ch 20 lower GI disorders

Nutrient absorption primarily takes place in the

Duodenum / Jejunum

_________ absorbs water and electrolytes and promotes the elimination of solid wastes

Large intestine

Accessory organs

liver, gallbladder, and pancreas

Constipation

• < 3 BM weekly

  • Daily BM’s aren’t necessary

• Passing hard stools

• Excessive straining during defecation

• Can occur secondary to irregular bowel habits, psychogenic factors, lack of activity, chronic laxative use, inadequate intake of fluid/fiber, metabolic and endocrine disorders, and bowel abnormalities (tumors, hernias, strictures)

• Can be caused by certain meds (Opiates, Antidepressants, Diuretics, Iron supplements)

Constipation - Nutrition therapy

• treated by treating the underlying cause

• relief & prevention: increasing fiber & fluid intake and aerobic exercise

  • Increase fiber gradually and throughout the day while drinking more fluids to prevent bloating, GI discomfort, and diarrhea.

  • Adequate fiber intake = 25-38 g/day

  • Fiber supplements may help if dietary intake is insufficient

• Consuming probiotics or prebiotics

  • Introducing probiotics too fast can also cause diarrhea or constipation

Diarrhea

• an increase in the frequency of BM’s and/or water content of stools

  • Potential for hyponatremia, hypokalemia, dehydration, acid–base imbalance, and metabolic acidosis

• Chronic → can lead to malnutrition

• Impaired digestion, absorption, and/or intake

• May lead to poor intake as some avoid eating to reduce BM’s

Osmotic diarrhea

• Increase in particles in the intestine

• Draws water in to dilute the high concentration

• Causes include maldigestion of nutrients (lactose intolerance), excessive intake of sorbitol or fructose, dumping syndrome, tube feedings, and some laxatives

  • If lactose isn't digested, larger particles reach the intestines undigested

    • interventions: avoid lactose or take a lactase pill to help digest it

• Cured by treating the underlying cause

• Low fiber or soluble fiber diet is helpful

Secretory diarrhea

• Related to an excessive secretion of fluid and electrolytes into the intestines

• Caused by infections, some medications, some GI disorders, and an excessive amount of bile acids or unabsorbed fatty acids in the colon

• Treatment:

  • Antibiotics if cause is infectious

  • Symptoms may be treated with meds that decrease GI motility or thicken the consistency of stools

  • Adding in soluble fiber into the diet will be very helpful

Antibiotic-acquired diarrhea

• Caused by disrupted gut bacteria or GI irritation from antibiotics

  • Usually acute; stops when antibiotics are discontinued

• Most cases are mild and self-limiting

• Overgrowth of C. difficile is the most clinically significant form; severe cases may cause watery diarrhea of up to 10-15 times/day

• Pseudomembranous colitis (toxic megacolon) is a severe complication

Diarrhea - Nutrition therapy

• Maintaining or restoring fluid and electrolyte balance

• Mild diarrhea lasting 24-48 hours:

  • usually resolves without intervention other than drinking plenty of fluids to replace losses

  • eat high-potassium foods (bananas and potatoes which are also gentle on the stomach)

  • limit clear liquids to avoid osmotic diarrhea

• severe cases = use commercial or homemade oral rehydration solutions (Gatorade, Pedialyte, etc.)

• avoid foods that stimulate GI motility

• A low-fiber, low fat, low lactose diet

• Probiotics

• Intractable diarrhea may require bowel rest

Malabsorption Disorders

• describes altered or inadequate nutrient absorption from the GI tract

  • Nutrient maldigestion = 1 or a few nutrients affected

  • Changes to the absorptive intestinal surface can cause nutrient deficiencies and weight loss.

• Symptoms vary with the underlying disorder

• Can cause metabolic complications

Malabsorption Disorders - Steatorrhea

• Excretion of fat in the stool

• Essential fatty acids, fat-soluble vitamins, calcium, and magnesium are also lost through the stool

Malabsorption Disorders - goals of nutrition therapy

• control steatorrhea

• promote normal bowel elimination

• restore optimal nutritional status

• promote healing, when applicable

• Individualized according to symptoms and complications

• Low fat, low fiber diet; fluids/electrolytes; avoid foods that trigger symptoms; small frequent meals

Inflammatory bowel disease (IBD), Celiac disease, Nonceliac gluten sensitivity (NCGS), Short bowel syndrome (SBS), and Lactose malabsorption/intolerance are _________ disorders

Malabsorption

Lactose malabsorption/intolerance

• Occurs when the level of lactase is absent or deficient, therefore impairing lactose digestion

• Undigested lactose increases the osmolality of the intestinal contents which may lead to osmotic diarrhea

• Types (all separate flashcards):

  • Congenital

  • Non-persistence

  • Secondary

Congenital lactase deficiency

rare; complete lack of lactase (born without this lactose enzyme at all)

Lactase non-persistence

common; lactase activity reaches a peak at birth but decreases during childhood

Secondary lactase deficiency

• occurs in people who digest lactose but develop a GI condition (gastroenteritis, IBD, celiac) that affects villi cells, where lactase is secreted

  • temporary but more severe/rapid symptoms

• malnutrition → decrease in number and function of intestinal cells that produce lactase → lactase loss

• Tends to be more severe than primary lactose intolerance

Primary lactose intolerance

• occurs in “well” people who simply do not secrete adequate lactase

• least common in people of Northern European descent, who eat more dairy, and more common in those who consume less dairy.

• Know individual limits

• Lactose-reduced milk and lactase enzyme tablets or liquid may be used

• may be asymptomatic with less than 12g of lactose (about ⅓ to 1 cup of milk) or when consumed with a meal

  • Some people tolerate cheese or yogurt better because the fermentation process breaks down lactose, making it easier to digest.

Lactose malabsorption - Nutrition therapy

• reduce lactose to the maximum amount tolerated by the individual

• A lactose-free diet is possible but a big lifestyle change

  • Lactose is sometimes in medications as well

Inflammatory bowel disease (IBD)

• Primarily refers to two chronic inflammatory GI diseases: Crohn’s disease (CD) and Ulcerative colitis (UC) (separate flashcards)

• Likely caused by an abnormal immune response to environmental and genetic factors

• Smoking, antibiotics, and diet are modifiable risk factors

• Marked by cycles of flare-ups and remission

• A diet high in fruits, vegetables, and omega-3s, but low in omega-6s, may reduce risk

• Vitamin D and zinc may lower the risk of CD but not UC

• Malnutrition risk is higher in CD than in UC, but can occur in both

Crohn’s disease (CD)

most commonly occurs in the ileum and colon, but can be anywhere in the GI tract

Ulcerative colitis (UC)

• most commonly occurs in the rectum and colon

• continuous pattern of inflammation only in the mucosal layer

• Malabsorption and inflammation can impact fluids/electrolytes and nutrient absorption, may lead to strictures/obstructions

• Tx: immunosuppressants, antidiarrheals, anti-inflammatories

Inflammatory bowel disease (IBD) - Nutrition therapy

• Depends on the presence and severity of symptoms, the presence of complications, and the nutritional status of the patient

• Diet restrictions are minimized and adjusted based on symptoms

• Patients are often reluctant to eat

• Low fiber diet minimizes bowel stimulation (ex: diarrhea)

• main goal during flare-up = correct deficiencies by providing easily digestible nutrients.

• Protein and calorie needs are elevated to facilitate healing

Celiac disease

• genetic autoimmune disorder causing chronic inflammation of the proximal small intestine mucosa

• Triggered by permanent gluten intolerance (wheat, barley, rye)

• Gluten is avoided to prevent intestinal damage, even without symptoms

• Leads to malabsorption of nutrients, causing diarrhea, gas, weight loss, and deficiencies.

• Children symptoms: Diarrhea, abdominal distention, failure to thrive (delayed milestones)

• Adult symptoms: Diarrhea, constipation, weight loss, weakness, gas, abdominal pain, and vomiting.

• Diagnosed with a duodenal biopsy and positive serology.

  • Gluten must be consumed before testing to confirm inflammation.

• Complications: Hyposplenism, intestinal lymphoma, small bowel adenocarcinoma, and ulcerative jejunoileitis

  • Suspected if symptoms persist despite a gluten-free diet

• At-risk individuals: having a first-degree relative, Down syndrome, autoimmune disease

Celiac disease - Nutrition therapy

• total and permanent gluten-free diet

  • expensive

• Lactose intolerance secondary to celiac disease may be temporary or permanent

Nonceliac gluten sensitivity (NCGS)

• Lacks celiac disease features but develops celiac-like symptoms from gluten.

• Experience improvement or disappearance of symptoms when gluten is eliminated from the diet

Short bowel syndrome (SBS)

• occurs when surgical removal of the bowel leaves insufficient length to absorb enough nutrients

  • seen in Crohn disease, traumatic abdominal injuries, malignant tumors, mesenteric infarction (Intestinal tissue death due to a sudden loss of blood supply, often due to a blockage in the mesenteric arteries)

• Nutrition complications depend on the amount and location of remaining bowel

  • Clients with <100 cm of small bowel ending in a jejunostomy may require permanent parenteral nutrition (PN) and hydration

• these pts need to increase their fluid intake

Short bowel syndrome (SBS) - Factors that influence adaptation

• Length of remaining jejunum and/or ileum and whether the colon is present

• Patient’s age

• Whether the ileocecal value remains

• Health of the remaining bowel

• Health of the stomach, liver, and pancreas

Short bowel syndrome (SBS) - Symptoms

• Diarrhea/malabsorption/steatorrhea

• Electrolyte imbalances/dehydration

• Weight loss

• Fat-soluble vitamin deficiencies

• Oxalate kidney stones

• Metabolic acidosis

• Metabolic bone disease

• Impaired wound healing

Short bowel syndrome (SBS) - Nutrition therapy

• In the early months post-bowel surgery, PN provides most nutrition and hydration

• Starting EN soon after surgery helps bowel adaptation, and later, adding oral feedings with EN can help reduce PN

• Consuming intact nutrients aids bowel adaptation by stimulating intestinal blood flow and digestive secretions

Irritable bowel syndrome, Diverticular disease (DD), and Ileostomies and colostomies are conditions of the ______________

large intestines

Irritable bowel syndrome (IBS)

• Most frequently diagnosed digestive disorder in USA

• Symptoms include lower abdominal pain, constipation, diarrhea, alternating periods of constipation and diarrhea, bloating, and mucus in the stools

• Can significantly impair quality of life

• Sometimes treated with antianxiety medications

• Life stressors can trigger or ­worsen symptoms, lack of regular sleep, and ­inadequate fluid intake

• Factors that may contribute: disruption of the brain–gut axis, gut dysmotility, visceral hypersensitivity, low-grade mucosal inflammation, increased intestinal permeability, and altered microbiota

Irritable bowel syndrome (IBS) - Nutrition therapy

• avoid FODMAPs which are poorly absorbed, fast-fermenting carbs

  • avoid them completely for 4–6 weeks, then slowly reintroduce foods one by one to identify triggers.

• Eat smaller, more frequent meals

• Reduce fat intake

• Avoid caffeine, chocolate, and alcohol

• Slowly increase soluble fiber intake

• Probiotics

• Peppermint oil improves cramping but may cause GERD or constipation

• unproven but safe supplements = chamomile tea, evening primrose oil, fennel seeds

Diverticular disease (DD)

• Typically, asymptomatic

• complicated if abscess, perforation, fistula formation, or obstruction occur

• occurs when diverticula become inflamed

• Dietary risk factors = unprocessed red meat intake

• rich in fruits, vegetables, whole grains, ­legumes, poultry, nuts, seeds, and fish

  • high fiber

  • “prudent diet” aka balanced diet

• No scientific evidence that proves nuts and seeds cause flares of diverticulitis

• Efficacy of probiotics in different phases of diverticular disease is not fully understood

Ileostomies and colostomies

• Performed after part or all the colon, anus, and rectum are removed

• The smaller the length of remaining colon, the greater is the potential for nutritional problems

Ileostomies

• occur in the small intestines

• cause a decrease in fat, bile acid, and vitamin B12 absorption

• Results in 1200 mL of output each day

• Stools are liquid to semi-liquid

Colostomies

• created in the colon

• little or no nutrient loss

• Output out 200-600 mL/day

• Stools range from semi-liquid to hard

Ileostomies and colostomies - Nutrition therapy

• process of nutrient absorption is interrupted at the point of the stoma

• Restrictions should be kept to a minimum

• Eat 4 to 6 small meals per day

• Chew food thoroughly

• Avoid mushrooms, nuts, corn, coconut, celery, and dried fruit for the first 2 weeks after surgery

  • Slowly reintroduce these foods, as desired, in moderation

• Eat a source of protein at each meal and snack

• Consume adequate fluid, at least 80 oz/day to protect kidney function

Liver disease

• almost all nutrients are transported here AFTER absorption

• Vital for detoxifying drugs, alcohol, ammonia, and other poisonous substances

• damage can have profound and devastating effects on the metabolism of almost all nutrients

• Failure can occur from chronic liver disease or secondary to critical illnesses

Fatty liver disease

• Abnormal fat deposition in the liver

• Occurs in clients with alcoholic liver disease

• Nonalcoholic fatty liver disease (NAFLD)

  • Simple hepatic steatosis, which is often asymptomatic

  • Benign to nonalcoholic steatohepatitis (NASH) characterized by inflammation and liver cell damage

  • Complications such as advanced fibrosis, cirrhosis, and hepatocellular carcinoma may result

Cirrhosis

• Irreversible liver disease that occurs when damaged liver cells are replaced by functionless scar tissue, impairing liver function and disrupting normal blood circulation through the liver

• Strongly associated with obesity and metabolic syndrome

• Twice as likely to die of CVD than liver disease

• Treatment: controlling underlying risk factors, such as obesity, diabetes, and hyperlipidemia

  • Sustained weight loss is the most effective treatment

• Lifestyle interventions: healthy eating and physical activity

Nonalcoholic fatty liver disease (NAFLD) - Nutrition therapy

• Reduce calories → gradual weight loss (7-10% recommended)

• recommended dietary pattern = Mediterranean

• Limit alcohol

• no liver-related restrictions on coffee intake as it may actually have a protective effect

• Both aerobic and resistance training reduce liver fat

  • 150-200 min/week of moderate intensity aerobic physical activities recommended

• bariatric surgery for those unable to achieve weight loss and metabolic improvements with lifestyle modification

Hepatitis

• inflammation of the liver

• cause: viral infections, alcohol abuse, hepatotoxic chemicals

• Early symptoms: anorexia, N/V, fever, fatigue, headache, and weight loss

• Later symptoms: dark-colored urine, jaundice, liver tenderness, and possible liver enlargement may develop

• Cell damage caused by acute type A is reversible with proper rest and nutrition

Hepatitis - Nutrition therapy

• avoid or minimize permanent damage and complications

• promote liver cell regeneration (if possible, depends on severity of condition)

• restore optimal nutritional status

• alleviate symptoms

• diet:

  • acute hepatitis (first 6 months) diet should be adequate in calories, protein, and micronutrients

  • chronic hepatitis (beyond 6 months) diet modifications are based on symptoms

  • food restrictions not necessary

  • Limit sodium to 2 g/day if there is fluid retention

  • Consume 4-6 small meals and/or snacks to promote adequate intake

  • Consume 1.0-1.2g protein/kg (Slightly more than the normal 0.8g)

  • if hyperglycemia develops, follow a carb-controlled eating pattern

  • Limit fat to <30% of total calories if steatorrhea develops

Hepatic encephalopathy - Nutrition therapy

• Protein restriction is contraindicated

  • Protein in plants and dairy products may be better tolerated than meats

• Supplements of branch chain amino acids may provide neuropsychiatric benefits

  • this condition causes confusion as a primary symptom

• Clients who are unable to consume an adequate oral intake need EN or PN

  • this condition causes confusion as a primary symptom

Liver transplantation - Presurgical nutritional recommendations

30 cal/kg/day and 1.2g of protein/kg/day for clients with adequate nutritional status

• Increase calories to 35 cal/kg and protein to 1.5 g/kg in clients who need nutritional repletion

Liver transplantation - Post-surgical nutritional recommendations

• start oral or EN intake within 24 hrs after surgery

• PN is used if EN is contraindicated or impractical

• 35 cal/kg and 1.5 g protein/kg after the acute postop period

• 25 cal/kg/day and 2.0 g protein/kg/day for obese patients receiving EN or PN

• Long-term survivors are at high risk of overweight or obesity and comorbidities of metabolic syndrome

Pancreatitis

• Inflammation of the pancreas

• Can be triggered by drugs, alcohol, gallstones, or hypertriglyceridemia

• Causes a breakdown of barrier defenses, impaired immune function, development of a virulent Patho biome, gut-derived sepsis, and multiple organ failures

• May develop hyperglycemia and self-digestion of the pancreas

• if digestive enzymes become active inside the pancreas, they start “digesting” the pancreas itself

• chronic ______ is characterized by loss of organ function, diabetes, steatorrhea, and malabsorption → diarrhea & malnutrition

  • steatorrhea and malabsorption since there isnt enough enzymes to break down fats

Pancreatitis - Nutrition therapy

• Mid acute ________ is treated by reducing pancreatic stimulation

• Encourage an oral diet

• Clear liquid diets are not necessary

• In severe acute ________, early initiation of EN via NG route is recommended

  • EN initiated within 24-48 hrs

• Most clients can be managed with an oral diet and pancreatic enzyme replacement

• Low-fat diets ease abdominal pain but may lower calorie intake and cause weight loss

• A carb-controlled diet is indicated for clients with diabetes

• Oral nutrition supplements can help promote an adequate intake of protein and calories

Cholelithiasis

Gallstones

Cholecystitis

inflammation of the gallbladder

_______ diet with resulting weight loss increases risk of gallstones

low fat

Gallstones - Nutritional therapy

consume a low-fat diet (<30% total calories from fat)

Cholecystectomy - Nutritional therapy

• Consume a low-fat diet

• Increased soluble fiber intake and prebiotics & probiotics help with diarrhea

• Consume small meals if reflux is a problem

• Avoid any foods not tolerated (spicy foods, caffeine)