EX2 MALDIGESTION, GERD, GALLBLADDER DISEASE

MALDIGESTION

what digestive problems/disorders contribute to maldigestion?

GERD, Gallbladder disease (also pancreatitis, and stomach surgeries may contribute)

what are the main 2 factors that contribute to maldigestion?

mechanical failures and enzymatic/chemical failures

which digestive problems/disorder are maldigested due to enzymatic/chem failures?

• Pancreatitis (may lead to fat malabsorption)

• Stomach surgery (may lead to dumping syndromes)

• GERD

for maldigestion, what is important concerning nutrition assessment (athropometrics)

weight history

for maldigestion, what is important concerning nutrition assessment (biochem )

Anemia labs, electrolytes, micronutrients of potential concern

for maldigestion, what is important concerning nutrition assessment (client history)

Other digestive or surgical history that may impact condition

for maldigestion, what is important concerning nutrition assessment (dietary assessment)

• Probe for food intolerance and/or meal intolerance: Rapid fullness, belching, etc.

• Dietary factors that are associated with worsened symptoms

• N/V/D

for maldigestion, what is important concerning nutrition assessment (nutrition-focused physical)

Affect, overall view, oral cavity (pallor, erosion), muscle or adipose wasting (malnutrition exam)

what are potential nutritional diagnosis for GI issues/disease

• Inadequate oral intake

• Inadequate fluid intake

• Intake of types of carbohydrates inconsistent with needs (simple sugars)

• Excessive fiber intake

• Excessive fat intake

• Altered GI function

• Food and nutrition-related knowledge deficit

• Undesirable food choices

• Limited adherence to nutrition-related recommendations (only once they have been told and still have not adhered)

nutrition intervention/ MNT for patients with symptoms of maldigestion

• promote adequate intake (alter diet?)

• nutrition education (on dietary modifications)

• nutrition counseling (motivational interviewing, goal-setting)

• coordination of care (referrals to other disciplines or support where needed)

GERD

what is GERD?

Reflux of stomach contents into the esophagus

common symptoms of GERD include:

other symptoms include:

common: Heartburn, regurgitation of acid

other: Abdominal pain, bad breath, epigastric pressure, chronic cough, sore throat, dental erosions, wheezing, or difficulty swallowing/dysphagia

the main issue with GERD is that severe GERD may lead to 

Barret’s esophagus which is a pre-cancerous condition of the esophagus which can then become cancer 

what causes GERD (simple)

multifactorial

what lifestyle factors contribute to GERD

• obesity

• smoking

• tight clothes

what functional/bodily factors contribute to GERD

• Anything contributing to incompetence or transient relaxations of the LES

• Factors increasing gastric pressure (weaken LES)

what is hiatal hernia?

Pushing of the stomach up through a weakened opening in the esophagus

what factors effect LES competence (6 + others)

• increased secretion of gastrin, estrogen, progesterone (in pregnancy)

• pregnancy

• smoking 

• dietary fat 

• alcohol 

• caffeine 

• other: coffee, tea, chocolate, spearmint, peppermint, capsaicin, black and red pepper

factors that increase gastric pressure (6)

• Hiatal hernia

• Scleroderma

• Obesity

• Pregnancy

• Delayed gastric emptying (gastroparesis, gastric outlet obstruction)

• Overeating

lifestyle modifications for GERD (5)

• Sitting upright after meals (30 minutes to 3 hours)

• Weight loss if have overweight or obesity

• Quit smoking

• Elevate HOB (head-of-bed)

• Loose-fitting clothing

MNT focuses on what regarding GERD

reducing foods that decrease LES pressure or cause transient relaxation

what are ways we can help decrease LES pressure/transient relaxation? (4)

• food diary to identify key triggers 

• basic elimination diet 

• smaller, more frequent meals (decrease stomach fullness)

• less fluid intake with meals (decrease stomach fullness)  

what types of medications are used for GERD (4)

antacids, H2 agonist, PPI’s, prokinetics

Antacids

• what are antacids

• what do they do

• issues

• made up of magnesium, calcium, and aluminum (Tums, MOM, Maalox)

• neutralize acids chemically

• may contribute to diarrhea or constipation

H2 agonist 

• what are H2 agonist

• what do they do

• effectiveness?

• Tagamet, Pepcid, Zantac 360 (HCl)

•  Block histamine receptors that stimulate acid

• Effective for about 50% of GERD sufferers

PPI’s

• names

• function 

• risk

• prisolec, protonix, prevacid 

• block k/ATPase enzymes-stopping HCL production 

• associated with lower Ca consumption (risk of fractures) and higher risk for CKD 

prokinetics

• function

• issues

• Promote motility

• Can have extrapyramidal symptoms; drug-induced movement disorders (dystonia); and neuroleptic malignant syndrome (NMS; fever, confusion, muscle stiffness, irregular heartbeat)

for patients on PPI’s what is encouraged

• increase of dietary calcium (more absorbable, especially with meal)

• calcium citrate supplement (does not require acid)

what is the surgical procedure for GERD

Nissen fundoplication

which wraps the stomach around the esophagus but this can loosen over time and limits ability to vomit SO is not commonly used

GALLBLADDER DISEASE 

what are the risk factors for gallbladder disease*** (7)

• >65 years old

• woman have 2x risk

• obese

• pregnant

• diabetic

• western diet increases risk

• rapid weight loss or surgery

what causes gallstones?

• too much absorption of water from bile

• too much absorption of bile acids from bike

• too much cholesterol in bile

• inflammation of epithelium

what are the 4 types of gallbladder disease?

in order from lowest to highest severity

• cholelithiasis

• cholecystitis

• choledochonlithiasis

• cholangitis

-lithiasis means 

-itis means

-thiasis = stone

-itis= inflammation

what is cholecystectomy

removal of the gallbladder 

what is cholelithiasis?

the presence of gallstone in the gallbladder or biliary duct

but no inflammation

cholelithiasis symptoms

RUQ pain (colicky-not continuous)

what is cholecystitis

inflammation of the gallbladder due to stones

usually due to blockage

cholecystitis symptoms

RUQ pain (constant), fever, leukocitis (high WBC)

choledocholithiasis is what 

the presence of gallstone in the common bile duct (CBD)

but usually no inflammation 

choledocholithiasis symptom

obstructive jaundice, no major pain, no fever or leukocytosis

choledocholithiasis can lead to (3)

obstructive jaundice

secondary biliary cirrhosis

dilated hepatic bile duct

what is cholangitis

cholelithiasis + infection

cholangitis symptoms (2 categories)

Charcot’s Triad

• Fever, Jaundice, RUA pain

• can progress

Reynold’s Pentad

• Fever, Jaundice, RUA pain

• Hypotension

• Cognitive impairment

what does cholelithiasis and/or cholecystectomy cause 

decreased ability to digest fat (long-chain FA) presented by indigestion pain 

MNT for gallbladder disease (4)

• reduce dietary fat intake if causes symptoms

• low fat diet (<30% fat) with modest protein (aid in controlling symptoms until surgery)

• small, frequent meals

• gradual weight loss indicated