Nutrition and Gastrointestinal Disorders

1. Nutrition and Gastrointestinal Disorders Amanda Gordon, RD, LD, CNSCAdvanced Practice Clinical DietitianThe George Washington University HospitalWashington, DCamanda.gordon@gwu-hospital.com

2. Agenda and Goals • Review Anatomy and Physiology • Review Digestion and Absorption of Macro and Micronutrients • Introduce Common Clinical Presentations of GI Disorders • Highlight MNT (Medical Nutrition Therapy) for each GI Disorder

3. The GI Tract

4. The GI Tract: Anatomy • Mouth • Esophagus • Stomach • Small Intestine (Small Bowel) • Duodenum • Jejunum • Ileum

5. The GI Tract: Anatomy • Large Intestine (Large Bowel) • Cecum • Colon • Ascending • Transverse • Descending • Sigmoid • Rectum • Anal Canal

6. The GI Tract: Accessory Organs • Salivary Glands • Tongue • Teeth • Liver • Gallbladder • Pancreas • Appendix • Peritoneum • Mesentery

7. The GI Tract The digestion of nutrients from dietary food sources requires a coordinated process of mechanical and chemical processes. Defects in any of these phases of digestion or absorption can lead to maldigestion or malabsorption of nutrients.

8. 2002 Canadian Medical Association

9. The Esophagus • Function: The Transport Tube • Protected on two sides by two sphincters • Upper Esophageal Sphincter • Lower Esophageal Sphincter

10. Disorders of the Esophagus : GERD • LES malfunction, does not close properly • Stomach contents leak back, or reflux, into the esophagus and irritate it • Can cause Barrett’s Esophagus (tissue changes in the esophagus) • Treatment: • Antacids (Maalox, Tums, Mylanta) • H2 blockers (Pepcid, Zantac, Tagamet) • Proton pump inhibitors (Prevacid, Protonix, Prilosec)

11. ★GERD: MNT • Limit or avoid peppermint, spearmint, chocolate, alcohol, caffeinated and carbonated beverages • Limit or avoid high fat foods • Wait 3 hours after eating before lying down • Raise the HOB by 6-9 inches • Eat several small meals throughout the day

12. GERD: Surgical intervention Nissen Fundoplication www.clevelandclinic.org

13. The Stomach • Where it all begins… • Anatomy • Fundus • Body • Pylorus • Pyloric Sphincter • Physiology • Chief cells • Parietal cells (HCl) • Endocrine cells (gastrin, ghrelin)

14. The Stomach: Digestion • Process of emptying takes 2-6 hours • Most occurs in the pyloric region • Beginning of protein digestion (proteolysis) via Pepsin

15. Disorders of the Stomach: Gastroparesis • Caused by delayed gastric emptying • Often occurs in people with Type 1 or Type 2 Diabetes • Symptoms include nausea, vomiting, early satiety, erratic BG  MNTProkinetic agents (Reglan), small, frequent meals (4-6x day), avoid high fat foods, full liquids if needed, jejunostomy tube

16. The Bowel: Digestion/Absorption Remember: The intestines can adapt/compensate

17. The Small Bowel • Where the REAL action is… • Anatomy • Duodenum, Jejunum, Ileum • Villi and Microvilli • Physiology • Gastric Inhibitory Peptide • Secretin: stimulates bicarbonate • CCK: stimulates ejection of bile from gallbladder

18. Small Bowel Disorders: Inflammatory Bowel Disease Crohn’s Disease • Inflammatory disease in the terminal ileum • Weight loss, anorexia, diarrhea • B12 deficiency • Medications: Antibiotics, Sulfasalazine, Corticosteroids Ulcerative Colitis • Ulcerative disease of the colon • Bloody diarrhea, weight loss, anorexia • Medications: Mesalamine, Corticosteroids, Anti-diarrheals

19. Crohn’s vs. Ulcerative Colitis

20. Small Bowel Disorders: Inflammatory Bowel Disease Malnutrition and Nutrient Deficiency Concerns: • Iron deficiency • Zinc deficiency • Folate deficiency (with use of Sulfasalazine) • Vitamin B12 deficiency (Crohn’s Disease) • Vitamin D and Calcium (bone disease concerns with long term steroid use)

21. ★ IBD: MNT • Maintain/correct fluid and electrolyte imbalances • High calorie, high protein diet (BEE x 1.5, 1-1.5 g/kg protein) • Low residue/low fiber diet (during flare ups) • Repletion and supplementation of micronutrients • Bowel Rest/TPN for acute flare-ups • Anti-diarrheal agents • Monitor closely for lactose intolerance

22. ★ IBD: MNT Specific Concerns After an Intestinal Resection • Integrity of the ileocecal valve • Encourage early PO or enteral nutrition • Villi adaption • Feeding transitions/overlapping feeding modalities • Use of soluble-fiber (pectins) may be beneficial • Low-fat diet, lactose-free diet

23. Small Bowel Disorders: Short Bowel Syndrome (SBS) • Diarrhea/steatorrhea malabsorption malnutrition • Occurs after extensive small bowel resection (Crohn’s Disease, Radiation Enteritis, Weight loss surgery)

24. Small Bowel Disorders: Short Bowel Syndrome (SBS) • Typically a 70-75% loss of small bowel (100-120 cm of small bowel without a colon or 50 cm of SB with a colon) • Resultant short-term and long-term problems with malabsorption which lead to fluid imbalance, weight loss, micronutrient deficiencies

25. Small Bowel Disorders: Short Bowel Syndrome (SBS) • Disruption of Ileocecal valve and Ileal break • Small bowel bacterial overgrowth • Role of bile salts in ileum • Unabsorbed bile salts enter colon and cause osmotic diarrhea • Bile salt deficiency can lead to fat malsorptionand steatorrhea Comparison of Normal to Adapted Villi http://www.shortbowel.com/information/beyond/intestinal.adaptation.asp

26. Small Bowel Disorders: Short Bowel Syndrome (SBS) • Medications: • Proton Pump Inhibitors (Nexium, Protonix, Prilosec, Prevacid) –acid reduction • H2 Receptor Antagonists (Tagamet, Pepcid, Zantac) – acid reduction • Anti-secretory agents (Octreotide) – reduce electrolyte and fluid losses • Anti-diarrheals (Immodium, Lomotil, Paragoric) • Antibiotics – treat small bowel bacterial overgrowth • Bile Acid Sequesters (Cholestyramine) – preserve bile acids to aid with fat absorption/prevent steatorrhea

27. ★ SBS: MNT • Whole food diet • High calorie (often 200-400% over their needs) • Adequate fat (as calorie source, despite risk of steatorrhea • Avoid concentrated sweets/simple carbs • Lactose free (only if lactose intolerant) • Moderate fiber (if colon is intact) • Oral rehydration agents • Nutrition support (TPN versus enteral nutrition) • Replace vitamins and minerals (zinc, potassium, Magnesium, fat soluble vitamins, Vitamin B12)

28. The Large Bowel • The often overlooked powerhouse… • Anatomy • Cecum, Colon, Rectum, Anus • Physiology • Absorptive cells (water, Na, Cl, Vit K) • Goblet cells (secrete mucus) • Functions • Absorption • Bacterial digestion • Defecation

29. Large Bowel Disorders: Diverticular Disease • Diverticulosis: small pouches in lining of colon that bulge outward through weak spots • Diverticulitis: small pouches become inflamed, usually treated with antibiotics • Role of fiber: High fiber versus low fiber?

30. Bowel Disorders: Irritable Bowel Syndrome (IBS) • Chronic gastrointestinal condition with symptoms including excess flatulence, abdominal discomfort, bloating • Causative factors can include abnormal gut motility, visceral hypersensitivity, imbalance of the gut flora • Lactose intolerance

31. Foods that Can Aggravate Symptoms of IBS • Milk • Caffeinated beverages • Alcohol • Fruits • Spices • Fast Foods/Chinese Food • Certain vegetables, including cabbage, broccoli, cauliflower and corn • Legumes and beans • Preservatives and artificial flavoring • Baked products

32. ★ IBS: MNT • Maintain food record to help ID problem foods • Eliminate foods that aggravate symptoms (see prior list) • Restrict lactose as needed • Eat small, frequent meals • Aim to consume 6-8 cups of water daily • Exercise regularly • Gradually increase fiber content of diet (goal: 25-30 gm/day) • Role of probiotics

33. Fiber and the GI System: A Review • Soluble fiber: Dissolves in water, slows intestinal transit time • Pectins, gums, mucilages, some hemicelluloses • Found in oat bran, legumes, psyllium (Metamucil) • Insoluble fiber: Does not dissolve in water, speeds intestinal transit time • Lignans, cellulose, some hemicelluloses • Found in wheat bran, most fruits and vegetables

34. Diarrhea Many clinical and medical causes. (1st - identify the underlying cause) • Fever • Dehydration • Infection (bacterial, viral) • Hospital/community borne • Secretory (laxatives, bile acids) • Medications, antibiotics • Electrolyte repletion (MagOx, Neutraphos) • Malabsorption • Malnutrition/Hypoalbuminemia • Post-op lactose intolerance • Clear liquid diets • PSBO “Patient presents with diarrhea. Consult nutrition, it’s probably the tube feed.”

35. Constipation • Common Causes: • Low fiber diet • Inadequate fluid intake/calorie intake • Medication • Vitamin/Mineral supplementation • Food Sensitivities • Treatment: • Fiber supplementation • Potential role of prebiotics/probiotics

36. “I know I learned this at some point”

37. The Gallbladder • Physiology • Stores and concentrates bile that enters from the hepatic and cystic ducts • Ejects bile into the duodenum during digestion

38. Disorders of the Gallbladder, Bile Duct Cholecystitis • Inflammation of the gallbladder • Gallstones (Choleliathsis) Jaundice • Obstruction of the bile duct, bile pigment builds up in the blood stream Cholecystectomy • Surgical removal of the gallbladder MNT Low-fat diet

39. References • American Dietetic Association, Evidence Analysis Library, Accessed electronically, August 2012. • American Dietetic Association, Nutrition Care Manual. Accessed electronically, August 2012. • Clark, Christian and Mark DeLegge. Irritable Bowel Syndrome: A Practical Approach. Nutr Clin Pract 2008 23: 263. • Hark, L, Morrison, G (eds). Medical Nutrition and Disease: A Case Based Approach: 3rd Edition. 2003: Blackwell Publishing. • Jeejeebhoy, K. Short Bowel Syndrome: a Nutritional and Medical Approach. Canadian Medical Association Journal 2002 166: 1297-1302. • Lykins, TC, Stockwell, J. Comprehensive Modified Diet Simplifies Nutrition Management of Adults with Short-Bowel Syndrome. JADA. 98(3): 309-315. March 1998.

40. References • Naik, A. and Nanda Venu. Nutritional Care in Adult Inflammatory Bowel Disease. Practical Gastroenterology, June 2012: 18-27. • Rees Parrish, C. The Clinicians Guide to Short Bowel Syndrome. Practical Gastroenterology, September 2005: 67-106. • Sanjeevi, A. et al. The Role of Food and Dietary Intervention in the Irritable Bowel Syndrome. Practical Gastroenterology, July 2008: 33-42. • Schiller, L. Nutrition and Constipation: Cause or Cure? Practical Gastroenterology, April 2008: 43-49 • Thibodeau, G. et al. Anatomy and Physiology: 5th Edition. 2003: Mosby Publishers.