Chapter 17 Nutrition and Upper Gastrointestinal Disorders

1717Nutrition and

Upper Gastrointestinal

Disorders

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Conditions Affecting the Mouthand Esophagus

• Dry mouth (xerostomia)– Caused by reduced salivary flow

• Side effect of many medications; associated with a number of diseases and disease treatments

– Ways in which dry mouth impairs health• Difficulty swallowing, mouth infections, dental

diseases, increased malnutrition risk, etc.• How can dry mouth be managed? (Table 17-1)



Conditions Affecting the Mouthand Esophagus (cont’d.)

• Dysphagia– Processes involved in swallowing

• Oropharyngeal phase– Mouth and tongue muscles propel the food bolus through

the pharynx and into the esophagus– Food entry into nasal cavity and trachea prevented

• Esophageal phase– Peristalsis forces the bolus through the esophagus– Lower esophageal sphincter relaxes to allow bolus

passage into the stomach



Conditions Affecting the Mouthand Esophagus: Dysphagia (cont’d.)

• Categories of dysphagia– Oropharyngeal dysphagia

• Inhibits the transfer of food from the mouth and pharynx to the esophagus

• Typically a neuromuscular disorder– Esophageal dysphagia

• Interferes with the passage of materials through the esophageal lumen and into the stomach

• Obstruction in the esophagus or a motility disorder



Insert image of second row/block of Table 17-2




• Complications of dysphagia– What are various complications that may

accompany dysphagia?• Nutrition intervention for dysphagia

– Physically modified foods and beverages– Dietary plan requires frequent reassessment– National Dysphagia Diet (Table 17-3)




• Food properties and preparation– Food textures and consistencies chosen or

altered to make them easier to swallow– Solid foods may be pureed, mashed, ground,

or minced– Box 17-4: tips to improve acceptance

• Properties of liquids: thin, nectarlike, honeylike, and spoon-thick




• Alternative feeding strategies for dysphagia– Change head and neck position while eating

and drinking– Strengthen the jaws, tongue, or larynx

(through exercises)– Learn new swallowing methods



Conditions Affecting the Mouthand Esophagus (cont’d.)

• Gastroesophageal reflux disease (GERD)– Frequent reflux (backward flow) of the

stomach’s acidic contents into the esophagus– Heartburn or acid indigestion

• Causes of GERD– Weak lower esophageal sphincter muscle– Predisposing factors: high stomach

pressures; inadequate acid clearance from esophagus



Conditions Affecting the Mouthand Esophagus: GERD (cont’d.)

• Causes of GERD– High rates of GERD associated with obesity,

pregnancy, and hiatal hernia



The Upper GI Tract, Acid Reflux, and Hiatal Hernia











• Consequences of GERD– Reflux esophagitis– Esophageal ulcers– Dysphagia– Pulmonary disease (due to aspiration)– Barrett’s esophagus– Mouth damage




• Treatment of GERD– Alleviate symptoms and facilitate healing– Acid-suppressing drugs: proton-pump

inhibitors, histamine-2 receptor blockers– Lifestyle changes (Box 17-6)– Surgery: fundoplication, esophageal dilation– Example: Box 17-7 (case study)



Conditions Affecting the Stomach

• Dyspepsia: symptoms of pain or discomfort in the upper abdominal area– Causes of dyspepsia

• Various medical problems: foodborne illness, GERD, peptic ulcers, gastric motility disorders, gallbladder or pancreatic disease, tumors

• Some chronic diseases, e.g., diabetes mellitus• Medications, dietary supplements• Other conditions



Conditions Affecting the Stomach: Dyspepsia (cont’d.)

• Potential food intolerances– Consume small, frequent meals– Avoid fatty or highly spiced foods– Avoid the specific foods believed to trigger

symptoms• Bloating and stomach gas

– Avoid air-swallowing practices: gum chewing, smoking, rapid eating, drinking carbonated beverages, and using a straw



Conditions Affecting the Stomach (cont’d.)

• Nausea and vomiting– What health problems occur with prolonged

vomiting?– Vomiting with abdominal pain: GI disorder or

obstruction– Vomiting without abdominal pain:

medications, foodborne illness, pregnancy, motion sickness, neurological disease, etc.



Conditions Affecting the Stomach: Nausea and Vomiting (cont’d.)

• Treatment of nausea and vomiting– Find and correct the underlying cause– Restore hydration– Take medication with food– May need suppressive medication– What may be necessary in cases of

intractable vomiting?



Conditions Affecting the Stomach: Nausea and Vomiting (cont’d.)

• Dietary interventions– Small meals– Beverages between meals– Dry, starchy foods or cold/room temperature

foods may be better tolerated– Fatty, spicy, strong-smelling, or hot foods may

be less tolerated




• Gastritis: inflammation of the stomach mucosa– Acute cases

• Caused by irritating substances or treatments that damage the gastric mucosa

– Chronic cases• Caused by long-term infections: Helicobacter pylori • Autoimmune disease• Nonsteroidal anti-inflammatory drugs (NSAIDs)





Conditions Affecting the Stomach: Gastritis (cont’d.)

• Complications of gastritis– Disrupted gastric secretory functions

• Hypochlorhydria or achlorhydria can impair absorption of nonheme iron and vitamin B12

• Pernicious anemia (reduces intrinsic factor) results in macrocytic anemia of vitamin B12 deficiency

• Dietary interventions for gastritis– Avoid irritating foods and beverages– Iron and vitamin B12 supplements




• Peptic ulcer disease– Peptic ulcer: open sore in the GI mucosa– H. pylori infection

• 30% to 60% of patients with gastric ulcers• 70% to 90% of patients with duodenal ulcers

– NSAIDs: damage the GI lining– Smoking and psychological stress can

increase risk



Conditions Affecting the Stomach: Peptic Ulcer Disease (cont’d.)

• Effects of psychological stress– May contribute to risk by producing hormonal

or behavioral changes• Symptoms of peptic ulcers

– Vary: asymptomatic or mild discomfort; hunger pain or burning pain in the stomach

– Tend to go into remission and recur every few weeks or months




• Complications of peptic ulcers– GI bleeding– Stomach or duodenum perforations– Ulcer penetration into an adjacent organ– Gastric outlet obstruction

• Drug therapy for peptic ulcers– What are the goals of ulcer treatment?




• Drug therapy for peptic ulcers– Discontinue aspirin and other NSAIDs– Antibiotics for H. pylori– Antisecretory drugs

• Nutrition care for peptic ulcers– What are the goals of nutrition care for peptic

ulcers?– What are typical interventions?



Gastric Surgery

• Gastrectomy– Partial gastrectomy

• Only part of the stomach is removed• Remaining portion is connected to the duodenum

or jejunum– Total gastrectomy

• Entire stomach removed• Esophagus connected directly to the small

intestine



Gastrectomy Procedures



Gastric Surgery: Gastrectomy (cont’d.)

• Nutrition care after gastrectomy (Table 17-6)– What are the primary goals of nutrition care

after a gastrectomy?– Feeding progression:

• NPO with intravenous feeding• Water and broth (oral fluids)• Liquid meals (with no sugar)• Solids with one or two foods at a time




• Nutrition care after gastrectomy– Dietary measures determined by size of

remaining stomach, stomach emptying rate– As many as 5-8 small meals per day

• Protein food in each meal– Avoid sweets and sugars (can potentiate

dumping syndrome)– Liquids restricted during meals




• Dumping syndrome: symptoms caused by rapid gastric emptying– Flow from stomach to duodenum normally

controlled by pyloric sphincter– After some types of gastric surgery, stomach

emptying is no longer regulated• Hyperosmolar chyme rushes into small intestine

– Box 17-11 offers symptom reduction tips





• Nutrition problems following a gastrectomy– Food avoidance; substantial weight loss; and

eventually, malnutrition– Fat malabsorption– Bone disease: osteoporosis and osteomalacia– Anemia



Gastric Surgery (cont’d.)

• Bariatric surgery: most effective and durable treatment for morbid obesity– Candidates

• BMI >40• BMI 35 to 40 accompanied by severe weight-

related problems• Patient should have attempted a variety of

nonsurgical weight-loss measures



Gastric Surgery: Bariatric Surgery (cont’d.)

• Bariatric surgical procedures– Gastric bypass: small gastric pouch

constructed; connected directly to the jejunum– Gastric banding: inflatable band placed

around uppermost portion of the stomach– Sleeve gastrectomy: large portion of stomach

removed, leaving narrow tube (3-5 oz.)• Can be converted to gastric bypass

– How do these surgeries compare?



Surgical Procedures for Severe Obesity




• Nutrition care after bariatric surgery– Objectives:

• Maximize and maintain weight loss• Ensure appropriate nutrient intakes• Maintain hydration• Avoid complications

– Diet progression similar to postgastrectomy– Small portions of food; liquids separately




• Nutrition care after bariatric surgery– Protein: 1.0 to 1.5 g/kg IBW/day– Vitamin and mineral supplementation

• After bypass, additional B12, D, calcium, iron– Avoid foods that may obstruct gastric outlet– Control food portions, avoid high-sugar foods,

consume liquids between meals– Box 17-14: behavior change strategies




• Postsurgical concerns– Common complaints

• Nausea, vomiting, and constipation– Long-term complications (after bypass)

• Fat malabsorption, bone disease, and anemia– Rapid weight loss

• Increases risk of gallbladder disease• Leaves excess skin that may need to be removed



Nutrition in Practice:Nutrition in Oral Health

• Dental caries development• Cariogenic and anti-cariogenic foods• Periodontal disease• Conditions that increase risk of oral health

problems– Diabetes mellitus, HIV/AIDS, oral cancers

• Role of dental bacteria in chronic disease– Heart disease, diabetes, respiratory illnesses


Education

Chapter 17 Nutrition and Upper Gastrointestinal Disorders