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Victor TambunanDepartment of Nutrition

Faculty of MedicineUniversitas Indonesia

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References

Krause’s Food & Nutrition Therapy 12th ed., 2008 ---- L.K. Mahan & S. Escott-Stump

Modern Nutrition in Health and Disease 10th ed., 2006 ---- M.E. Shils et al

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GASTROINTESTINAL TRACT

Upper Gastrointestinal (GI) Tract• Esophagus• Stomach• Duodenum

Lower GI Tract• Small intestine• Large intestine• Rectum

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Gastroesophageal Diseases

Gastroesophageal reflux disease (GERD)

Gastritis and peptic ulcer disease

Gastric cancer

Dumping syndrome6

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GERD consists of irritation & inflammation of the esophagus in response to reflux of gastric acid into the esophagus

Symptom:

heartburn Factors that contribute to GERD:

Excessive volume of acidic contents in the stomachLooseness of lower esophageal sphincter (LES)Motility disorders in the esophagus

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Medical Nutrition Therapy

Objectives:1. Prevent esophageal reflux2. Prevent pain & irritation of the

inflamed esophageal mucosa1. ↓ the erosive capacity or acidity of

gastric secretion

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Nutrition Care Guidelines for Reducing Gastroesophageal Reflux:

1. Avoid large, high-fat meals2. Not eating within 3 to 4 hours before retiring3. Avoid tobacco smoking4. Avoid alcoholic beverages5. Avoid caffeine containing foods & beverages6. Stay upright & avoid vigorous activity soon after eating7. Avoid tight-fitting clothing, esp. after a meal8. Consume a healthy, nutritionally complete diet with

adequate fibre9. Avoid acidic & highly spiced foods when inflammation

exists10. Reduce weight if overweight

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Alcohol

Chocolate

Fatty foods

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relaxing the LES & inducing GERD

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Gastritis & peptic ulcers may result when• infectious• chemical• neural abnormalities

disrupt mucosal integrity of the stomach or duodenum

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The most common cause: Helicobacter pylori infection

H. pylori infection is responsible for:

Most cases of chronic inflammation of gastric mucosa

Peptic ulcer

Atrophic gastritis

Gastric cancer

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Acute gastritis: refers to rapid onset of inflammation & symptoms

Chronic gastritis: may occur over a period of months to decades, w/ increasing & decreasing of symptoms

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Atrophic gastritis:

chronic inflammation w/ deterioration of the mucous membrane & glands, resulting in:

achlorhydria (loss of secretion of HCl) loss of intrinsic factor

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Factors that may also compromise mucosal integrity and ↑ the chance of acquiring acute & chronic gastritis

• Chronic use of aspirin or other NSAIDs

• Steroids

• Alcohol

• Erosive substances

• Tobacco

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Medical Nutrition Therapy

∼ as for peptic ulcersIn patients w/atrophic gastritis: evaluate vitamin B12 status

because lack of intrinsic factor & HCl

results in malabsorption of vitamin B12

In chronic gastritis: ↓ absorption of Fe, Ca, & other nutrients

occurs because ↓ gastric acid can ↓ their bioavailability

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Primary causes:H. pylori infectionGastritisAspirin & other NSAIDsCorticosteroidsStress-induced ulcer

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Involve two major regions:- Stomach- Duodenum

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Excessive use or high concentration drinks (alcohol) can:

damage gastric mucosaworsen symptoms of peptic ulcersinterfere w/ ulcer healing

Beers & wines: ↑↑ gastric secretion

Coffee & caffeine: stimulate acid secretion ↓ LES pressure

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Medical Nutrition Therapy

• Avoid alcohol∀ ↓ consumption of spices, esp. chili, cayenne, &

black peppers. Turmeric may inhibit adhesion of H. pylori to the gastric wall

• Avoid coffee & caffeine∀ ↑ intake of n-3 & n-6 fatty acids• Use probiotics as complementary therapy• Regular use of cranberries which contain phenolic

antioxidants may have the capacity to help eradicate H. pylori

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Frequent small meals may:

↑ comfort↓ the chance for acid refluxstimulate gastric blood flow

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persons w/ peptic ulcers should avoid consuming large meals, esp. before retiring, to reduce latent increases in acid secretion

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Cancer of the stomach can lead to malnutrition because of:• Excessive blood & protein losses, or• Obstruction & mechanical interference w/ food intake

more commonly

Consumption of fruits, vegetables, & selenium may have a modest role in the prevention of GI cancersAlcohol & overweight ↑ the riskOther factors:- Chronic infection w/ H. pylori- Smoking- Intake of highly salted or pickled foods- Inadequate amounts of micronutrients

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the risk

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Dietary regimen is determined by:• Location of the cancer• Nature of the functional disturbance• Stage of the disease

Patients w/ advanced, inoperable cancer should receive a diet that is adjusted to their tolerances, preferences, and comfortAnorexia: almost always present from the early stages.In the later stages:- liquid diet or- parenteral nutrition (intravenously)

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Medical Nutrition Therapy

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Dumping syndrome: a complex physiologic response to the rapid emptying of hypertonic contents into the duodenum & jejunum

May occur as a result of: total or subtotal gastrectomy manipulation of the pylorus after fundoplication after some gastric bypass procedures for

obesity23

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Nutrition care:Frequent small mealsHigh-protein, moderate-fat foods w/ sufficient calories. Complex CHOs (starches) can be included. Simple CHO (lactose, sucrose, & dextrose) should be limitedSufficient fibres (pectin in fruits, or guar gums) beneficial because they ↓ upper GI transit time & ↓ the rate of glucose absorption

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Medical Nutrition Therapy

Prime objective: to restore nutrition status & quality of life

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Nutrition care: ……………………….. (cont’d)

Limit the amount of liquids taken w/ meals, but adequate amounts should be consumed during the day, small amounts at a timeLie down immediately after meals & avoid activity an hour after eatingVery small quantities of hypertonic, concentrated sweets (soft drinks, juices, pies, cakes, cookies, and frozen desserts) can be ingestedLactose, esp. in milk & ice cream, are poorly tolerated, but cheeses & yogurt are better

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Diet for preventing symptoms of dumping syndrome:

Moderate fat (30% of calories intake) High protein (20% of calories intake) Low in simple CHO

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helps the patient achieve & maintain optimal weight & nutritional status

When intake is inadequate vit. D & Ca supplements may be needed

When steatorrhea (+) → give oil or fat which high in medium-chain triglycerides (MCTs)

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• Intestinal gas & flatulence

• Constipation

• Diarrhea

• Steatorrhea

• Gastrointestinal stricture & obstruction

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Instestinal Gas & FlatulenceCauses: Inactivity ↓ GI motility Aerophagia Dietary components GI disorders

Medical nutrition therapy:Reduce intake of CHO that are likely to be malabsorbed & fermented

e.g. legumes, soluble fibre, resistant starches, & simple CHO such as fructose & alcohol sugars 30

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Constipation

Most common causes:

Ignoring the urge to defecate Lack of fibre in the diet Insufficient fluid intake Inactivity Chronic use of laxatives

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Medical Nutrition Therapy

Consumption of adequate amounts of both soluble & insoluble dietary fibreFibre: colonic fecal fluid microbial mass stool weight & frequency the rate of colonic transit

softens feces & makes them easier to pass

Adequate water32

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Recommended amount of dietary fibre

about 14 g/1000 kcal

Fibre can be provided in the form of:Whole grainsFruitsVegetablesLegumesSeedsNuts

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Diarrhea

Causes may be related to:

Inflammatory diseaseInfections w/ fungal, bacterial, or viral agentsMedicationsOverconsumption of sugarsInsufficient or damaged mucosal absorptive surfaceGI resectionsMalnutrition

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Medical Nutrition TherapyFirst step in managing diarrhea: replacement of necessary fluids & elctrolytes, using:

electrolyte solutions soups & broths vegetable juices other isotonic liquids

Later: Starchy CHOs (cereals, breads) Low-fat meats Added small amounts of vegetables & fruits,

followed by lipids 35

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Probiotics

Modestly successful in:

Antibiotic-related diarrhea Traveler’s diarrhea Bacterial overgrowth Several types of pediatric diarrhea

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Steatorrhea

Steatorrhea:

excessive fat in the stool caused by disease or surgical resection of organs involved in the digestion & absorption of lipid

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Medical Nutrition Therapy

Steatorrhea can result in chronic weight loss → may require ↑ calorie intake, mainly in the form of protein & complex CHOs

MCTs can be given because: able to enter the portal vein for transport to the

liver without micelle formation digestion & absoprtion, & resynthesis into triglycerides in intestinal cell

easier to be absorbed in the abscense of bile acids

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Food source of MCTs:coconut oil

Micronutriens supplementation:Fat-soluble vitaminsCaZnMg

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because losses are ↑ as a result of insoluble soaps’ formation

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Gastrointestinal Strictures & Obstruction

Causes (partially or completely obstruction):Instestinal tumorsScarring from GI surgeriesInflammatory bowel disease (IBD)Peptic ulcerRadiation enteritis

If parts of the GI are partially obstructed

obstructions from foods may occur

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The most common foods that may cause obstructions are fibrous plant foods

Phytobezoars:obstructions in the stomach that result from the ingestion of plant foods

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Restricted-fiber diet → limit fruits, vegetables, & coarse grains

Provide <10–15 g of dietary fibre, usually in the form of small particle size such as vegetable & fruit juices, cereals, & breads

In distal obstructions or strictures: Keep the feces soft by:

including moderate amounts of fibre, but of small particle size (such as juices)

adequate water

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Medical Nutrition Therapy

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Some Diseases and Conditions Associated with Malabsorption

• Inadequate digestion Pancreatic insufficiency Gastric resection

• Altered bile salt metabolism w/ impaired micelle formation

Hepatobiliary disease Bacterial overgrowth

• Abnormalities of mucosal cell transport Biochemical or genetic abnormalities

- Disaccharidase deficiency e.g. lactase deficiency- Celiac disease (gluten-sensitive enteropathy)

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Some Diseases and ……………… (cont’d)

Inflammatory or infiltitative disorders- Crohn’s disease- Ulcerative colitis- Radiation enteritis- Short-bowel syndrome

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• Abnormalities of intestinal lymphatics & vascular system

Instestinal lymphangiectasia Chronic congestive heart failure

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Two major forms of IBD:

Crohn’s disease

Ulcerative colitis

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Clinical characteristics:

Diarrhea Fever Weight loss Anemia Food intolerances Malnutrition Growth failure Extraintestinal manifestations (arthritic,

dermatologic, & hepatic)46

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Segments of inflamed bowel

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Abnormal activation of the mucosal

immune response Secondary systemic

response

Unknown “irritant”Viral? Bacterial?Autoimmune?

Genetic predisposition

Damage to the cells of the small and/or large intestinew/ malabsorption, ulceration, or stricture

- Diarrhea- Weight loss- Poor growth

Pathophysiology of inflammatory bowel disease

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Medical Nutrition Therapy

IBD patients are at ↑ risk of malnutrition

primary goal of MNT to restore & maintain the nutritional status

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Energy: energy requirements are not greatly ↑

Protein: protein needs may ↑ but rarely >50% than normal needs

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Vitamins & mineral supplementation:• folic acid, vitamins B6, and B12• Zn, K, and Se

Small, frequent feedings may be tolerated better

Small amounts of isotonic, liquid, oral supplements may be valuable

If fat malabsorption (+)

foods made w/ MCTs useful to ↑ calories intake & for absorption of fat-soluble nutrients

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↑ n-3 fatty acids intake antiinflammatory effect

Probiotics can modify the microbial flora

Prebiotics (such as oligosaccharides): alter the mixture of microorganisms in the

colonic flora favoring lactobacillus & bifidobacteria suppressing pathogenic or opportunistic microflora ↑ production of SCFAs

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Risk factors associated w/ the onset of exacerbations of IBD include:

↑ sucrose intake

lack of fruits & vegetables

dietary fibre <<

red meat >>

alcohol

altered n-6/n-3 fatty acid ratios

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