mouth oro Begins preparation of food for digestion

pharynx/throat pharyng Chewed food passes through to the esophagus

esophagus esophag Passes food to the stomachstomach gastr Mechanical and chemical

digestion, little absoptionsmall intestines enter Completion of digestion,

absorptionlarge intestines col Absorption of water, excretionanus or rectum an, proct, rect Opens up to the body surface to

excrete feces.liver hepat Produces bile for fat absorption,

detoxifies the blood, produces blood proteins, stores substances.

gallbladder cholecyst Stores bile.pancreas pancreat Secretion of enzymes for digestion

and absorption, production of hormones (insulin, glucagon).

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2. Break the following words up into their prefix, root and suffix* and then provide the meaning of the word. (Not all words will have all parts.)

Medical Term Prefix & Meaning* Root & Meaning*

Suffix & Meaning* Meaning of Medical Term

Ex: Gastrointestinal gastro - stomach intestin - intestine al – pertaining to Pertaining to the stomach or intestines

Dysphagia dys - difficult, painful

phagia - eat ia - condition difficulty/inability to swallow

Gastritis gastro - stomach

itis - inflammation

inflammation of the stomach

Dyspepsia dys - difficult, painful

pept - digestion ia - condition indigestion

Hematemesis hemat - blood emesis - vomiting

vomiting of blood

Colitis col/o - colon itis - inflammation

inflammation of th colon

Colonoscopy col/o - colon scopy - visual examination

visual examination of the colon

Gastrectomy gastr/o - stomach

ectomy - excission

surgical removal of the stomach or part of the stomach

Gastrostomy gastr/o - stomach

stomy - forming of an opening

forming of an opening from the stomach to the body surface

Colostomy col/o - colon stomy - forming of an opening

forming of an opening from the colon to the body surface to form an artifical anus

Cholecystectomy cholecyst/o - gallbladder

ectomy - excision removal of the gallbladder

Reference for this section: Leonard, P.C., (2011). Quick and Easy Medical Terminology. Maryland Heights, MO: Saunders

Elsevier

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B.) NORMAL DIGESTION 1. Fill in the blanks on the next page for each part of the digestive system from this diagram.

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Fill in the blanks below

1. Parotid gland 11. Anus

2. Pharynx or epiglottis ? 12. Appendix

3. Submandibular gland 13. Ileum

4. Esophagus 14. Ascending colon

5. Stomach 15. Transcending colon

6. Pancreas 16. Duodenum

7. Jejunum 17. Bile duct

8. Descending colon 18. Gallbladder

9. Rectum 19. Liver

10. Anal canal 20. Sublingual gland

Reference for this section: Insel, P., Ross, D., McMahon, K., Bernstein, M. (2011). Nutrition (4th ed.). Sudbury, MA: Jones and Bartlett

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2. The following table provides a list of digestive juices and related enzymes. Fill in the substrate (food or nutrient digested by the enzyme) and its end product.

Digestive Juices/Enzymes Substrate (Food digested) End Product (Nutrient)

a) In saliva

● Ptyalin starchshorter polysaccharides and

maltose

b) In gastric secretions

● Pepsin protein amino acides and peptides

c) In pancreatic secretions

● Trypsin polypeptides smaller peptides, amino acids

● Chymotrypsin polypeptides smaller peptides, amino acids

● Pancreatic lipase triglycerides, diglycerides glycerol, monoglycerides, free

fatty acids

● Pancreatic amylase starch maltose

d) In the small intestine

● Aminopeptidases peptides amino acids

● Dipeptidases dipeptides amino acids

● Maltase maltose glucose

● Lactase lactose glucose, galactose

● Sucrase sucrose glucose, fructose

Reference for this section:

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Insel, P., Ross, D., McMahon, K., Bernstein, M. (2011). Nutrition (4th ed.). Sudbury, MA: Jones and Bartlett

C.) GI-RELATED DISEASES AND CONDITIONS

For each of the following GI-related diseases and conditions:a Define the disease or conditionb Explain the causes (etiologies)c Describe the physical changes specific to the disease process and progression

(pathogenesis) d Explain how the disease impacts the patient’s nutritional status (in some cases there will be

no impact.)e Is a modified diet recommended for this condition? If so what is the diet prescription?

Please answer all using your own words. See the example below for hemmorhoids.

EXAMPLE:Hemorrhoids:

a Definition – Hemorrhoids are swollen veins of the rectum and anus.

b Etiology – Pregnancy, obesity, prolonged sitting, or straining during bowel movements

particularly with constipation can result in added stress to the veins of the rectum and

anus

c Pathogenesis - The swollen vessels protrude into the anal and/or rectal canals where they

become exposed; thrombosis, ulcerations, and bleeding may develop, resulting in chronic,

steady pain and irritation.

d Nutritional impact – Inadequate intake of a variety of foods during periods of hemorroidal

discomfort may compromise nutrition status. Chronic anemia can result from blood loss

associated with hemorrhoids.

e Modified diet is recommended – Consume adequate levels of fiber and fluids. The

Adequate Intake (AI) of fiber for adults is set at 25 g/day for women and 38 g/day for men,

and it is based on 14 g/1000 kcal in the diet.

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Disease/Condition:

1. Gastroesophageal Reflux Disease

a. Definition: Gastroesophageal Reflux Disease is the flowing back of gastric content

into the esophagus.

b. Etiology: An increase in the secretion of gastrin, estrogen, and progesteron, obesity,

scleroderma, hiatal hernia (part of the stomach comes up through an opening in the

diaphragm), smoking, medications and certain foods can lower pressure of the Lower

Esophageal Sphincter. The Etiology is usually multi factorial.

Gastroesophageal Reflux Disease can also occur in young infants. The cause can be

low pressure of the LES, overfeeding, food allergies, delayed gastric emptying,

increased acid production.

c. Pathogenesis: Due to the reflux of gastric content patients experience difficulty

swallowing (dysphagia), heartburn, an increase in salivation and belching and pain.

Pain is often worse at night or when laying down, and it can be confused with chest

pain.

d. Nutritional Status: Difficulty swallowing and restriction of food groups the patient

identifies as problematic can lead to nutritional deficits. Medications used to treat the

disease can affect calcium absorption and the status of iron and vitamin B12.

In infants an insufficient intake of nutrients can lead to delays in growth and

development.

e. MNT: The diet should take into account the patients needs and individual trigger

foods. A food diary can help identify foods that cause problems for the individual

patient. In general patients should avoid foods that relax the LES, like mint,

chocolate, high-fat/fried food, alcohol, and coffee; and avoid foods that increase

gastric secretion like alcohol, coffee, and pepper. Addressing obesity and smoking

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can have a big impact. Avoiding carbonated beverages and acidic foods and drinks

that can irritate the esophagus, as well as eating smaller more frequent meals can be

helpful. Patients should remain upright after eating, and raise the head of the bed. An

increased intake in dietary fiber and physical activity can have a protective effect.

For infants is can help to have smaller, more frequent feedings, and elimination of

foods the child is allergic against.

Reference:

Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &

Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

Escott-Stump, S. (2011). Nutrition and Diagnostic Related Care (7th ed.). Lippincott

Williams & Wilkins.

2. Esophagitis

a. Definition: Esophagitis is an inflammation of the esophagus due to a back flow of

gastric content into the esophagus.

b. Etiology: Alcohol, smoking, surgery or radiation of the chest, medications like

aspirin, tetracycline, NSAIDs (non-steroidal antiinflammatory drugs) and others,

vitamin C , pregnancy, obesity, and vomiting can increase the risk of esophagitis.

Eosinophilic esophagitis is an autoimmune disease.

c. Pathogenesis: Patients experience some of the same symptoms as patients with

GERD, like dysphagia, heartburn, and also hoarseness and a sore throat.

d. Nutritional Status: Difficult and painful swallowing can lead to inadequate food

intake and deficits.

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e. MNT: To avoid reflux the patients should be advised to avoid food that lower LES

pressure or increase gastric secretion (see above). Avoiding acidic foods and

beverages and carbonated beverages and any other food that cause discomfort for the

individual patient can help. Addressing smoking, alcohol intake, and intake of

vitamin C supplements is important.

Reference: Mukherjee, S., (May, 2011). Esophagitis Clinical Presentation. Retrieved

June 12 from http://emedicine.medscape.com/article/174223-clinical.

3. Dysphagia

a. Definition: Dysphagia is defined as difficulty swallowing. It is a symptom that can be

caused by different diseases and disorders.

b. Etiology: Dysphagia can be cause by acute neurological diseases (stroke, head

injury), chronic neurological diseases (Alzheimer's, Parkinson's disease, MS et al.),

muscule disorders, gastrointestinal diseases (GERD), cancer, aging, intubation, and

other conditions.

c. Pathogenesis: Depending on the stage of swallowing that is affected the patient can

experience different symptoms. Pocketing of food in the cheek, choking, coughing,

drooling are common. A primary concern is the aspiration of food into the lungs,

which can lead to pneumonia.

d. Nutritional Status: Food intake often does not meet the needs of the patients and this

can lead to weight loss and malnutrition.

e. MNT: National Dysphagia Diet is recommended. There are three main stages. In

NDD- 3 or "Dysphagia Advanced" only very hard, crunchy, or sticky foods are

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excluded (like nuts, seeds, hard vegetables). In NDD-2 or "Dysphagia Mechanically

Altered" allowed food is mostly soft and moist, either ground or finely diced. Dry

bread, rice, cheese cubes are not allowed. In NDD-1 or "Dysphagia Pureed" only

foods that have a pudding-like consistency are allowed. All the food is pureed and has

a smooth consistency. Fruited yogurt, peanut butter, gelatin desserts are not allowed.

Some institutions use mixes of these classifications. "Dysphagia Mixed" is NDD-1

with one mechanically altered food. "Dysphagia Soft" is NDD-2 plus bread, cake, and

rice. There is a certain terminology used to describe the consistency of liquids (spoon-

thick, honey-like, nectar-like, thin liquids). There are thickening agents and specialty

foods available for the this diet. The recommendation for the dysphagia diet is usually

made by the speech therapist. The RD makes sure the diet is followed and the the

nutritial requirements are met. An adequate intake of calories is important to maintain

weight or gain weight if the patient has lost weight. If needed the patient can be fed

enterally.

Reference:




Williams & Wilkins

4. Esophageal Varices

a. Definition: Esophageal Varices are enlarged veins in the esophagus.

b. Etiology: Esophageal Varices occur as a result of portal hypertension due to liver

diseases.

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c. Pathogenesis: Due to blocked arteries in the liver the pressure in the portal vein that

carries blood from the intestines, stomach, spleen, and pancreas to the liver increases

and blood is backed up into blood vessels in the esophagus. These enlarged veins can

rupture which can lead to serious bleeding.

d. Nutritional Status: Inadequate intake of food due to discomfort and fear of bleeding

can compromise nutritional status and lead to weight loss and deficits. Bleeding can

lead to anemia.

e. MNT: Modify diet according to underlying liver disease. Nutrition therapy should

promote healing and prevent reoccuring. Soft food and small meals are

recommended. Added fiber and foods like prune juice can help avoid constipation

and straining.

Reference:




Williams & Wilkins

5. Gastritis and Gastroenteritis -- include an explanation of the difference between these two

a. Definition:

1. Gastritis – Gastritis is the inflammation of the mucosa of the stomach.

2. Gastroenteritis – Gastroenteritis is the inflammation of lining of the stomach and

the intestines.

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b. Etiology:

1. Gastritis – Gastritis can be caused by bacteria (heliobacter pylori), autoimmune

processes, drug use (aspirin and NSAIDs), alcohol, and bile reflux.

2. Gastroenteritis – Gastroenteritis can be caused by viruses, food poisoning, toxins in

food, alcohol consumption, cathartics and drugs.

Although the symptoms can be similar, the difference is the location of the infection.

Another main difference is that gastroenteritis - if it is cause by a virus - is

contagious, gastritis is not contagious.

c. Pathogenesis:

1. Gastritis – Gastritis can be chronic or acute. Normally the mucus in the stomach, a

high turnover rate and other protective measurements keep the stomach walls healthy.

In acute gastritis the stomach mucosa gets irritated by bacteria, food poisons, alcohol

or drugs, the patient experiences pain, vomiting, and anorexia. Serious complications

are bleeding and vomiting of blood. Chronic gastritis can either be Type A, which is

an autoimmune process that causes inflammation at the fundus of the stomach, or

Type B, which is usually cause by Heliobacter pylori and causes atrophy of the

mucosa. Symptoms are mostly anorexia and pain.

2. Gastroenteritis – Gastroenteritis can cause diarrhea, nausea, vomiting, fever and

malaise.

d. Nutritional Status:

1. Gastritis – Gastritis can lead to insufficient intake of fluids and food. Dehydration

is a concern if there is persistent vomiting and inadequate intake of fluids. This is of

special concern in small children. Malnutrition is a concern if the patient is unable to

eat over a long period of time due to anorexia or fear of certain food groups. Chronic

gastritis is often seen with atrophy of the mucosa and can lead to achlorhydria.

Insufficient vitamin B12 absorption and pernicious anemia can result, as well as iron

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and calcium malabsorption.

2. Gastroenteritis – Gastroenteritis can also lead to insufficient intake of fluids and

food, and malnutrition can result if the patient is unable to eat over a long period of

time.

e. MNT:

1. Gastritis – The patient needs to consume adequate fluids and omit foods that are

not tolerated on an individual basis. B12, iron and calcium deficiencies need to be

treat, with supplements if necessary.

For chronic gastritis smaller, frequent meals of foods that are well tolerated. Restrict

alcohol.

2. Gastroenteritis – Adequate fluid intake. Rehydration solutions can be helpful.

Nothing per mouth as long as patient can not tolerate it, then progress to food as

tolerated. BRAT diet (bananas, rice, applesauce, toast) if the patient had diarrhea.

Avoid sugar alcohols, lactose, caffeine, alcohol, gas-producing food. Increase fiber

intake to Adequate Intake as tolerated.

Reference:




Williams & Wilkins

6. Ulcers – include an explanation of the difference between gastric and duodenal ulcers

a. Definition:

1. Gastric Ulcers – A gastric ulcer is a defect or break in the lining of the stomach,

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that penetrates the underlying tissue (submucosa). It usually occurs in the antrum of

the stomach.

2. Duodenal Ulcers – A duodenal ulcer is a defect or break in the lining of the

duodenum that penetrates the submucosa. It usually occurs in the first part of the

duodenum

b. Etiology:

1. Gastric Ulcers – Heliobacter pylori is a main cause of gastric ulcers (estimated to

cause 70%). Other causes are medications (NSAIDs, steroids) alcohol, excessive

glucocorticoid secretion, stress, smoking, or shock.

2. Duodenal Ulcers - Heliobacter pylori is a main cause of duodenal ulcers (estimated

to cause 92%). Other causes are the same as for gastric ulcers.

c. Pathogenesis:

1. Gastric Ulcers – The mucosa of the stomach is ulcerated and the erosion can reach

into underlying tissue and can cause a rupture. The patient experiences pain. With

gastric ulcers the pain is more common after eating.

2. Duodenal Ulcers – The mucosa of the duodenum gets ulcerated and the erosion can

reach into underlying tissue and can cause a rupture. Both kinds of ulcers can bleed,

and blood may be seen in stool or vomit. Patients complain about pain. With

duodenal ulcers the pain is more common 90 minutes to 3 hours after eating and can

be relived by food intake.

d. Nutritional Status: Abdominal pain can lead to anorexia and subsequent weight loss

and malnutrition.

e. MNT: The diet should support other medical treatments by providing adequate intake

of nutrients to promote healing (protein, vitamin C). Use small meals. Avoid any food

the patient can not tolerate (for example) citrus fruits, but these restrictions should be

made on an individual basis. Foods that increase acid production like pepper,

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peppermint, garlic, caffeine, coffee, alcohol should be restricted if the patient can not

tolerate them.

Reference:


Pathophysiology (2nd ed.). Belmont, CA: WadsworthEscott-Stump, S. (2011).

Nutrition and Diagnostic Related Care (7th ed.). Lippincott Williams & Wilkins

7. Celiac Disease

a. Definition: Celiac disease is a autoimmune disease, in which the body reacts to the

exposure to gluten. As a result the intestinal mucosa is damaged.

b. Etiology: Celiac disease is caused by a combination of genetic factors and

environmental factors that trigger the abnormal processes that occur when the patient

is exposed to gluten. Some major genes that contribute to the disease have been

identified, but not everybody with these genes has celiac disease. Exposure to

infections, short duration of breastfeeding and early exposure to gluten in infants can

also increase the risk .

c. Pathogenesis: Gluten is a protein found in wheat, rye, malt, and barley. Patients with

Celiac Disease react to the part of gluten called gliadin. Upon exposure to gluten

certain cytokines are produces that cause an inflammatory reaction, and activated T-

cells damage enterocytes. This results in an decrease in the height of the villi. There is

a decrease in absorptive surface area and digestive enzymes as a result which can lead

to malnutrition. The patient can experience abdominal discomfort with cramping,

bloating, gas, pain, and diarrhea. Other syptoms can include muscle and joint pain,

fatigue, skin rashes and others. Patients with other autoimmune diseases like thyroid

disease, diabetes type I, lupus et al., as well as patients with unexplained iron

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deficiency, Down's syndrom, abnormal liver function should be tested for CD since

those conditions often occur together.

d. Nutritional Status: The decrease in absorptive surface area can lead to malnutrition,

weigth loss and deficiencies (especially iron, folate, calcium and vitamin D). Due to

protein breakdown the patient can suffer from protein-energy malnutrition. In

children and adolescents growth and development can be stunted.

e. MNT: A lifelong gluten-free diet modification is recommended. The patient needs to

avoid all foods that can contain gluten (wheat, rye, barley, and everything produced

with these grains). Patients need to be thoroughly educated about processed foods that

can contain gluten, like dressing, soups, processed meats, and about appropriate

alternative grain products. Oats contain a similar protein as wheat, but this can often

be tolerated, if the oats are otherwise gluten-free, and a gluten-free diet is established.

Secondary lactose intolerance often occurs when the villi are damaged and therefor

the diet needs to be lactose-free at the beginning.

Reference:




Williams & Wilkins

8. Lactose Intolerance

a. Definition: Lactose intolerance is the inablility to digest the disaccharide lactose, due

to insufficient levels of the enzyme lactase in the small intestines.

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b. Etiology: In a majority of the world population the activity of lactase decreases in

adulthood. Only in Europe and in people of European descent lactase often remains

active into adulthood. Lactose intolerance can also be secondary due to an underlying

gastrointestinal disease like celiac disease, inflammatory bowel diseases, or others.

c. Pathogenesis: When lactase activity is not sufficient, lactose can not be digested and

absorbed. It moves to the large intestines and causes pain, diarrhea, bloating and gas

production.

d. Nutritional Status: If symptoms of diarrhea and vomiting are severe and a diagnosis is

not made for some time, malnutrition, weight loss and deficiencies may occur. If

young children have lactose intolerance and are not treated growth may be

compromised.

e. MNT: A restriction of milk and dairy intake is recommended. Some patients tolerate

small amounts of milk and sometime a slow increase in the consumption of dairy can

increase tolerance. Cheese and yogurt are often better tolerated because lactose levels

are lower than in milk itself. Enzyme supplements ("Lactaid") can be taken before

meals to help with digestion. Patients who avoid milk and dairy should be educated

about other calcium-rich foods (fish with bones, green vegetables, dried beans,

fortified foods).

Reference:




Williams & Wilkins

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9. Irritable Bowel Syndrome

a. Definition: Irritable Bowel Syndrome is the occurrence of abdominal pain and

discomfort that occur together with diarrhea or constipation or both over a period of

at least three month.

b. Etiology: The etiology of Irritable Bowel Syndrome is multi factorial. Some of the

factors that can contribute are genetic predisposition, an prolonged and altered

response to gastrointestinal infections, food sensitivities, altered microbial

environment, small intestinal bacterial overgrowth, increased sensitivity of the

nervous system that results in altered motility, and abnormal serotonin metabolism.

c. Pathogenesis: There are three subgroups of IBS: IBS-D, with predominantly diarrhea;

IBS-C, with predominantly constipation, and IBS-M, with diarrhea and constipation.

Other than the common sypmtoms of pain and diarrhea/constipation the patient can

have fever, rectal bleeding, anemia, and weight loss. The pathophysiology of IBS is

not fully understood but it is thought that an alterations in neurological and hormonal

processes result in altered motility and subsequent symptoms.

d. Nutritional Status: Due to abdominal pain, and other symptoms, nutritional intake can

be insufficient and weight loss can occure. Many patients with IBS link their

symptoms to allergies and intolerances. Avoidance of food groups can result in

malnutrition and deficiencies in vitamins and minerals.

e. MNT: Therapy should be matched to the patients symptoms with the goal of

normalizing eating patterns and providing adequate nutrition. If constipation is

predominant an increase in fiber (as tolerated), adequate fluids and exercise can be

helpful. For all patients fiber should be adequate, but in acute phases a low-fiber diet

may be needed. A food diary is useful to find individual trigger foods and identify

abnormal eating patterns. To find individual food sensitivities an elimination diet can

be useful. It can be useful to eliminate fermentable oligosaccharides, disaccharides,

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monosaccharides and sugar alcohols (FODMAPs), these food contribute to

fermentation and can possible lead to IBS symptoms. Probiotis are another helpful

tool for the therapy of IBS but there are no general recommendation. If gas

production is a particular problem patients should be educated about avoiding gas-

producing food and other measures to decrease gas production, like eating slowly,

avoiding straws, gum, smoking. Over-the-counter medications like "Beano" and

"Lactaid" might also be useful with gas-production from vegetables, beans, and dairy.

Reference:




Williams & Wilkins

10. Constipation

a. Definition: Constipation are bowel movements that are less frequent than normal and

hard to pass.

b. Etiology: In general constipation occurs when the fecal mass moves too slowly

through the colon. This can be due to obstruction, pelvic floor dysfunction, or irritable

bowel syndrome. Constipation can also be secondary as a result of neurological

disorders like MS or Parkinson's, scleroderma or amyloidosis. It can also be a side

effect of medication or supplements.

c. Pathogenesis: Bowel movements are infrequent, stool is hard and patients strain

during defecation. Other symptoms are pain, bloating, and gas production.

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d. Nutritional Status: Constipation has usually no significant impact on nutritional

status.

e. MNT: Patients should consume adequate amounts of fiber (Adequate Intake is 24 g

per day for women and 38 g per day for men) together with adequate fluid and

exercise. If fiber intake is low it should be increased gradually to avoid discomfort.

Fiber should be consumed in form of fruits, vegetables, whole grains, nuts, and seeds.

If that is not possible fiber supplements can be used.

Reference:




Williams & Wilkins

11. Ileus

a. Definition: The forward movement of the bowel is decreased, usually without an

obstruction.

b. Etiology: Ileus occurs most often after abdominal surgery, but also as the result of

inflammation, trauma, metabolic changes, and drugs.

c. Pathogenesis: Due to the underlying cause the muscle of the bowel wall do not propel

the content of the intestines forward and as a result fluids and gas accumulate. If ileus

occurs after abdominal surgery, motility in the small intestines returns to normal

fairly quickly, the colon may show little or no peristalsis for 2 or 3 days. Patients may

experience discomfort, abdominal distention, and vomiting.

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d. Nutritional Status: Malnutrition only occurs if symptoms, especially vomiting is

severe and persist over a long time without treatment. Catabolism is enhanced

because nutritional intake postoperative is usually low.

e. MNT: NPO (nothing per mouth) until motility returned was the traditional treatment.

Enteral feeding can be done with caution, that means with low strength and small

rate. Chewing gum can help increase motility.

Reference: Mukherjee, S. (April, 2011), Ileus Treatment and Management. Retrieved

June 12, 2012, from http://emedicine.medscape.com/article/178948-treatment#a1130.

12. Ileostomy

a. Definition: Ileostomy is a surgical procedure in which the large intestines (colon,

rectum, anus) are removed and an opening to the outside of the body is formed from

the ileum. Through this artificial opening waste is removed from the body.

b. Etiology: Ileostomy is the result of resection of the colon due to a disease of the lower

GI tract, like Crohn's disease, ulcerative colitis, cancer, or diverticulitis.

c. Pathogenesis: Because the colon is removed the patient looses the function the colon

usually has, which is removal of fluid and minerals from the feces, removal of waste,

and absorption of some vitamins.

d. Nutritional Status: If the ileocecal valve is removed in the process, motility is

increased and this results in fluid, vitamin and mineral deficiencies. If the valve can

be preserved the impact is less severe.

e. MNT: After surgery the patient is transitioned from a liquid diet to a low-residue diet

to a normal diet. Adequate energy and protein is needed to help with wound

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healing.The amount of insoluble fiber should be reduced and soluble fiber increased

to help with large stool volume and watery stools. The patients needs to avoid

anything that causes gas (chewing gum, using straws, eating to quickly, carbonated

beverages, smoking) to reduce odor and inflation of the bag. To further reduce odor

the patient can add parsley, buttermilk, yogurt et.al to the diet. The patient should

consume foods that thicken the stool like banana flakes, applesauce, tapioca, oatmeal,

rice and pasta. Vitamins of concerns are vitamin K and B12, supplements may be

needed, a multivitamin is often recommended. Additional fluids might be needed to

avoid dehydration

Reference:




Williams & Wilkins

13. Colostomy

a. Definition: Colonostomy is a surgical procedure in which the lower part of the large

intestines (rectum, anus) are removed and an opening to the outside of the body is

formed from the colon. Through this artificial opening waste is removed from the

body.

b. Etiology: Colonostomy is the result of resection of the colon due to a disease of the

lower GI tract, often cancer, but also diverticulitis, perforations, after radiation, and

with Hirschsprung's disease.

c. Pathogenesis: Because the opening is formed lower than with Ileostomy stool output

is generally more formed. Stool can be collected in a bag or directly in the colon and

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removed from there.

d. Nutritional Status: Since fluid and electrolytes can still be absorbed the nutritional

impact is not as severe as with an ileostomy. Depending on the location of the stoma

the stool is more or less formed.

e. MNT: After surgery the patient is transitioned from a liquid diet to a low-residue diet

to a normal diet. Adequate energy and protein is needed to help with wound healing.

The patients needs to avoid anything that causes gas (chewing gum, using straws,

eating to quickly, carbonated beverages, smoking) to reduce odor and inflation of the

bag. To further reduce odor the patient can add parsley, buttermilk, yogurt et.al to the

diet. Depending on the amount of the remaining colon, dehydration might be a

problem. Adequate fluid intake is important.

Reference:




Williams & Wilkins

14. Fistula

a. Definition: A fistula is an abnormal pathway between the two organs or an organ and

the outside of the body. In case of an intestinal fistula this connection is between the

intestines and nearby organs, for example the bladder.

b. Etiology: Fistulas can occur after abdominal surgery, cancer, trauma or inflammatory

bowel disease.

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c. Pathogenesis: A fistula can result a large fluid and electrolyte loss. Sepsis can occur

and can be deadly.

d. Nutritional Status: Fluid and electrolyte balance can be disturbed due to high losses.

Energy and protein requirements are high and when they are not met the patient can

become malnourished. Hypertriglyceridemia can often be seen, often as a result of

enteral nutrition therapy.

e. MNT: Nutritional support needs be be aggressive to promote healing. Enteral

nutrition is often necessary. To promote a positive nitrogen balance high amount sof

protein are needed (2g/kg).

Reference:




Williams & Wilkins

15. Cholelithiasis

a. Definition: Cholelithiasis is the presence of stones in the gallbladder.

b. Etiology: Obesity, diabetes, inflammatory bowel disease, cystic fibrosis, pregnancy,

rapid weight loss, fat restricted diets, bariatric surgery, medications, and biliary stasis

as a result of enteral nutrition or short bowel syndrome can be risk factors for

gallstones.

c. Pathogenesis: Gallstones can either consist of primarily cholesterol (80%), primarily

pigment or a mix of both. Cholesterol can crystallize when the bile that is stored in

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the gallbladder becomes supersaturated with cholesterol or the composition of of bile

is imbalanced. The stones cause severe pain, vomiting, bloating, indigestion and an

intolerance for fatty foods.

d. Nutritional Status: If bile can't reach the small intestines, fat-malabsorption is the

result.

e. MNT: In an acute gallbladder attack the patient should have nothing by mouth to

keep the gallbladder inactive (parenteral nutrition as needed). A low-fat diet with

small frequent meals helps to control symptoms pre surgery.

After surgery patients advance to low-fat liquids and then to a low- fat diet for a short

time. Since fat absorption is compromised patients need a water-soluble form of

vitamin A, D, E and K. If the patient experiences diarrhea after surgery fiber can help.

To avoid reoccurance the patient should be encouraged to lose weight if obesity is

pressed, but rapid weight loss and starvation should be avoided.

Reference:




Williams & Wilkins

16. Cholecystitis

a. Definition: Cholecystitis is an inflammation of the gallbladder.

b. Etiology: Cholecystitis is usually a secondary condition. The reason can be

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obstruction of the gallbladder with stones (most common), infection, or ischemia.

c. Pathogenesis: In most cases a gallstones blocks the cystic duct or irritates and scars

the gallbladder and this results in the inflammation of the gallbladder. It can become a

chronical condition.

d. Nutritional Status: If not enough bile can be released by the gallbladder fat-

malabsorption is the result.

e. MNT: Since most gallbladder inflammations are caused by gallstones, the MNT is the

same.

Reference:




Williams & Wilkins

17. Steatorrhea

a. Definition: Steatorrhea is the malabsorption of fat, which results in fat in the stool.

b. Etiology: Cystic fibrosis, pancreatitis, pancreatic cancer, gastrectomy, blind loop

syndrome, Crohn's disease, and HIV are some of the most common causes for fat in

the stool.

c. Pathogenesis: If any part of the fat digestion is compromised this can lead to fat

malabsorption. This could be insufficient production of enzymes, insufficient

production or storage of bile, or increased motility in the GI tract. Fat is not absorpt

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and remains in the stool. This leads to abdominal pain, diarrhea, cramping, and

frothy, foul smelling stools. Calcium can bind to fat instead of oxalate in the

intestines. This can lead to increased oxalate absorption and oxalate kidney stones.

d. Nutritional Status: Since fat is not absorbed this can lead to malnutrition, especially if

pain and abdominal discomfort leads to inadequate intake of food. Fat-soluble

vitamins are also not absorbed and can become deficient.

e. MNT: Fat in the diet should be restricted to 25 to 50 g/d. Choose low-fat protein

sources and complex carbohydrates; these might be better tolerated than simple

carbohydrates. MCT supplements can be used, these are absorbed directly. Fat-

soluble vitamines need to be supplemented, as well as other micronutrients that are

lost because of diarrhea. For severe cases enteral or parenteral feeding is necessary.

Reference:



18. Diarrhea – in sections b. and c. include the difference between osmotic, secretory, and exudate diarrhea.

a. Definition:

1. Osmotic – Osmotic diarrhea is the increase of water content in the stool as a result

of an increase in osmotically active particles in the stool. Frequency can also be

increased.

2. Secretory – Osmotic diarrhea is the increase in volume and/or frequency of stools

due to secretion of water into the stool in response to an infection.

3. Exudate – Exudate diarrhea is the increase of frequency and/or volume due to an

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injury to the small intestines.

b. Etiology:

1. Osmotic – Osmotic diarrhea is often caused by carbohydrate intolerance, but also

by laxatives and enteral feeding.

Diarrhea can also be caused by stress or anxiety that can lead to increased motility.

2. Secretory – Secretory diarrhea can be caused by bacteria, viruses, bile acids,

protozoa, medication (antibiotics and others), Crohn's disease, Colitis ulcerosis, AIDS

and other conditions.

3. Exudate – Exudate diarrhea is caused by an injury to the small intestines that

results in inflammation or ulceration.

c. Pathogenesis:

1. Osmotic – Carbohydrates can not be fully digested either due to lack of enzymes,

or an overload the body can not handle. These particles have a higher osmolality and

pull water into the intestines. The result are more frequent, watery stools. NPO results

in improvement of the diarrhea.

2. Secretory – In secretory diarrhea there is also an increase in water in the intestines,

but the water here is secreted into the intestines as a response to - for example - a

bacterial infection. Mucus and/or blodd can be found in the stool. This type of

diarrhea does not improve by NPO.

3. Exudate – In exudate diarrhea water and electrolytes can not be properly absorbed

due to the inflammatory response to an injury. Mucus, serum protein and blood are

also released into the bowel.

d. Nutritional Status: The primary concern in diarrhea is dehydration. If diarrhea is

persistent or becomes chronic (longer than 1 month) weight loss is possible and

malnutrition is also a concern. Diarrhea in early childhood can lead to serious

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dehydration very quickly and children can become malnourished.

e. MNT: Dehydration needs to be addressed first, oral rehydration solutions can be used

to ensure adequate fluid and electrolyte intake. If the cause of the diarrhea is nutrition

related (for example celiac disease, excessive intake of fructose in juices or high

intake of sorbitol) this needs to be addressed. BRAT diet (bananas, rice, applesauce,

toast) is usually well tolerated. Transition from there to a normal diet as tolerated.

Beverages with high sugar content should be avoided, as well as sugar alcohols,

caffein, and alcohol should be avoided as well as gas-producing foods. To thicken the

stool resistant starches and soluble fiber can be used. Probiotics and prebiotics are

useful to restore the normal gut flora, help the immune system in the intestines, and

can reduce harmful bacteria.

Reference:

Lever, D.S., Soffer, E. (August 2010). Acute Diarrhea. Retrieved June 12

fromhttp://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/

gastroenterology/acute-diarrhea/




Williams & Wilkins

19. Clostridium difficile (C.diff) infection

a. Definition: Infection with the bacterium Clostridium difficile.

b. Etiology: After the use of antibiotics the intestines are overpopulated by C. diff.

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c. Pathogenesis: Antibiotics can destroy the normal flora in the intestines and

Clostridium difficile can overpopulate the intestines causing watery diarrhea with or

without blood, pain, cramping, and fever. The bacterium can already be normal part

of the gut flora or it can be picked up in a hospital setting.

d. Nutritional Status: see Diarrhea

e. MNT: See Diarrhea. It is especially important to restore a healthy flora in the

intestines with probiotics and prebiotics.

Reference:


Williams & Wilkins

20. 20. Diverticulosis and diverticulitis – include the relationship between these conditions in b. and c. Note: the diet recommendations differ, and please include the progression of the diet during the acute and recovery phase of diverticulitis as well as the diet for diverticulosis.

a. Definition:

1. Diverticulosis – Abnormal pockets in the surface of the small or large intestines.

2. Diverticulitis – Inflammation of diverticulas.

b. Etiology:

1. Diverticulosis – Dietary habits, especially low fiber intake, can lead to

diverticulosis. Other risk factors are obesity, sedentary life style, steroids, alcohol

intake, and smoking.

2. Diverticulitis – Diverticula become infected when something is trapped in the

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outpockets.

Relationship Between the Two – Diverticulitis can only occur if diverticulosis is

present.

c. Pathogenesis:

1. Diverticulosis – Low fiber intake can lead to hard, compact feces, that can put

pressure on the colon walls and lead to constipation. Patients usually don't experience

symptoms. Diverticula are most often detected during a colonoscopy.

2. Diverticulitis – Stool content and bacteria can become trapped in the pockets and

cause inflammation. The patient will experience fever, abdominal pain, and

gastrointestinal bleeding. Diverticulitis can lead to bowel obstruction, fistulas, or

perforations.

Relationship Between the Two – Feces moves through the colon slowly and becomes

compacted and trapped. This causes small pockets to develop. If fecal matter and

bacteria get trapped in those pouches, the intestinal mucosa can become inflammed

and infected.

d. Nutritional Status: Diverticulosis does not usually effect nutritional status. If

diverticulitis is persistent, abdominal pain can lead to poor food intake.

e. MNT:

Progression of Diet for Diverticulosis

Acute – Low-fiber diet with soft food, low-fat diet might be better tolerated.

Recovery Phase – Modify diet to increase fiber intake to at least 25 - 35 g, or

even a high-fiber diet with 6 to 10 g more. Patients need to make the transition

to a high-fiber diet slowly and need to take in enough fluids to help with

tolerance. If the patient can not met the fiber recommendation a supplement can

be used.

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Progression of Diet for Diverticulitis:

Acute – NPO until acute symptoms are gone. Then progression to clear liquids.

Recovery Phase – Progression from soft low-fiber diet to a diet with high fiber

content. A low-fat diet might be better tolerated. Progression needs to be slow

and adequate fluids are important.

Reference:




Williams & Wilkins

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21. . Using the a. - e. criteria above, compare and contrast ulcerative colitis and Crohn’s disease.

Ulcerative Colitis Crohn’s Disease

a. Definition: Ulcerative Colitis is an autoimmune inflammatory bowel disease. Only the colon is affected.

Definition: Crohn's disease is an autoimmune, inflammatory bowel disease. Any part of the GI tract can be affected.

b. Etiology: Genetic susceptibility and environmental factors play a role in the development of UC. Onset usually between 20 and 30 years, second peak between 50 and 70 years.

Etiology: Genetic susceptibility and probably environmental triggers (smoking, allergies). Onset is usually between 15 and 30 years.

c. Pathogenesis: The immune system attacks the mucosa of the colon, resulting in inflammation, atrophy, and dysplasia. The mucosa becomes very thin and a toxic megacolon can develop. Patient experiences bloody diarrhea, fever, tachycardia, and pain. Symptoms can be outside the intestines, like skin rash and arthritis.

Pathogenesis: Any part of the mucosa of the GI tract can be attacked and become inflammed, it gets a "cobblestone" look. The resulting diarrhea can be chronic with/without blood and mucus. Patients can be anorexic, have fever, and experience cramping and pain. Fistulas can develop.

d. Nutritional Status: Diarrhea can lead to maldigestion and malabsorption. Weight loss and nutritional deficiencies are common. If children have UC growth and development can be compromised.

Nutritional Status: Diarrhea can lead to maldigestion and malabsorbtion. Weight loss and nutritional deficiencies are common. If children have UC growth and development can be compromised.

e. MNT: In acute phases energy and protein requirements are increased (stress factor of 1.3 - 1.5 in the Mifflin-St.Jeor equation for energy and 1.5 - 1.75 g/kg for protein). If needs cannot be met orally, enteral nutrition is needed.Fluid and electrolyte balances need to be addressed. To reduce stool volume a low-fiber diet is recommended.If oral feeding is tolerated the diet should be low-fiber (to decrease stool volume) and lactose free. Fat should be reduced if

MNT: In acute phases energy and protein requirements are increased (stress factor of 1.3 - 1.5 in the Mifflin-St.Jeor equation for energy and 1.5 - 1.75 g/kg for protein). If needs cannot be met orally, enteral nutrition is needed.Fluid and electrolyte balances need to be addressed. To reduce stool volume a low-fiber diet is recommended.If oral feeding is tolerated the diet should be low-fiber (to decrease stool volume) and lactose free. Fat should be reduced if

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steatorrhea is present and MCT oils can be used. Glutamine supplementation promotes healing .Micronutrients need to be supplemented to replace losses and promote healing. Patients should receive a multivitamin and additional zinc, calcium, magnesium, and copper is recommended.Other foods helpful to avoid during exacerbation are spicy food, caffeine, gas-producing food, and carbonated beverages.When patients are in remission fiber can slowly be increased and lactose and other foods the patient has avoided can be reintroduced on an individualized basis with small, frequent meals. During remission the patient should take in adequate energy to promote weight gain, if there was weight loss. The patient should be encouraged to eat a healthy diet with antioxidants, omega-3 fatty acids, pre- and probiotics.Intolerances against lactose or gluten can still be present and the diet should take all individual intolerances into account.

steatorrhea is present and MCT oils can be used. Glutamine supplementation promotes healing.Micronutrients need to be supplemented to replace losses and promote healing. Patients should receive a multivitamin and additional zinc, calcium, magnesium, and copper is recommended.Other foods helpful to avoid during exacerbation are spicy food, caffeine, gas-producing food, and carbonated beverages.When patients are in remission fiber can slowly be increased and lactose and other foods the patient has avoided can be reintroduced on an individualized basis with small, frequent meals. During remission the patient should take in adequate energy to promote weight gain, if there was weight loss. The patient should be encouraged to eat a healthy diet with antioxidants, omega-3 fatty acids, pre- and probiotics.Intolerances against lactose, gluten can still be present and the diet should take all individual intolerances into account.

Reference:Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy & Pathophysiology (2nd ed.). Belmont, CA: WadsworthEscott-Stump, S. (2011). Nutrition and Diagnostic Related Care (7th ed.). Lippincott Williams & Wilkins

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22. Dumping syndrome

a. Definition: A large amount of food from the stomach with high osmolality enters the small intestines.

b. Etiology: Occurs after gastric surgery when the volume of the stomach is reduced and can no longer store large amounts of food.

c. Pathogenesis: The food that enters the small intestines has a higher osmolality and draws fluids into the bowel. This has different consequences. 10 to 20 minutes after eating pain, cramping, hypermotility and diarrhea can occur, together with dizziness and tachycardia due to the rapid fluid changes. This is called early dumping syndrome. A little later it comes to fermentation of the food stuff with gas production in the colon. The patient will experience more pain, cramping, and diarrhea. This is the intermediate dumping syndrome and occurs 20 - 30 minutes after eating. The late dumping syndrome is caused by fast digestion of carbohydrate and the subsequent insulin response. This results in late hypoglycemia 1 - 3 hours after eating.

d. Nutritional Status: Due to the rapid transport through the intestines it can come to maldigestion and malabsorption followed by weight loss. Steatorrhea can be present and fat-soluble vitamins are not adequately absorbed.

e. MNT: After gastric surgery the patient should transition to solid food slowly. Initially all simple sugars should be avoided. If clear liquids are given those need to be free of simple sugars, including lactose. Later meals should be small and frequent. Liquids should be consumed in between meals. To delay gastric emptying fiber can be added to the diet. The patient should lay down after eating. A multivitamin should be given, and special consideration need to be given to vitamin B12 (depending on the gastric surgery vitamin B12 shots may be necessary).

Reference:Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy & Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

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D.) NUTRITION PRESCRIPTIONS

For each of the following:a Describe the diet in detail. Be specific – think about how you would instruct a client/patient.b Explain the when the diet would be used and the pathophysiological response to the diet. (How

should the diet improve the condition?)c NOTE: The Nutrition Care Manual and the EAL may indicate that some of these diets are

obsolete. No matter. They are still used and they are still relevant, You will learn that in some cases a doctor’s (and RD’s!) years of practical experience trumps “lack of evidence” especially when that lack of evidence is because there simply hasn’t been enough research done.

1. Low Residue

Description The diet is low in fiber and anything that adds bulk. This means the patiens needs to avoid whole grain products, fruits and vegetables with tough skin, nuts, seeds, tough cuts of meats, legumes, fruit juices with pulp.

Response The diet should limit the amount of stool that is produced and the frequency of bowel movements to give the intestines time to heal.

2. Low Fiber

Description The diet is low in fiber (usually 10 - 15 g). The diet is not as restrictive as a low-residue diet. The patient needs to avoid foods with a lot of fiber like whole grain products, bran cereal, fruits and vegetables with tough skin.

Response The diet should limit the amount of bowel movements.

3. High Fiber

Description Diet is rich in fiber, usually 6 to 10 g more than the Adequate Intake recommendation. The patients should consume whole grain products, plenty of fruits and vegetables (if possible with skin), legumes, nuts, and seeds.

Response Increase stool weight to normalize bowel movements.

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4. NPO

Description The patient should consume nothing by mouth.

Response The GI tract can rest.

5. Clear Liquids

Description The diet contains only liquids that don't add bulk to the GI tract. The diet can include water, fruit juice (no pulp), coffee, tea, broth, popsicles, Jell-O, and certain liquid supplements for nutrition support.

Response The diet provides fluids, electrolytes, some calories and vitamins without stressing the GI system. Usually used as a transition from NPO to a more normal diet.

6. Full liquids

Description The diet contains all foods and beverages that are liquid at room temperature. In addition to everything that is allowed under the clear liquid diet, the patient can have custard, ice cream, yogurt, strained soup, cream, oil, and butter.

Response The diet adds little bulk to the GI tract but can provide fluids, electrolytes, minerals and vitamins. It is higher in calories than a clear liquid diet and the patient can consume this diet over a long period if all nutrition requirements are met.

7. Gluten-free

Description The diet is free of gluten and all products that are made with gluten. Gluten can be found in wheat, rye, barley and malt. It is important not only to avoid those grains, but also everything that is made from them. It is also important to check all processed foods for their ingredients or chose certified gluten-free products.

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Response Patients who have celiac disease or are sensitive to gluten should experience improvement of their symptoms. Inflammation in the intestines can heal and villi return to their normal size.

8. Low lactose

Description Diet is low in lactose (sugar found in milk, dairy and othe products). The amount of lactose is limited to a level the patient can tolerate. Small amounts of lactose in milk, yogurt, and cheese might be tolerated.

Response Patients with lactose intolerance (primary or secondary) should experience improvement of their symptoms.

9. 50 g Fat

Description This is considered a low-fat diet. 50 g of fat provide 450 kcal. In a 2000 kcal diet this is below the AI of 25 - 35 % of calorie intake from fat. The patients needs to avoid foods that are high in fat like fried foods, dairy products with a high fat content, high-fat meat products

Response The diet is prescribed to avoid or improve fat malabsorption in different diseases. Steatorrhoe and the associated discomfort should improve and absorption of fat and fat-soluble vitamins should improve.

10. Six Small Feedings

Description Six small meals are spread out over the day.

Response Smaller more frequent meals improve nutritional intake if patients can not tolerate big meals.

11. Dysphagia Diet

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Description There are three main stages in the dysphagia diet. In NDD- 3 or "Dysphagia Advanced" only very hard, crunchy, or sticky foods are excluded (like nuts, seeds, hard vegetables). In NDD-2 or "Dysphagia Mechanically Altered" allowed food is mostly soft and moist, either ground or finely diced. Dry bread, rice, cheese cubes are not allowed. In NDD-1 or "Dysphagia Pureed" only foods that have a pudding-like consistency are allowed. All the food is pureed and has a smooth consistency. Fruited yogurt, peanut butter, gelatin desserts are not allowed. Some institutions use mixes of these classifications. "Dysphagia Mixed" is NDD-1 with one mechanically altered food. "Dysphagia Soft" is NDD-2 plus bread, cake, and rice. There is a certain terminology used to describe the consistency of liquids (spoon-thick, honey-like, nectar-like, thin liquids). There are thickening agents and specialty foods available for the this diet.

Response The diet should prevent choking and aspiration of food in patients who have problems swallowing.

References for this section: Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy & Pathophysiology (2nd ed.). Belmont, CA: WadsworthEscott-Stump, S. (2011). Nutrition and Diagnostic Related Care (7th ed.). Lippincott Williams & Wilkins

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12. Your patient is hospitalized with a diagnosis of acute, necrotic diverticulitis. He is now two days post-op from a bowel resection, and his diet order is clear liquids. The surgeon has warned the patient that he could develop new diverticulum if he does not improve his diet.

The patient is requesting nutrition education to prevent a re-occurrence. Typical intake is shown below. Plan some sample meals to meet the patient’s nutrient needs. Explain your rationale and calculations for kcals, protein, fat, fiber, and fluids.

Your patient is a 43 year-old male, 5’8” tall, 185#. He has a sedentary job, sales for the local Verizon cell phone store. His lunch consists of fast food five days a week.

Typical Intake Sample Menu Recommendation

Breakfast:Dunkin’ Donuts large coffee, cream and sugar

Breakfast:1 multigrain bagel1 container cream cheese1 apple1 small cup coffee

Dunkin’ Donuts plain bagel with 2 cream cheese packets

Snack:1 container plain yogurt with ½ cup cheerios and ½ cup blueberries

1 fried egg (occasionally)

Lunch:Whopper with Cheese

lunch:Fast food salad with grilled chickensmall fries

Large French Fries

Large Diet Coke Snack:5 whole wheat cracker with 1 tbsp peanut butter and 1 pear

Dinner: Dinner:

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Large chicken breast (6 ounce) chili con carne with beans (1 cup)with cooked bell peppersand ½ cup cooked brown rice

Baked potato with butter and sour cream

throughout the day:10 8oz glasses of water or other beverages without additional calories (herbal tea)

Iceberg lettuce with shredded carrots, cucumber slices, tomato quarters, Ranch dressing

24 ounce pre-sweetened iced tea

HS Snack: 1 cup of Ben & Jerry’s Chunky Monkey ice cream

Nutrient Analysis (typical intake): Calories: 4211 kcal, Protein: 117g, Fat:198 g (42% of kcal) , Fiber: 20g , Fluid: 72 ozNutrient Analysis (your suggestions): Calories: 1830, Protein: 90 g, Fat: 51 g (25% total kcal) , Fiber: 42g , Fluid: 2000 ml

Rationale: I calculated the Energy Requirement (Mifflin-St.Jeor formular) with Desirable Body Weight (70 kg +/- 10%) and an activity factor of 1.2 as approximately 1878 kcal. He needs about 56 g protein and his fat intake should be 25 - 30 % of total kcal to keep it on the lower side for better tolerance. The patient should progress from clear liquids to a soft low-fiber diet. From there he should progress to a high-fiber diet to avoid reoccurance. The Sample Menu is planned for well into the recovery phase. It contains about 1830 kcal which should promote weight loss (patient has a BMI of 28.3 and is overweight). His protein needs are well met. The fat intake is with 25% on the low side and can be adjusted up as tolerated and within staying in his kalorie limits. His fiber intake is with 42 g above the AI and his fluid intake should be about 2 l. The components of the meal were chosen to make it easy for him to find food on the go. He might not be willing or able to do anything else than fast food, but I certainly would show him other options, too, which he could bring from home.

References for this section: MyPlate Food Tracker, retrieved June 15th from https://www.choosemyplate.gov/SuperTracker/default.aspxNelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy & Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

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13. Your client is a 60 year old man, Don, 5’6” tall, 240#, who has a sedentary lifestyle. His physical activity is limited by painfully arthritic knees. He has been suffering from acid reflux for several years, which he self-treats with OTC Nexium. Lately he is finding less relief from the OTC Nexium. His MD has made a referral for MNT to help Don with dietary changes to relieve his discomfort.

Typical intake is shown below. Plan some sample meals to meet the patient’s nutrient needs. Explain your rationale and calculations for kcals, protein, fat, fiber, and fluids.

Typical Intake Sample Menu Recommendation

Breakfast:Large cup of black coffee

Breakfast:1 cup cooked oatmeal (old fashioned)1 cup milk, 1% fat½ cup blueberries1 tbsp. oil in oatmeal

8 ounces of orange juice

2 fried eggs with white toast, butter and strawberry jam

Snack:1 slice whole wheat bread1 pear

Lunch:3 ounces of bologna on 2 slices of white bread with mustard

Lunch:2 slices whole wheat bread2 slices chicken breast, mustard1 cup salad with vegetables1 tbsp. dressing1 bag baked potato chips

3 ounce potato chips

16 ounce Diet Pepsi Snack:1 apple1 tbsp. peanut butter

Dinner:Large piece of fried chicken (6

Dinner:3 oz salmon

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ounce) 1 cup cooked carrots1 cup brown rice2 tbsp. cooking oil1 cup milk, 1%

1 cup of mashed potatoes made with butter and whole milk

1 cup of canned corn

16 ounce Diet Pepsi

HS Snack: Slice of chocolate cake and a glass of whole milk

Throughout the day: uncarbonated beverages without additional calories (water and herbal tea) 7 - 8 8oz glasses.

Nutrient Analysis (typical intake): Calories: 2678 kcal, Protein: 96 g, Fat: 136 g (45 % of total kcal), Fiber: 16g, Fluid: 64 ozNutrient Analysis (your suggestions): Calories: 1755 kcal, Protein: 61 g, Fat: 46 g (23% of total kcal), Fiber: 33 g , Fluid: 1800 cc

Rationale: The patients has a BMI of 38.6 and is obese. Weight loss is first priority of the meal planning. It would also be good to find out his individual trigger foods. In general he should avoid chocolate, high-fat/fried food, alcohol, coffee, pepper, carbonated drinks, acidic foods. He should increase dietary fiber and I would work with him to find appropriate physical activities (maybe swimming). He should remain upright after eating and raise the head of his bed. I calculated the Energy Requirement with Desirable Body Weight (64.5 kg +/- 10%) and an activity factor of 1.2 as approximately 1680 kcal. He needs about 52 g protein and his fat intake should be 25 - 30 % of total kcal to keep it on the lower side.In the sample meal the calories are 1755 kcal, protein is well met, fat is with 23 % of total kcal on the low side and can be even a little higher if tolerated. Fiber intake is 33 g and his fluid needs of about 1700 cc are well met.The sample day contains 5 smaller meals and this should help with his symptoms.

References for this section: Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy & Pathophysiology (2nd ed.). Belmont, CA: WadsworthMyPlate Food Tracker, retrieved June 15th from https://www.choosemyplate.gov/SuperTracker/default.aspx

E. NUTRITION RELATED TOPICS

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Please answer all using your own words.

Obesity

1. Discuss the health concerns related to obesity:

Obesity is a serious health concern because it increases the risk for diabetes, hypertension,

cardiovascular disease, hyperlipidemia, gallstones, acid reflux, diverticulitis and more. It is

associates with an increased risk for some types of cancer. Obesity can also lead to

infertility and to problems during pregnancy and delivery. An increased weight can put

stress on the scleletomuscular system and make mobility difficult. Aside from these

physical health problems obesity can lead to psychological problems. Because we live in a

society where “skinny” is the ideal, obese indivuals can feel guilty, insecure, depressed, and

have low self-esteem.

References for this section: Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy & Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

2. Discuss your opinion about Health at Any Size:

The approach Health at Any Size tries to shift the focus away from conventional dieting and

weight loss. The focus is healthy eating and enjoyable physical activity. The goal is a

healthy body that can still be heavy. I think it is a great approach because it takes the focus

away from the "scale"and emphazise the ultimate goal of weight loss, which is health. Many

patients who have been through a lot of diet and subsequent weight gain periods have a hard

time losing weight and it often takes an unrealistic low energy intake to get them to a

"healthy BMI". Low self esteem and self worth is often a consequence when patients

"follow all the rule", exercise even though they don't enjoy it, and they still can't lose

weight. The goal seems to be unreachable. But if the goal is to be healthy even in a heavier

body this can increase self-esteem and can in turn lead to a healthier life style because

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patients might not eat because of frustration and low self esteem.

Note: The above is NOT a trick question. As a professional you will be asked about topics that may be controversial. You need to know something about the topic, and you should begin forming a personal perspective on these topics. As you gain life experience you will find that your opinions will change – that’s good! The intention here is to get you thinking about it. No right or wrong answer, just be able to defend your position.

FIBER

1. Compare and contrast soluble and insoluble fibers. Describe:a. How they function in the body, including their

health benefits. Be specific about the differences.

b. What are the suggested daily intakes of soluble and insoluble fiber?

c. Give 4 examples of foods rich in this type of fiber.

Soluble Fiber Insoluble Fiber

a. Soluble fiber slows digestion in the upper GI

tract because it attracts water and forms a gel

which fills up the GI tract. This leads to a

feeling of fullness which can help with hunger

and satiety control and ultimately weight loss.

Soluble fiber also slows down the absorption of

glucose into the blood with blood glucose

control. This is important for patients with

diabetes, but a more even blood sugar level is

beneficial for everybody. Soluble fiber can also

lower cholesterol level by binding to bile acids

Insoluble fiber do not dissolve in water and

pass through the gut relatively unchanged.

They add bulk to the stool and this helps to

move the stool along faster.

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GI_2012Due: June 22, 2012

in the small intestines and transporting these out

of the body, they can not be reabsorbed. To

produce more bile the body uses blood

cholesterol. Low blood cholesterol can prevent

cardiovascular disease.

b. The Adequate Intake recommendation for fiber

is 38 g for men under 50 years of age, 30 g for

men over 50 years and women under 50 years,

and 25 g for women over 50 years.

The Adequate Intake recommendation for

fiber is 38 g for men under 50 years of age,

30 g for men over 50 years and women

under 50 years, and 25 g for women over

50 years.

c. oats, beans, apples, barley Whole grains, products made from whole

grains, seeds, vegetables

2. Describe how a low fiber diet contributes to the development of diverticulosis.

If fiber intake is low the stool becomes harder

and more compact. The stool moves through the

larger intestines more slowly. This hard stool

can put pressure on the walls of the colon and

lead to the development of little pouches.

3. Describe the mechanisms of action by which fiber affects blood glucose and blood lipids.

Fiber slows down the absorption of glucose into

the blood stream which help with blood glucose

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GI_2012Due: June 22, 2012

control.

Fiber can lower cholesterol level by binding to

bile acids in the small intestines and transporting

these out of the body, so they can not be

reabsorbt. The body has to make more bile using

blood cholesterol. Low blood cholesterol can

prevent cardiovascular disease.

References for this section: Insel, P., Ross, D., McMahon, K., Bernstein, M. (2011). Nutrition (4th ed.). Sudbury, MA: Jones and Bartlett

2. a. Explain what is a “resistant starch:

Resistant starches are complex carbohydrates that get only partially digested in the small

intestines, or fermented in the large intestines. They add bulk to the stool and increase GI

mobility. They can be found in whole grains, legumes and some fruits and vegetables. They are

also called the third type of fiber.

b. Discuss your opinion about chemical processing of starches to make them more resistant and then adding them to food products, for example, Dreamfields Pasta:

On one side functional food and supplements make it easier for clients to increase their intake

of fiber. Especially older people sometimes have a hard time to consume the recommended

amount of fiber. But consumers need to look at those functional foods individually, compare

them to “normal food” and have a critical attitude toward all health claims. Do these provide

more fiber than normal whole wheat pasta? Does the consumer want or need the lower

carbohydrate content these pasta have? Is a possibly higher price for these foods justified?

Often I find that functional food make it harder for consumers to chose healthy foods, because

their health claims are more visible than those of “normal” foods, like whole grains, fruits, and

vegetables. And often some added fiber is used to make products with a high sugar content

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GI_2012Due: June 22, 2012

(granola bars, cereal) seem more healthy.

Note: As with the HAES question above, this is NOT a trick question. This is another “controversial hot topic”, particularly for diabetics or those who choose to follow a “low carb” diet. The intention here is to get you thinking about it. No right or wrong answer, just be able to defend your position.

GUT INTEGRITY

1. Describe GALT (gut-associated lymphoid tissue) and its immune function.

GALT is the lymphoid tissue in the GI tract. It contains different types of tissue with immune

cells like B- + T-lymphoids, and macrophages. The tonsils and the appendix are part of the gut-

associated lymphoid tissue as well as Peyer’s patches, lymph nodes found in the small

intestines. The immune function of the GI system is very important because the gut is

essentially exposed to the outside. It needs to deal with bacteria, viruses, and other pathogens

that enter the body with our food.

2. Discuss the relationship between intestinal micro-flora and gut health.

The human gut is populated by a great number of different microorganisms, most of them

bacteris. If the intestines are populated with “good bacteria”, these can keep the number of

unhealthy bacteria in check and keep the colon healthy, because they compete with the

pathogens for nutritents and receptors. They can also produce antimicrobial factors. These

bacteria can deal with partially digested food. They can strengthen the barrier between the

“outside” of the body and the inside. They have important functions in developing the immune

system in the gut. And they may even be protective against cancer by metabolizing dietary

carcinogens. They produce vitamins like vitamin K and they add a considerable amount to the

stool mass.

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GI_2012Due: June 22, 2012

3. Discuss the relationship between gut integrity and sepsis. Include translocation of bacteria in your discussion.

Gut integrity can be compromised by trauma, antibiotics, enteral, or parenteral nutrition. It

means that bacteria leave the interior of the intestines, and are transported to other sides of the

body where they can cause a serious infection.. It is important to maintain a healthy gut flora to

avoid bacterial translocation. This can be done by initiating oral feeding as early as possible and

by avoiding total inactivity of the gut.

4. egDiscuss probiotics and prebiotics:a. Give a definition for each

b. Give several examples of each.

c. Where in the gut do they reside?

Probiotics Prebiotics

a. Probiotics are bacteria that help maintain the

heathy balance of microorganisms in the gut.

Prebiotics are parts the food that can not be

digested by the human body, but are nutrients

for the micro-flora in the gut and stimulate

their growth and activity.

b. Bacteria found in fermented dairy products,

like yogurt and kefir, and other fermented

food like kimchi and sauerkraut, for example

lactobacilli and bifidobacteria.

For example inulin, polydextrose, and fructo-

oligosaccharides. They can be found in whole

grains, garlic, honey, leeks, bananas and more

and also in fortified foods.

c. Bacteria can be found in everywhere in the

GI tract, but digestive juices in the upper part

(stomach, upper part of the small intestines)

make life for them difficult. They are mostly

found in the lower part of the small intestines

Poebiotics are mostly food sources for the

bacteria in the lower part of the small

intestines and the colon.

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GI_2012Due: June 22, 2012

and expecially in the colon.

5. What diet changes encourage the growth of healthy/unhealthy bacteria?

To promote a growth of healthy bacteria in the gut it is beneficial to include fermented foods in the diet, like yogurt, kefir, kimchi and other fermented foods. To feed the “good” bacteria in the colon, the diet should contain whole grains and whole grain products, and a variety of fruits and vegetables.To repopulate the intestines after a course of antibiotics special supplements with high amounts of probiotics and prebiotics can be beneficial.

6. What is the role of glutamine in maintaining gut integrity? When is it used?

The amino acid glutamine can protect the integrity of the mucosa and decrease the permeability of the intestinal walls. It is the fuel for enterocytes and T-lymphocytes in the GI tract. In metabolic stress glutamine becomes essentiell and it is supplemented to avoid translocation of bacteria.

References for this section: Insel, P., Ross, D., McMahon, K., Bernstein, M. (2011). Nutrition (4th ed.). Sudbury, MA: Jones and

Bartlett

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GI_2012Due: June 22, 2012

Escott-Stump, S. (2011). Nutrition and Diagnostic Related Care (7th ed.). Lippincott Williams & WilkinsMacFie, J., O’Boyle, C., Mitchell, C.J., Buckley, P.M., Johnstone, D., Sudworth, P. (1999). Gut

Origin of Sepsis: A Prospective Study Investigating Associations between Bacterial Translocation,

Gastric Microflora, and Septic Morbidity. Gut 1999;45:223-228 doi:10.1136/gut.45.2.223.

etrieved June 19th 2012.O’Hara, A.M., Shanahan, F. (2006). The Gut Flora as a Forgotten Organ. EMBO reports (2006) 7,

688 - 693 doi:10.1038/sj.embor.7400731. Retrieved June 19th, 2012.

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BirgitHumpert-GI_2012-google.doc.docx · Web viewEtiology: An increase in the secretion of gastrin, estrogen, and progesteron, obesity, scleroderma, hiatal hernia (part of the stomach