Medical nutrition therapy 1

Medical Nutrition Therapy

التغذية العالجية

1

Dr. Louay Labban

أمراض الجهاز الهضمي العلوي•

أمراض الجهاز الهضمي السفلي•

الداء السكري•

أمراض القلب واالوعية الدموية•

االمراض الكلوية•

NUTRITION AND DISORDERS OF THE UPPER GASTROINTESTINAL

TRACT التغذية في أمراض الجهاز العضمي العلوي

© 2006 Thomson-Wadsworth

Conditions Affecting the Esophagus

االمراض التي تؤثر على المري

Dysphagia عسر البلع

The act of swallowing is complex.

The initial phase – oropharyngeal

The second phase - esophageal


Types of dysphagia

– Oropharyngeal dysphagia – affects the transfer of food from the mouth and pharynx to the esophagus.

• Symptoms include:

• Inability to initiate swallowing

• Coughing during or after swallowing

• Nasal regurgitation

• Other signs include:

• Bad breath, gurgling noise after swallowing, a hoarse or “wet” voice, speech disorder

– Esophageal dysphagia – difficulty passing a bolus of food through the esophageal lumen and into the stomach due to either an obstruction in the esophagus (usually a stricture) or to a motility disorder (achalasia).

Complications of dysphagia

– Aspiration

– Malnutrition

– Weight loss may occur

– Increased risk of dehydration

Evaluating dysphagia

– Barium swallow study

– Endoscopy

– Neurological examination

Dietary interventions

– factors that may help:

– Physical properties of foods and beverages

– Food preparation

– Alternate feeding methods

– Reassessment of the dietary plan over time

– Adjustment to suit a person’s swallowing abilities and tolerances

– Consultation with a swallowing expert – speech and language therapist




Food Properties

– Easy-to-manage textures and consistencies

– Soft, cohesive foods – not hard or crumbly

– Moist foods – not dry or sticky or gummy

– Viscous beverages (milk shakes)


Food Preparation

– Alteration of food texture – pureed, mashed, ground, or minced

– One consistency

– Avoid nuts and seeds

– Addition of commercial starch thickeners or baby cereals to thicken liquids


Feeding strategies

– Learn exercises that strengthen the jaws, tongue, or larynx

– Changing head and neck posture while eating

Speech and language therapists can help patients learn these techniques.


Enteral nutrition support

– Tube feedings given to patients – unable to consume adequate amounts of foods

– Intestinal feedings used if an individual is at high risk of aspiration


Gastroesophageal Reflux Disease – GERD

القلس أو أرتداد الطعام



Symptoms

– Hearburn – most common GI complaint

– Regurgitation – reflux of small amounts of stomach acid into the mouth

With GERD – gastric reflux causes frequent discomfort and, sometimes, tissue damage.


Causes of GERD

– Weakening or inappropriate relaxation of lower esophageal sphincter

– Associated with pregnancy, asthma, and hiatal hernia



Consequences of GERD

– Reflux esophagitis

– Esophageal ulcers

– Scarring of ulcerated tissue

– Strictures

– Barrett’s esophagus – increased risk of cancer

– Pulmonary disease


Treatment of GERD

– drug therapy

– Proton-pump inhibitors

– Histamine-2-receptor blocking agents

– Antacids


lifestyle modifications

– Avoid eating bedtime snacks or lying down immediately after meals

– Consume meals 2-3 hours before bedtime

– Elevate head of bed on 6-inch blocks

– Prop pillows under the head and upper torso


– Consume small meals and drink liquids between meals

– Limit foods that weaken lower esophageal sphincter pressure or increase gastric acid secretion

– Avoid smoking and alcohol

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– Avoid bending over and wearing tight clothing that increases pressure in the stomach

– Lose weight if needed

– Avoid foods and beverages that irritate the esophagus during periods of esophagitis


– Avoid use of non-steroidal anti-inflammatory drugs (NSAIDS)


• Other interventions

– Surgery – fundoplication

– Esophageal strictures – dilatation of the esophagus


Conditions Affecting the Stomach

االمراض التي تؤثر على المعدة


Dyspepsia عسر الهضم

• Symptoms

– Indigestion in the upper abdominal area

– Stomach pain

– Heartburn

– Fullness

– Nausea

– Bloating


Causes of dyspepsia

– Medical conditions – peptic ulcers, GERD, motility disorders, malabsorptive disorders, gallbladder disease, abdominal tumors

– Medications

– Dietary supplements


– Systemic disorders – Diabetes mellitus, renal disease, thyroid disease, heart failure

– Lactose intolerance and irritable bowel syndrome can mimic dyspesia


• Bloating and stomach gas

– Chewing gum

– Smoking

– Rapid eating, drinking carbonated beverages

– Using a straw


Potential food intolerances

– Overeating

– Specific foods – spicy

– Coffee including decaffeinated

– High-fat foods

– Advised to consume small meals, well-cooked foods - not overly seasoned, in a relaxed atmosphere


Nausea and Vomiting

• Causes

– Side effects of medications

– Triggered by motion sickness, food odors, and emotional stress

– Common in pregnancy

– Chronic vomiting can lead to malnutrition and nutrient deficiencies


Treatment of nausea and vomiting

– Correct the underlying disorder

– Restore hydration

– Intractable vomiting may require intravenous nutrition support


Dietary interventions

– Eating and drinking slowly

– Drinking clear, cold beverages – carbonated drinks or fruit juices may ease symptoms

– Dry, salty foods – crackers or pretzels

– Avoid fried or spicy foods at bedtime

– Avoid foods with strong odors

– Cold or room temperature foods better tolerated


Gastritis

Inflammation of the stomach mucosa

• Causes – H. pylori, use of NSAIDS

• Can lead to disruption of gastric secretory functions

– Hypochlorhydria

– Achlorhydria

– Pernicious anemia



– Avoid irritating food and beverages

– Avoid food intake for 24-48 hours if food consumption increases pain or causes nausea and vomiting

– Nutrition support may be needed if food not tolerated for prolonged period

– Supplementation of iron and B12 may be warranted


Peptic Ulcer Disease

Primary cause –

H. pylori

• Gastric ulcers –

60%

• Duodenal ulcers 80%

• Zollinger-Ellison syndrome


• Effects of emotional stress

– Has effects on physiological processes

• Rapid stomach emptying

• Hormonal changes that impair wound healing

• Increased acid and pepsin secretions

– Behavioral changes

• Use of alcohol

• Tobacco use

• NSAID use


Peptic Ulcer Disease

• Signs and symptoms

– Hunger pain

– Gnawing or burning pain in stomach region

– Sometimes aggravated by food – causes loss of appetite and weight loss


Complications

– GI bleeding, hemorrhage

– Perforations of the stomach or duodenum

– Gastric outlet obstruction


Drug therapy

– Proton-pump inhibitors

– H2 blockers

– Antacids

– Bismuth preparations

– Triple therapy – two antibiotics (amoxicillin, tetracycline, metronidazole, or clarithromycin) and one other drug


Dietary considerations

– Individualized to personal tolerances

– Avoid foods that irritate – alcohol, coffee, caffeine, spicy foods

– Avoid large meals


Gastric Surgery

• Effective treatment for severe obesity

• Treat peptic ulcers – resistant to drug therapy or to correct ulcer complications

• Treat stomach cancer


Surgical procedures

Bariatric surgery

– Gastroplasty رأب المعدة

– Gastric bypass surgery تجاوز المعدة

Total gastrectomy أستئصال المعدة

Gastric resection أعادة تقسيم المعدة

Vagotomy فطع المبهم

Pyloroplasty رأب البواب


Gastric Surgery


The post-gastrectomy diet

– Fluids and food withheld until some healing has occurred

– Fluids initially given intravenously

– Fluid balance carefully monitored

– Ice chips or small sips of water allowed 24-48 hours post-op

– Progressed from clear liquids to solid foods by 4th or 5th post-op day


– Dietary adjustments influenced by the size of the remaining stomach

– Small, frequent meals and snacks

– Includes mostly soft, low-fat foods

– High in complex carbohydrates

– Avoid sweets and sugars

– Liquids limited during meals (½ cup)

– Specific food intolerances



Dumping syndrome

– Group of symptoms resulting from abnormally rapid gastric emptying

– Common complication of gastrectomy and gastric bypass surgery

– Caused by hypertonic gastric contents rushing into the intestines after meals


– Early symptoms occur within 30 minutes

– Early symptoms include nausea, vomiting, abdominal cramping, diarrhea, lightheadedness, rapid heartbeat

– Above symptoms caused from

• Large fluid shift from blood plasma to intestines that lowers blood volume

• An increase in peristaltic activity


– Later symptoms occur several hours later – Hypoglycemia due to spike in blood glucose following meal – and excessive insulin response

– Small frequent meals, limit fluids during meals, sugars restricted

– Addition of pectin and guar gum

– Medications – octreotide

– Additional surgery



Post-surgical complications and nutrition status

– Discomfort with meals

– Food avoidance

– Weight loss

– Malnutrition

– Steatorrhea


Steatorrhea

– Fat malabsorption

– Bacterial overgrowth

– Treat with medium chain triglycerides and supplemental pancreatic enzymes


Bone disease

– Fat malabsorption – calcium and vitamin D malabsorption

– Avoidance of milk to minimize dumping syndrome – increases risk of calcium and vitamin D deficiencies

– Osteoporois and osteomalcia incidence is high in gastrectomy patients – monitor bone density – during years after surgery

– Supplementation of calcium and vitamin D


Anemia

– High risk for iron and B12 anemia

– May take several years to develop

– Reduced gastric secretions impair absorption of iron and B12

– Duodenum is major site of iron absorption – iron absorption reduced if duodenum has been removed or bypassed

– Supplementation of iron and B12


Bariatric surgery

– Effective treatments for morbid obesity

– Can dramatically affect health and nutrition status

– Patients require lifelong management

– Weight loss most rapid in first six months after surgery – stabilizes after 18-24 months


Dietary guidelines after bariatric surgery

– First day or two – ice chips and small sips of water

– Full liquid diet – given 1-2 weeks

– Progressed to pureed foods for 1-2 weeks

– Progressed to soft foods and finally regular foods

– 5-6 small meals per day


– Patient education and counseling – critical

– Food portion sizes – controlled

– Teach patient elements of a healthy diet

– Avoid foods that may cause abdominal discomfort, vomiting or dumping syndrome

– Dietary supplements


Post-surgical concerns – Dumping syndrome

– Malabsorption

– Multiple nutrient deficiencies

– Gallbladder disease – patients at risk may have their gallbladders removed during bariatric surgery

– Plastic surgery may be necessary to remove extra skin


Dental Health and Its Relationship with Chronic Illness


Dental Health

• Periodontal disease – Inflammatory conditions involving the

periodontium – tissues that support the tooth in its bony socket (gingiva, connective tissues, and bone underneath)

– Gingivitis – characterized by redness, bleeding, and swelling of gum tissue

– Periodontitis – inflammation of tissues surrounding the tooth; may cause tooth loss if untreated



– Risk factors • Dental plaque • Tobacco smoking • Impaired immunity

– Signs and symptoms • Gingivitis – bleeding, swollen, tender gums • Gap between infected gum and tooth deepens • Bad taste in mouth / persistent bad breath • Treatments: cleaning, antimicrobial rinses, topical

antibiotics, surgery


Dry mouth

– Many medications reduce salivary flow

– Poorly controlled diabetes

– Conditions that affect salivary gland function (e.g. Sjögren’s syndrome)

– Radiation therapy

– Can impair health: interferes with speech, bad breath, mouth infections, difficulty chewing/swallowing, discomfort or ulcerations from dentures



Dental health and chronic illness

– Diabetes mellitus

• Periodontal disease is more prevalent

• High risk of dental caries and oral fungal infections

– Human immunodeficiency virus (HIV) / AIDS

• Decreased immunity increases risk of periodontal disease


– Oral cancers

• Radiation treatment can cause severe oral and dental complications


– Dental health and disease risk

• Immune response – inflammatory process induced by periodontal disease activates cytokines and other mediators

• Respiratory illnesses – caused by bacteria which colonize teeth

• Atherosclerosis and heart disease – blood vessel cells attacked by bacteria associated with gingivitis

• Diabetes mellitus – periodontal disease can make attaining glucose control difficult

Health & Medicine

Medical nutrition therapy 1