.10 GI Tract Disorders

What are the upper GI diseases?

Gastroesophageal Reflux Disease (GERD)

Peptic Ulcer Disease (PUD)

Gastric surgery

GERD define

Chronic symptoms or complications resulting from the abnormal reflux of gastric contents into the esophagus

What are the symptoms of GERD?

Pyrosis Chronic heartburn)

• Painful during sesation

• 10 - 20% of GERD population

Noncardiac chest pain

Nocturnal coughing spasms

Regurgitation

Odynophasia

• Painful swallowing

Typically occurs after meals, after exercise, when reclining

What are the associated factors of GERD?

Increased abdominal pressure

• LES partially controlled by pressure gradient

Relaxed LES

Decreased/slowed gastric emptying

Sensitive esophageal mucosa

Pyloric obstruction

What’re the pre-disposing conditions of GERD?

Obesity

Ascities

• Excessive fluid in ab city usually associated with liver disease

Scleroderma

• Disease that leads to hardening of tissues

Pregnancy

• Increased ab pressure

• Delayed gastric emptying

Hiatus hernia

• Part of stomach passes above diaphragm

Incompetent LES

• Congenital

Various treatments of GERD:

Diet modifications

Lifestyle modifications

GERD Treatment: Diet Modifications

Alcohol, chocolate, high fat meals, carbonated bevs, citrus and spicy foods

Varies person to person

GERD Treatment: Lifestyle modifications

Upright position for 1 hour after eating

Avoid eating 2 - 3 hours prior to bed

Avoid tight clothing around abs

Smoking cessation

Achieve and maintain a healthy weight

Elevate head of bed when sleeping

Peptic Ulcer Disease (GUD)

Break in the protective mucous and exposure to gastric acid (Hal) and pepsin

• Produced in stomach

GERD Treatment: Drug therapy

Antisecetory drugs

• Decrease gastric acid production

• Proton pump inhibitors (PPI)

• H2 blockers

Prokinetic agents

• Increase gastric emptying

GERD Treatment: Surgery

Tightening of LES

Deduction of hiatal hernia

GERD Treatment: Antacids*

Will alleviate symptoms but will not change the disease process because problem is not too much acid but rather acid is in the wrong place

What is the purpose of nutrition care of GERD?

To minimize into the reflux of gastric fluid into the esophagus

To omit foods that irritate the esophageal mucosa

Nutrition Care of GERD

1. May require energy modified diet to facilitate weight loss

2. Eat smaller meals

   1. Reduce volume of reflux and ab pressure

3. Decreasing or elimination from the diet

(GERD) When using nutrition care, what to decrease or eliminating trigger foods from the diet?

Fatty Foods

• Fat delays gastric emptying

• Decreases LES pressure

• May help with weight loss

Chocolate

• Decreases LES pressure

Caffeine

• Decreases LES pressure

Spicy and Acidic Foods

• May irritate esophageal mucosa

• If citrus eliminated, ensure adequate vit C intake

Alcohol

• Decreases LES pressure

What are the complications of GERD?

Esophagitis

Scar tissue

Stricture-narrowing of esophagus

Esophageal cancver

All these can lead to dysphagia

In GERD, removal of alcohol, chocolate, high fat meals in diet = ___

decreased LES pressure

PUD, What are the exposed areas?

Erosion

Ulceration

What are the types of ulcers that could of occur when suffering from PUD?

Esophageal Ulcer

Gastric Ulcer

Duodenal Ulcer

PUD: Esophageal Ulcer

Rare

May occur with chronic untreated GERD

PUD: Gastric Ulcer

Defective mucosal lining

Decreased mucosal blood flow

Generally poor nutrition

PUD: Duodenal Ulcer

Hypersecretion of acid in stomach

• Over acidic chyme to duodenum

Reduction in bicarbonate secretion

How is PUD diagnosed?

History and symptoms

Endoscopy

• Flexible tube with camera passed into GI tract

• Biopsies can be taken

• Meds can be administered to site

What are the pre-disposing factors for PUD?

H. pylori infection

Meds

• NSAIDS

  • Ibuprofen and Naproxen

Poor nutrition

Smoking

Stress

Genetics

Excessive alcohol intake

H. Pylori

Found between gastric epithelial cells and mucosa

Responsible for most cases of peptic ulcers

• 90% duodenal

• 70 - 90% gastric ulcers

Incidence and pfravelance of PUD decreasing

H. Pylori bacterial toxin secretion induces:

Inflammation

Tissue damage

Break in mucosa

Ulceration

PUD: Symptoms

Dyspepsia (discomfort or acute ab pain)

• Following meals vs empty stomach

n/v, distention, burping, poor appetite

Melena stools (bloody or black stools)

• Indicator of GI tract injury

• Stools are black due to old blood

Vomiting blood (hematemesis)

• Old clots or fresh blood

What are the various types of treatment for PUD?

Meds

• First line

Diet

• Adjunct treatment

Lifestyle

• To reduce recurrence

Surgery

• May be necessary when complications are present

  • Bleeding ulcer

  • Perforation

What meds can be used to treat PUD?

Proton pump inhibitors

H2 histamine receptor antagonists

Antacids

Antibiotics

Discontinue NSAID use

Probiotics

PUD Med Treatment: Proton pump inhibitors

Reduce acid secretion by parietal cells

• Acid secreting cells

PUD Med Treatment: H2 histamine receptor antagonists

Benefits 60 - 70% of pts

Decrease stimulation of parietal cells = decreases H2 secretion

PUD Med Treatment: Antacids

Neutral gastric acids by acting as a buffer

PUD Med Treatment: Antibiotics

Effective against H. pylori

2 weeks

PUD Med Treatment: Probiotics

May improve the eradaction of H. Pylori

What is the purpose of nutrition care of PUD?

To avoid extreme elevation of gastric acid secretion and direct irritation of gastric mucosa

What is the major factor of PUD?

H. pylori

How to treat PUD using diet modifications?

Eat well-balanced diet

Avoid frequent meals/bedtime eating that promote acid secretion

Limit foods that may increase gastric acid secretion

How to treat PUD using lifestyle modifications?

Stop smoking

Eliminate alcohol

Avoid aspirin and other NSAIDS

What are the foods that may worsen PUD?

Caffeine/Coffee

Wine and beer

Black pepper

Chili

Cayenne

The first part of the stomach is responsible for production of:

Gastrin (Hormone)

HCl

Intrinsic factor

Pepsin

What are the indications for gastric surgery?

Severe/chronic peptic ulcer

• Hemorrhage, obstruction

Cancer

Obesity

• Weight loss or surgery

Total vs Partial Gastrectomy

Total

• Removal of entire stomach

Partial

• Removal of part of stomach

What are the various surgical procedures of gastric surgery?

Roux en Y Gastric bypass

Gastric Surgery Surgical Procedures: Billroth I

Gastroduodenostomy

Removal of pylorus/antrum

Anastomosis of duodenum to remnant stomach

Gastric Surgery Surgical Procedures: Billroth II

Gastrojejunostomy

Removal of antrum

Anastomossis of remnant stomach to side of jejunum

Anastomosis

Surgical connecting between two structures

Billroth I and II are indicators for:

Chronic PUD

Cancer

Bariatric surgery

Vagotomy and Pyloropasty are indicators forL

Chronic PUD

Gastric Surgery Surgical Procedures: Vagotomy

Severing vagus nerve

• Responsible for motility and parietal cell stimulation :(complete or partial)

Gastric Surgery Surgical Procedures: Pyloroplastly

Widen the pylorus

Often performed with vagotomy

Correction of pyloric stricture/stenosis (narrowing and scar tissue)

Gastric Surgery Surgical Procedures: Royx en Y Gastric bypass

Jejunum anastomosed to esophagus or remnant stomach

Duodenum connected to SI

• Bile and pancreatic secretions can enter SI

Commonly used as form of bariatric surgery

• Create small gastric push

What is the purpose of nutrition care for gastric surgery?

To provide adequate energy and nutrients to support tissue healing following surgery

To prevent nutrient deficiencies

To minimize reflux, early satiety, dumping syndrome, and/or weight loss

Gastric Surgery: Nutrition Care

Multivit and mineral supplementation required

• Usually pre-op

24 hours post-op

• NPO of small frequent liquid foods

• Low sugar, clear fluids

• Progress as tolerated

Fluids

• Consume fluids 30 min before/after meals

• ½ to 1 cup servings

Small frequent meals

• Eat slow and chew throughly

• Moderate seasonings

Avoid hypertonic foods

• Avoid simple CHO, eat complex CHO

Eat protein often, limit fat

Moderate temperature of food and fluids

If there is any complications in nutrition care:

Clear fluids

EN and/or PN and progress to small frequent meals

What are the complications of gastric surgery?

Dumping syndrome

• Bypasses or excises the pyloric sphincter which results in an inability to regulate normal stomach emptying

Gastric Nutrition Care: Iron

HCl in stomach reduces Fe3 to Fe2 which facilitates absorption

Decreased absorption following total or partial gastrectomy

• Hypochlorhydria = increased infection

Gastric Nutrition Care: Vitamin B12 (Pernicious Anemia)

Requires IF from parietal cells to be absorbed from the intestine

Decreased absorption following total or partial gastrectomy

Gastric Nutrition Care: Folate

Reduced intake

Secondary to B12 deficiency

• Activate folate