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87 Cards in this Set
- Front
- Back
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Pancreatitis: common Causes
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alcoholism and cholelithiasis
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Dumping Syndrome
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A complex physiologic response to the rapid emptying of hypertonic contents into the duodenum and jejunum
Dumping syndrome occurs as a result of total or subtotal gastrectomy |
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Short-Bowel Syndrome
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A malabsorption syndrome resulting from major resections of the small bowel; characterized by diarrhea, steatorrhea, and malnutrition
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Blind Loop Syndrome
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-Bacterial overgrowth from stasis in intestine, obstruction, radiation enteritis, fistula, or surgical repair/resection
-Treatment(Rx) *Antibiotics to control bacterial overgrowth, use of prebiotics and probiotics *Limit refined carbohydrates; emphasize whole grains, vegetables, oligosaccharides *May use MCT oil |
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MNT for Dumping Syndrome
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Proteins and fats are better tolerated than carbohydrates because they are hydrolyzed more slowly into osmotically active substances
Basically a diet that aims to prevent symptoms of dumping syndrome is somewhat higher in fat content, low in simple carbohydrates, and high in protein. |
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MNT- Short Bowel Syndrome
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Most patients who have significant bowel restrictions require total parenteral nutrition initially to restore and maintain nutrition status.
The two general principles for resuming enteral nutrition after small-bowel restrictions are (1) to start enteral feeding early, and (2) to increase feeding concentration and volume gradually over time. Glutamine is the preferred fuel for small intestinal enterocytes and thus may be valuable in enhancing adaption. |
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Tropical Sprue
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A syndrome of unknown etiology that causes diarrhea and malabsorption but is not responsive to gluten-free diet therapy
The syndrome may include bacterial overgrowth, changes in GI motility, and cellular changes in the GI tract |
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MNT-Tropical Sprue
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Nutrition management includes restoration and maintenance of fluids and electrolyte, macronutrients, and micronutrients, and introduction of a diet that is appropriate for the extent of alabsorption.
Along with other nutrients as needed, folate is given at 5 mg daily, along with intramuscular vitamin B12 until symptoms subside. |
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MNT- Celiac Disease
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-Gluten free diet
-Omit sources of gluten: wheat, rye, barley, and perhaps oats -Use uncontaminated corn, potato, rice, soybean, tapioca, arrowroot, amaranth, quinoa, millet, and buckwheat -Major life change -Read labels -Many unexpected food products contain gluten, eg., beer and malt |
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Celiac Disease- Possible causative food ingredients
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-Dextrin-usually made from corn but may be made from wheat
-Flavorings -Modified food/starch -Seasonings -"Starch" in pharmaceuticals, vitamin/mineral and herbal supplements -Unidentified sources of hydrolyzed plant protein, hydrolyzed vegetable protein, textured vegetable protein |
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Celiac Disease
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Gluten-Induced Enteropathy
-Gluten sensitive enteropathy to >20ppm -Adverse reaction to gluten;gliadin fraction -Intestinal mucosa is damaged -Nutritional consequence is malabsoption of nutirnets p683 *Iron deficiency *Osteomalacia *Growth Failure *Projectile vomiting |
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Brush Border Enzyme Deficiencies
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-Lactose Intolerance
-Causes: genetic or secondary deficiency of lactase *African Americans, Asians, South Americans *Secondary to infection, inflammatory disorders, HIV, or malnutrition -Dx: history, lactose tolerance test or breath hydrogen test -Rx: avoid large amounts of lactose, individual tolerance, foods made with lactase enzyme; processed dairy sometimes tolerated |
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Inflammatory Bowel Diseases
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-Crohn's disease or ulcerative colitis
-Both cause diarrhea, fever, weight loss, anemia, food intolerances, malnutrition, growth failure, and extraintestinal manifestations (arthritic, dermatologic, and hepatic); associated with malignancy |
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Crohn's Disease
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May involve any part of the GI tract; most in distal ileum and colon; segments of inflamed bowel
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Ulcertative Colitis:
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Begins at rectum and progresses up the large intestine
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MNT for IBD
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-Fears and misconceptions, individualize
-Nutrition support with parenteral or enteral nutrition to bring clinical remission -"complete bowel rest" using PN not necessarily required -Enteral nutrition preferred -Enteral nutrition may temper inflammatory process and be steroid sparing -Children benefit from enteral nutrition to maintain growth and reduce steroid dependence |
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MNT for Acute IBD
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-Treat diarrhea, fluids and electrolytes
-Avoid caffeine and hyperosmolar foods -Provide MCT with malabsorption -Moderate fiber accordingly -Small frequent low fat meals -Omega 3, glutamine, antioxidants -Pre-and pro-biotics |
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Factors that influence severity of short-bowel syndrome
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Malabsorption, Complications, Dependence on Perenteral Nutrition
-Length of remaining small intestine -Loss of ileum, especially distal one third -Loss of colon -Disease in remaining segments of GI tract -Radtation enteritis -Coexisting malnutrition -Older age surgery |
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Short Bowel Syndrome: Nutritional Care
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Step 1
-Parental only for patients who cannot absolutely tolerate enteral feeding or do not have much absorptive surface left Step 2 -Gradually introduce enteral nutrition;start early -Glutamine, nucleotides and SCFAs (from bacterial digestion) are important nutrients for the gut -Narcotic drugs for pain caues GI problems and should be evaluated |
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Irritable Bowel Syndrome
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-Common syndrome involving abdominal discomfort and altered intestinal motility, bloating, feelings of incomplete evacuation, mucus in stool. straining or increased urgency, GI distress with psychosocial distress
-Ensure adequate nutrient intake, tailor diet for specific pattern of IBS, management of symptoms, adequate fiber, pre and pro biotics |
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Diverticular Disease
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-Herniations of the colon, chronic diverticulosis, acute diverticulitis
-Diverticulosis: high-fiber diet, increase gradually, supplements if necessary, adequate fluid intake -Diverticulitis: low-residue or elemental diet, possibly low-fat diet *Seeds, nuts, or skins unresolved |
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Intestinal polyps and colon cancer
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-Colorectal cancer is the third most common cancer among US adults
*Polyps are considered precursors of colon cancer -Recommendations: Sufficient exercise, weight maintenance or reduction, modest and balanced intake of lipids, adequate micronutrients, and limited alcohol |
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Fistula
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Abnormal Opening
-Causes: birth defects, trauma, inflammatory disease, malignant disease -Nutrition Therapy: Restore fluid and electrolyte balance; TPN or defined liquid formulas |
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Illeostomy or Colostomy
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Surgical Opening of Intestine to Outside
-As a result of intestinal disease such as Hirschsprung's disease, ulcerative colitis, Crohn's disease, colon cancer, trauma -Rx:Nutrition needs vary with location and individual; Avoid gas- or odor-forming foods;Fluid and electrolyte needs;Vitamin B12 if terminal ileum is removed |
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Hemorrhoidectomy
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-Delay of stool formation until healing can take place
-After Surgery:Minimal-residue diet or elemental diet -After recovery:High-fiber diet with adequate fluids to prevent constipation |
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Intestinal Gas and Flatulence
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-Belching (eructation) and rectal gas (flatulence)
-Nitrogen, oxygen, carbon dioxide, hydrogen, and in some people methane -To Minimize aerophagia, eat slowly, chew with mouth closed, avoid straws -Bacterial fermentation may be increased by dietary fiber (especially soluble fiber), resistant starches, lactose (If lactase deficient), fructose, or alcohol sugars (e.g. sorbitol) |
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Causes of Constipation:
Systemic, Neurogenic, Metabolic |
-Inadequate fluid intake
-Poor diet, low in fiber -Lack of exercise -Side effects of medication -Ignoring the urge to defecate -Pregnancy -Laxative abuse -Endocrine or metabolic abnormalities: hyperthyroidism, uremia, and hypercalcemia -Spina Bifida -Parkinson's disease -Vascular disease of the large bowel -Systemic neuromuscular disease leading to deficiency of voluntary muscles |
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Causes of Constipation: Disease of the GIT
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-Cancer
-Diseases of the upper GI tract -Diseases of the large bowel resulting in: *Failure of propulsion along the colon (colonic inertia) *Failure of passage through anorectal structures (outlet obstruction) -IBS -Anal Fissures or hemorrhoids -Hirschsgrung's disease |
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MNT for Constipation
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-Adequate fluids (1 mL per Kcal)
-Adequate soluble and insoluble dietary fiber -14 g per 1000 kcal ~25g for women, 38g for men, 19 to 25 g for children *Whole grains, fruits, vegetables, legumes, seeds, nuts *Supplements may be helpful (Benefiber, Metamucil, Citrucel, FiberCon) |
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Diarrhea
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-Frequent liquid stools ~300mLs or more accompanied by fluid and electrolyte loss
-Decreased digestion and absorption of food -Increased secretion into GIT -Osmotic -Secretory- caused by viral or bacterial infections, gut hormones -Exudative- mucosal damage allowing outflow of blood, mucus, fluid, plama proteins (Crohn's, UC, radiation enteritis) -Medication- Induced -Malabsorptive- steatorrhea eg. celiac disease, IBD, bowel resection |
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MNT Diarrhea
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-Identify and treat underlying problem
-Replace fluid and electrolytes; oral rehydration solutions, soups and broths, vegetable juices and other isotonic liquids -Introduce starchy CHOs, low-fat meats, small amounts of vegetables and fruits, followed by lipids -Avoid sugar alcohols, lactose, fructose -Prebiotics and probiotics may be helpful |
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Oral Rehydration Solution
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~ 2 t sugar, 1/2 t salt, 1/4 baking soda, 1/4 t K+ based salt substitute in 1 cup H2O
*2% glucose *Sodium *Potassium *Chloride *Bicarbonate *Citrate base |
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Steatorrhea
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> 7% fecal fat
Causes: pancreatic lipase deficiency, insufficient surface for absorption (celiac disease, inflammatory bowel diseases, amyloidosis, short bowel syndrome), secondary to liver disease, bilary obstruction or resection of distal ileum (blind loop syndrome) |
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MNT for Steatorrhea
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-Decrease fat intake
-Increase energy to reverse weight loss, especially protein and carbohydrate -Use medium and short chain fatty acids -Vitamin and mineral supplements:fat soluble vitamins; calcium, zinc, magnesium |
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MCT oil can be given with Steatorrhea
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-8 to 10 carbons long
-Bile not needed for absorption -Delivered to liver via blood -8.3 kcal/g -Available in some enteral formulas -Oil is best incorporated into foods or in recipes but hospitals give it like cough medicine |
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Upper Digestive Tract
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Oropharyngeal
Esophageal Gastric |
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Dysphagia: Causes
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stroke
surgery GERD medication |
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Gastroesophageal reflux disease
GERD |
Backward flow of the stomach and/or duodenal contents into the esophagus
-Burning sensation after meals; heartburn -Esophagitis: inflammation of the exophagus -Competency of the LES -Possible discomfort during and after eating |
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Causes of GERD
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-Congenital (neurological and structural)
-Physical (pregnancy, central obesity, tight clothing) -Mechanical- weak Lower Esophageal Sphincter (LES) -Smoking, alcohol, caffeine -Chemical (medication, excipients) |
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Hiatal Hernia
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-An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm
-Epigastric discomfort after large, energy-dense meals -Medicalt nutrition therapy: weight reduction, decreasing meal size |
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Hiatal Hernia
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-An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm
-Epigastric discomfort after large, energy-dense meals -Medicalt nutrition therapy: weight reduction, decreasing meal size |
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Effects of tobacco use
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-Decreased sphincter pressure
-Increased reflux -Decreased biocarbonate secretion by pancreas -Accelerated gastic emptying of liquids -lower duodenal pH -Increased response to gastrin -Impairs effect of medication to lower overnight acid secretion -Impairs healing, increased risk of perforation -Causes cancer |
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Guidelines for Patients with Reflux and Esophagitis
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-Avoid large, high-fat meals
-Avoid eating at least 3 to 4 hours before retiring -Avoid smoking or second hand smoke -Avoid caffeine containing foods and beverages -Avoid alcoholic beverages -Avoid caffeine containing foods and beverages -Stay upright and avoid vigorous activity soon after eating -Avoid tight-fitting clothing, especially after a meal -Consume a healthy, nutritionally complete diet with adequate fiber -Avoid acidic and highly spiced foods when hyperacidity or inflammation exists -Achieve or maintain a healthy BMI |
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Complications of GERD
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Esophageal ulcer
Barret's esophagitis Cancer Strictures |
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Cancer and surgery of the mouth or esophagus (Nutritional Concerns)
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-Nutritional problems, deficits, and eating difficulties may be compounded by regimen of cancer treatments
-Chewing, swallowing, salivation, and taste acuity are often affected -Weight loss is common -Often need complete oral liquid formulas;or may require gastrostomy or jejunostomy tube feeding -Prevent dry mouth, provide regular periodontal care |
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Disorders of the Stomach:
Indigestion and dyspepsia |
-Epigastric discomfort following meals
-Abdominal pain, bloating, early satiety, nausea, and belching -Reduce dietary fat intake, use smaller meals, eat meals with low caloric density, limit alcohol -No specific cause found |
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Gastritis
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-Helicobacter pylori
-Infection and Inflammation -Acute gastritis: rapid onset of inflammation and symptoms -Chronic gastritis: occurs over period of time -Symptoms: nausea, vomiting, malaise, anorexia, hemmorrhage, and epigastric pain |
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Peptic Ulcer Disease (PUD)
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-Primary causes: H. pylori infection, gastritis, use of NSAIDs exacerbated by cortico-steroid use, stress
-Secondary causes: trauma, injury, shock, radiation therapy, surgery, renal failure -Can involve gastric and/or duodenal regions -Gastric ulcers: in stomach commonly associated with duodenal reflux -Duodenal ulcers: in duodenum assoc w/ high acid secretion, nocturnal secretion, and decrease in biocarbonate |
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Characteristics and Comparisons between Gastric and Duodenal Ulcers
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-Gastric ulcer formation involves widespread gastritis, inflammation of parietal cells and atrophy of acid- and pepsin- producing cells
-Duodenal ulcers are associated with high acid and low biocarbonate secretion -Increased mortality and hemorrhage are associated with gastric ulcers -What is melena? |
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Factors that increase gastric acidity
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1. Cephalic phase
2. Gastric phase |
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Cephalic Phase of Digestion
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Thought, taste, smell of food, and chewing and swallowing initiate vagal stimultaion of the parietal cells in the fundic mucosa resulting in secretion of gastric acid
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Gastric Phase of Digestion
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Effect of food on the stomach:
-Distention of the fundus stimulates the parietal cells to produce acid -Distention of the antrum causes release of gastrin -Substances in certain foods and digestive products increase stomach acidity (e.g., coffee, both with or without caffeine, alcohol, protein, polypeptides and amino acids) Acidification of the antrum reduces gastrin release and thus gastric acid secretion. Food, especially protein, has an initial buffering effect. But increased alkalinity of antrum causes the release of gastrin, which stimulates gastric acid secretion |
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Management of Peptic Ulcers
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Nutrition Therapy
Antibiotics Acid Suppresion Surgery Stress reduction |
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MNT for peptic Ulcers
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Moderate alcohol intake of less or none
Limit caffeine of coffee Limit spices, especially chill, cayenne, and black pepper Overal good diet; frequent small meals; polyphenols |
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Drugs Commonly Used to Treat PCD
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Antibiotics: to eradicate Helicobacter pylori, and to prevent or treat infection after abdominal wounds or surgery
Antacids: to neutralize gastric acid in acid reflux, peptic ulcer Proton Pump Inhibitors (omeprazole, lansoprazole): stop gastric acid secretion Histamine-2 receptor antagonists (cimetidine, ranitidine): histamine blocker inhibits effect of histamine in prompting gastric acid production -Sucralfate (sulfated disaccharide): protects stomach lining and may increase mucosal resistance to acid of enzyme damage |
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Gastric Surgery
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Less common for ulcer treatment
More for cancer trt and bariatric reasons Surgical resection or gastrectomy GI cancer protective nutrition: fruits, vegetables, selenium GI cancer risk factors: alcohol, overweight, high salted, smoked or pickled foods, inadequate micronutrient intake |
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Dumping Syndrome: Symptoms
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First stage. Abdominal fullness, nausea, flushing, rapid heartbeat, faintness, sweating
Second stage. Flatulence, abdominal cramps, diarrhea Third stage. alimentary hypoglycemia Often causes weight loss due to chronic malabsorption |
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Stomach Cancer risk factors
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-age
-sex -diet:pickled, salted, smoked, charred -overweight, inadequate micronutrient intake -H. pylori -Smoking -Inflammation: stomach surgery, gastritis, pernicious anemia -Family history |
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Pancreatitis
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-Ranges from mild to severe
-Acute or chronic -Upper abdominal pain, may radiate to the back, may worsen with ingestion of food -Nausea, vomiting, abdominal distention, steatorrhea, impaired glucose tolerance -Complicated by hypotension, oliguria, dyspnea -Ranson's Criteria score 0-2:minimal mortality score 3-5:10%-20% mortality Score >5 has more than 50% mortality and is associated with more systemic complications |
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Alcoholism and Pancreatitis
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<10% of heavy alcohol users develop pancreatitis
Direct toxic (ROS and acetaldehyde) effects on acinar cells Pancreatic fibrosis Duct obstruction Results in autodigestion |
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MNT for acute pancreatitis
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rest
maintain hydration intravenously Clear liquid, negligible fat Progress diet as tolerated; low-fat diet, six small meals, pancreatic enzyme Nutrition support as needed, monitor glucose and lipids, serum calcium EN as much as possible vs PN, via jejunostomy |
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MNT for chronic pancreatitis
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NT same as for Acute
Increased risk for PEM (usually assoc w/ alcoholism), decreased pancreatic enzyme secretion and decreased food intake, promote healthy weight Antioxidants, pancreatic enzymes, MCT Monitor glucose tolerance |
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Physiology and Functions of the Liver
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Structure- looks like a filter
Functions (over 500 functions) -Metabolism of macronutrients -storage and activation of vitamins and minerals -detoxification -conversion of ammonia to urea -Protein and enzyme synthesis, blood clotting and immune factors, metabolism of steroids, drug metabolism and excretion -Filter and flood chamber |
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Alcoholic Liver Disease
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-Disease resulting from excessive alcohol ingestion characterized by fatty liver (hepatic steatosis), hepatitis, or cirrhosis
-Widespread problem(17.6 M alcoholics) -Three stages: hepatic steatosis, alcoholic hepatitis, and cirrhosis -Alcoholic cirrhosis may lead to GI bleeding, hepatic encephalopathy, portal hypertension, ascites |
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Malnutriton in the alcoholic
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-Replacement of food by alcohol
-Interaction of alcohol with nutrients(B6) -Morphologic and physiologic alterations: *pancreatic insufficiency *bile production *impaired protein metabolism -Excess NADPH and impaired fat oxidation -Insulin resistance -Vitamin and mineral deficiencies |
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Fulminant Hepatitis
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Syndrome in which severe liver dsyfunction is accompanied by hepatic encephalopathy
Causes: viral hepatitis, hepatotoxic chemicals, Wilson's disease, fatty liver, Reeye's Syndrome, hepatic ischemia, hepatic obstruction, malignancy |
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Cholestatic LIver Disease
Primary bilary cirrhosis (PBC) |
A chronic cholestatic disease caused by progressive destruction of small and intermediate-sized intrahepatic bile ducts, whereas the extrahepatic bilary tree and larger intrahepatic ducts are normal
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Chronic Hepatitis
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At least 6-month course of hepatitis or biochemical and clinical evidence of liver disease with confirmatory biopsy findings of unresolving hepatic inflammation
Most common causes: Hep B, Hep C, auto-immune hepatitis, drug induced liver disease, "metabolic diseases", fatty liver Symptoms: for mild are fatigue, sleep disorders, difficulty concentrating and mild pain in liver area Severe symptoms: jaundice, muscle wasting, tea colored urine, ascites, edema, hepatic encephalopathy, GI bleeding, splenomegaly, palmar erythema, spider angioma |
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Cholestatic Liver Disease:
Sclerosing Cholangitis |
Fibrosing inflammation of segments of extrahepatic bile ducts, with or without involvement of intrahepatic ducts
Usually associated with IBD Hepatic osteodystrophy may occur from vitamin D and calcium malabsorption |
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Inherited Disorders in Liver Disease
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-Hemochromatosis:inherited disease of iron overload
-Wilson's disease:Autosomal recessive disorder associated with impaired biliary copper excretion -alpha-1-Antitrypsin deficiency:Causes cholestasis or cirrhosis and can cause liver and lung cancer |
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Other causes of liver disease:
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Liver tumors
Systemic diseases(rheumatoid arthritis, systemic lupus erythematosus, etc.) Acute ischemic and chronic congestive hepatopathy Parasitic, bacterial, fungal, and granulomatous liver diseases |
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Objective Nutrition Assessment for Liver Assessment
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-Body weight
-Anthropometric measurements -Creatinine-height index -Nitrogen Balance Studies -Visceral Protein Levels -Immune Function tests -Bioelectrical Impedance |
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Nutrient Requirements in Cirrhosis
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-Feeding problems: anorexia, nausea, dysgeusia, and other GI symptoms
-Energy -Carbohydrate and fat -Protein: controversial and complex -Vitamins and minerals -Herbal supplements |
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Malnutrition in Liver Disease
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Inadequate intake
Maldigestion/malabsorption Abnormal macro and micro nutrient metabolism (review functions of the liver) |
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Vitamin/Mineral Deficits in Severe Hepatic Failure
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Vitamin A, D, E, K, B6, B12
Folate Niacin Thiamin Zinc Magnesium Iron Potassium Phosphorus |
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Complications of Cirrhosis
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Portal Hypertension: PN for at least 5 days
Ascites: Sodium restriction Hyponatremia: Fluid restriction, moderate sodium intake |
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Four Stages of Hepatic Encephalopathy
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Stage 1-Mild confusion, agitation, irritability, sleep disturbance, decreased attention
Stage 2-Lethargy, disorientation, inappropriate behavior, drowsiness Stage 3-Somnolence but arousable, incomprehensible speech, confusion, aggression when awake Stage 4-Coma |
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Hepatic Encephalopathy is Precipitated by:
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GI bleeding
Fluid and electrolyte abnormalities Uremia Use of sedatives Hypo- or hyperglycemia Alcohol withdrawl Constipation Acidosis |
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Hepatic Encephalopathy
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-Ammonia, glutamine, alpha-ketoglutarate
-Ammonia comes from gut thus treatment with: (Lactulose, Neomycin) are used to minimize ammonia absorption -Amino acid imbalace occurs b/w BCAA(decreased) and aromatic AA(increase) -BCAA provides 30% of energy req. of muscle, heart and brain thus provide BCAA (LIV) -Provide 1.2 g pro/kg BW |
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Other Problems from LIver Disease
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Glucose control: treat as diabetes
Fat malabsorption: use MCTs, low-fat diet Renal insufficiency and hepatorenal syndrome- IV volume, fluid balance, dialysis Osteopenia: weight maintenance, well-balanced diet, adeaquate protein, high calcium, adequate vit D, avoid alcohol, minimize steatorrhea |
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Liver Disease: Suggested Nutrition Diagnoses
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-Excessive alcohol intake
-Evident protein calorie malnutrition -Inadequate protein-energy intake -Imbalance of nutrients -Inadequate vitamin intake -Inadequate mineral intake -Altered GI function -Altered nutrition related labs -Knowledge deficit about food and nutrition -Harmful belief of attitude about food and nutrition |
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Bile
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-Produce by the liver
-Composed of cholesterol, bilirubin, bile salts -Concentrated and stored in gallbladder -Release stimulated by CCK and secretin -Necessary for ? -Recycled through ? -Carries immunoglobulins for mucosal health -Primary excretory pathway for copper and mangenese |
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Diseases of the Gallbladder:
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-Cholelithiasis: healthy weight; low-fat diet
-Choledochothiasis; stones in duct -Secondary biliary cirrhosis- liver damage due to back-up of bile to liver -Cholecystitis- inflammation calculous or acalculous chronic or acute -Acute cholangitis- inflammation of bile duct -Schlerosing Cholangitis- fibrosing inflam. -Cholestasis: little or no flow of bile into gut |
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Who are more likely to present with gall bladder disease?
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Women more than men, usually over 40
10% of the population 70% NA women over 30 MNT: high fiber, low fat diet Monitor intolerances and avoid them Address weight or other metabolic issues such as diabetes |
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MNT
Acute cholecystitis |
-hold feedings
-may need PN -low-fat diet (25%) |
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MNT
Chronic cholecystitis |
-25 – 30% low-fat diet
-may be accompanied by intolerances -use elimination diet |
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MNT
Cholestasis |
usually due to lack of use therefore stimulate intestinal and biliary motility even with minimal enteral feeding
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