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           MNT 427, March 24th, 2008
      Anu Manthripragada, MSRD,LDN,CNSD
                       GERD and Esophagitis

Reflux: 7-8% experience daily “heartburn”- gastric contents refluxing
Regurgitation ocurs in 50% of infants in the first few months and resolves
   after 1 year. Ranges from 2-20%
Symptoms in adults: Reflux; substernal pain; belching;and esophageal
Symptoms in children: Vomiting; dysphagia; refusal to eat; abdominal
MANIFESTATIONS are: pharyngeal irritation, frequent throat clearing,
   hoarseness, and worsening of asthma symptoms
Eroded esophagus esophagitis leads to erosions, ulceration, scarring,
   stricture,and dysphagia. Barrett’s esophagus is cells lining the
   esophagus becomes abnormal and pre-malignant
                    Management os esophagitis

Viral infection; Irrtitants & intubationacuteIncreased abdominal
   pressure reduced LES pressure; recurrent vomiting;hiatal hernia; &
   delayed gastric emptying timeChronic
Behaviour mofification: AVOID: Eating within 3 hrs before bed
   time;lying down after meals; tight fitting garments; cigarette smoking
Medical/Surgical management: PPI; histamins-2 receptors;
   antacids;prokinetic agents;fundoplication
Nutrition management : Avoid Big meals; high fat foods & alcohol to
   reduce exposure to gastric contents
Avoid Coffe and fermented alcoholic beverages to reduce gastric
Avoid Acidic foods, spices to prevent pain and irritation
   Oral cavity, pharynx and esophageal cancer and surgery

Nutritional deficiencies compounded by: eating difficulties
Treatment therapies include chemo, XRT and surgery Difficulty with
   chewing/swallowing salivation, taste acuity; extensive dental decay;
   osteoradionecrosis; infections and N/V/and anorexia w/chemo
Depending on the extent of the surgery oral nutritional supplements or
   Enteral nutrition support via PEG/GT/JT, if GI function is inadequate,
   then Pareneteral nutrition support via central lines placed
Other treatments include- artificial saliva solutions, NS rinses; topical
   anesthetics, oral hygiene and fluoride use
                     Disorders of the Stomach

Dyspepsia abdominal pain or discomfort
Functional dyspepsia refers to unexplained discomfort
Gastritis and peptic ulcers Helicobacter pylori
H.pylori is responsible for chronic inflammation of the gastric mucosa,
   peptic ulcers. Atrophic gastritis is inflammation leading to
   deterioration of the mucosa and glands leading to Achlorhydria to loss
   of intrinsic factor and gastric cancer
Other causes of Gastritis NSAIDS- Aspirin; steroids; ETOH;erosive
   substances; tobacco
Treatments are eradicate H.Pylori, withdraw provoking agents; PPI and
   antibiotics are the medical treatments
                        Disorders of the Stomach

MNT: Deficiencies of B12; reduced absorption of Fe, Ca
Carcinoma of the stomach: Treatment includes surgical resection
Nutritional management includes  partial or total Gastrectomy
Factors that increase acidity:
• Cephalic phase-Thought, smell, taste and chewing/swallowing initiate vagal
   stimulation of parietal cells in the fundus
• Gastric phase: Distention of the fundus and antrum; antrum
   alkalinity;substances in foods and the digestive products that increase acidity
   (coffee- both decaf and regular; alcohol, AA and peptides)
Factors that decrease acidity:
• Gastric phase:acidification of the alkaline rich antrum limits gastrin secretion;
   protein buffers initially
• Intestinal phase: Fat, protein stimulate hormones that inhibit gastrin
                        Dumping syndrome

MNT is starting oral intake with liquids and advanced to solids a s
   tolerated in carcinoma/surgery patients
Dumping syndrome is a physiological response to large hypertonic food
   and fluids in the proximal small intestine
Occurs in surgical procedures (patients)such as gastrectomy; manipulation
   of pylorus and fundoplication. Induced in normal persons with glucose
   injected into the jejunum.
Stage 1 – 10-20 minutes of eating a meal due to vascular symptoms
Stage 2- 20 minutes –1 hr – may be due to production of SCFA
Stage 3-1-3 hrs after a meal- called alimentary hypoglycemia
              Common medications in GI disorders

Antibiotics- to eradicate H.Pylori
Antacids- neutralize acid
PPI(proton pump inhibitor)-omeprazole, lansoprazole- reduce secretion
H2 receptor blockers (cimetidine/pepcid;ranitidine/zanta)-inhibit secretion
Sucralfate(sulfated disaccharide)protects stomach lining and may increase
   mucosal resistance to acid or enzyme activity
Nutritional care for Dumping syndrome and alimentary hypoglycemia:
Small meals; High protein+moderate fat+complex CHO; high fiber; lying
   down and avoiding activity 1 hr after eating; fluids between meals;very
   limited simple sugar items; lactose-free
                         Lower GI disorders

Gas: swallowed or produced within- expired through lungs or belching or
   flatus. Gases includes N2, 02, C02 and methane. ~ 200 ml gas is
   present in the GI tract
Eat slowly, chew with mouth closed and avoid sipping through a straw
Upright stance and exercise may relieve gas
Increased gas production may be due to bacterial fermentation of large
   amounts of CHO in the stomach/small intestines; bacterial overgrowth
   in partial obstruction, surgical patients, immune disorder patients due
   to mal-digestion and mal-absorption.
Increased amounts of H2, C02 and CH4 with lowered fecal pH indicate
   excessive colonic bacterial fermentation of a fermentable substrate
   (reducing sugars in the feces) indicating mal-absorption
                         Lower GI disorders

Fructose- from furits/juices and HFCS (high fructose corn syrup)is
   absorbed as sucrose or a very small amount of HFCS.
10-20 g in children and 25 g in adults leads to mal-absorption
Sucrose, if taken in large amounts with GI dysfunction, is mal-absorped
Both Fructose and sucrose are the reducing sugars in the fecal matter
Constipation if fiber/fluid /exercise fail, next step is laxatives such as
   psyllium, lactulose. Bulking & osmotic agents used are Mg hydroxide;
   sorbitol. In case of toxic megacolon surgery is needed
Recommended fiber intake- Adult woman 25 g fiber; adult man 38 g and
   children between 19-25g/d (Box 27-2 page 677)

>300 ml with loss of Na and K and other electrolytes
Occurs with rapid transit time of small intestinal contents
Decreased enzymatic digestion of food
Decreased absorption of fluids and nutrients
Increased secretion of fluids into the GI tract
 causes are inflammatory disease; fungal infections;viral;over
   consumption of sugars;insufficient or damaged mucosa;GI resection&
Osmotic diarrhea dumping syndrome and lactose intolerance
Secretory diarrhea Active secretion of elctrolytes and water by the
   intestinal epithelium resulting in bacterial exotoxins;viruses;increased
   intestinal hormone secretion. Unlike osmotic diarrhea- fasting does not

Exudative diarrhea due to mucosal damage outpouring of mucus,fluid,
   blood, and plasma proteins with a net accumulation of electrolytes and
   water in the gut. Prostaglandin and cytokines may be involved.
Occurs in Crohn’s; UC; radiation enteritis (osmotic and secretory also
   may occur in these disease states)
Medication –induced SCFA in normal amounts is absorbed in the colon
   and helps to absorb sodium and water but in excess amounts leads to
   excessive gas and discomfort
Antibiotics used to reduce SCFA (by eradicating the bacteria) may also
   eradicate colon enhancing bifidogenic bacterium leads to
   osmotically active sodium exacerbating diarrhea
Mal-absorptive diarrhea or Steatorrhea is fat mal-absorption

Oral rehydration solution (page 679- Table 27-2) in pediatric patients
Pro and pre biotics
Probiotics beneficial gut flora lactobacillus and L.Bifidus
Steatorrhea Dx based on ration of fecal fat to ingested fat or a coefficient
   of absorption
75-100 g fed for 72 hrs. Normal fecal fat range of 7%
Causes: pancreatic lipase insufficiency; short bowel syndrome; inadequate
   bile secretion due to liver disease or biliary obstruction; mal-absorption
   of bile saltsdue to blind loop syndrome(resection of distal ileum); and
   reduced reeseterification of fatty acids with decreased formation and
   transportation of chylomicrons as in abetalipoprotenemia and intestinal
   lymphagiectasia. Treatment- MCT oil
                             Celiac disease

Gluten sensitive enteropathy. Genetic susceptability and a trigger induces
   immune response to gluten. Gluten is present in wheat, rye and barley.
Glutenins and glaidins in wheat; secalinus in rye and hordeins in barley
   are resistant to digestion and their interaction with GI tract immune
   system triggers an inflammatory response
Gluten free diet is the treatment Box 27-5 Page 685
IBD are Crohn’s disease and Ulcerative Colitis. Common characteristics
   are : diarrhea, fever, weight loss, anemia, food intolerances,
   malnutrition,growth failure, and extra-intestinal manifestations such as
   arthritis, dermatitis, and hepatic.
                         Crohn’s Vs UC

Crohn’s                                           UC
50-60% involves distal ileum+colon       disease process is continuous
15-25% affects either small intestine
or colon
Inflammed tissue is separated
from healthy tissue
Affects all layers of mucosa             affects only the lining of
(transmural)                             mucosa
Abscesses, fistulas,fibrosis,            bleeding is common
Submucoasl thickening, localized
Strictures, narrowed segments of bowel
Partial or complete onstruction
                          Crohn’s Vs UC

Crohns’                                      UC
Abdominal pain & mass                        Bloody diarrhea
Sclerosing cholangitis                       gall stones
Pyoderma gangrenosum                         migratory polyarthritis,
                                             erythema nodosum
Causes: Viral, genetic, bacterial autoimmune damage to the cells of the
  small/large intestines with ma-absorption, ulceration, or stricture
  diarrhea, Wt.loss, poor growth
Medical: Corticosteroids; anti inflammatory;
  antibiotics,immunosuppresents, anticytokine
Nutritional: oral or EN or TPN
                 Potential nutrition related problems

Anemias – blood loss, poor PO intake
GI narrowing and strictures- bloating, N, bacterial over growth and diarrhea
Surgical resections- diarrhea, ma-absorption of bile acids and nutrients
Increased GI secretions wih inflammation and reduced transit time diarrhea and
Mal-absorption related to N/V/D/abdominal pain, bloating
Food aversions, anxiety, fear of eating
Food –drug interactions
Diet restrictions both iatrogenic as well as self imposed
Growth failure, macr/micro nutrient deficiencies
Elevated homocystein levels indicate depletion of B vitamins especially folate
                   Irritable Bowel Syndrome (IBS)

Characteristics: abdominal discomfort, altered intestinal dysmotility
Feeling of incomplete evacuation, urgency,mucus in the stool increased
    GI stress due to psychosocial distress
In persons with IBS- reactions to stimuli from CNS is very significant
    compared to normal persons. Psychosocial stressors play a major role
    in the stimuli. Mediators of GI response may be abnormal secretion of
    peptide hormones & signaling of neurotransmitters
S&S: Other than the stress and diet habits excess/abuse of laxatives,
    antibiotics; GI illness; lack of regularity in sleep, rest and fluid intake.
    Allergy also may be a cause
MNT: Caffeine, fat, sugars such as lactose, fructose and sorbitol, and
    alcohol are poorly tolerated in diarrhea predominant and those with
    alternating constipation and diarrhea

MNT: Recommended fiber intake will likely normalize the symptoms, however
   large doses of wheat bran is no longer recommended and may exacerbate the
   symptoms. Psyllium is recommended for those unable to consume fiber from
   the diet. Adequate fluid is recommended.Prebiotics foods such as resistant
   starch, OS are recommended to enhance the growth of healthy gut microflora
   to prevent pathogenic infections
Diverticular diesease: Sac like herniations of the colonic wall due to long term
   constipation and increased colonic pressures. Diverticulitis- modified diet (low
   residue, elemental), bowel rest and antibiotics. Exercise helps some
   individuals. High fat meal may intensify discomfort, so low fat diet may be
   recommended initially.?seeds/nuts/skins aggravate- unresolved. Avoid
   nuts/pumpkin, sunflower, caraway and sesame seeds; popcorn hulls. Seeds in
   tomatoes, zucchini,cucumbers, strawberries, raspberries, and poppy seeds are
   not problematic.In perforation /obstruction coarse plant foods are to be
   avoided and encourage to chew fibrous foods.
                          Intestinal Surgery

SBS: Nutritional and medical consequences resulting form resections
Digestive & absorptive capacity depends on: age, original reason for
   resection, which portions of the GI tract remains and the health of the
   remaining intestines
Reasons for resections in adults: Crohn’s, XRT enteritis, mesenteric
   infarct, malignancy, and volvulus
Pediatrics: congenital anomalies, atresia, volvulus, NEC
Consequences are mal-absorption, diarrhea, steatorrhea, dehydration with
   electrolyte imbalance, weight loss and growth failure. Other
   complications include gastric hypersecretion, oxalate renal stones, gall
   stones, and rarely d-lactic aidosis

Removal of 70-80 % of small intestine results in SBS with intestinal
   adaptation to varying degrees.
Factors affecting the course of SBS are:
length of the remaining bowel,
loss of ileum, especially distal 1/3 rd
Loss of colon
Disease in the remaining segments
Radiation enteritis
Coexisting malnutrition
Older age at surgery
                 SBS- Consequences of ileal resection

Rapid transit time
Decreased fluid absorptive area
Mal-absorption of B12/intrinsic factor complex
Mal-absorption of bile salts
Inadequate bile salts for lipid solubilization, digestion & absorption leading to fat
   and fat-soluble vitamins
Loss of secreted bile salts into colon because of decreased reabsorption- irritate
   the colonic mucosa and increase secretion of water and electrolytes and
   increase the osmotic load and colonic motility- worsening diarrhea
Formation of hydroxy fatty acids by colonic bacteria from mal-absorbed fat
   resulting in decreased fluid and electrolyte absorpttion
Mal-absorption of Ca, Mg and Zn due to formation of insoluble soaps with mal-
   absorbed free FA
Risk of oxalate stones due to increased colonic absorption of oxalate which would
   otherwise be bound to Ca, Zn, and Mg

Medications: Somatostatin and it’s analogs glucagon-like peptide, and
   growth hormones with anti-secretory, anti- motility and trophic actions
   are used
Surgical procedures: reversal of segments of bowel to slow transit time,
   creation of “pouches” to serve as a form of colon, intestinal
   lengthening, and intestinal transplant
MNT: TPN – initial with a goal to transition to TEN. Duration of TPN is
   dependent on extent of the resection, health of the remaining bowel
   and he individual. Older patients with major ileal resections, loss of
   ileocecal valve, and disease in the remaining segments may need life
   time TPN
  Nutritional management of SBS and Blind loop syndrome

TEN: a. Start EN early & b. increase concentration and volume
Blind loop syndrome: bacterial overgrowth due to stasis of the intestines
   because of obstruction, radiation enteritis, fistulas, surgical repair of
   the intestines.
Bacteria – deconjugate bile salts which are cytotoxic and less effective in
   micelle formation. Results in steatorrhea
CHO mal-absorption is due to injury top brush border because of toxic
   effects of the products of bacterial catabolism and the enzyme loss
The bacteria use the available B12 and other nutrients for their own
   growth and the host becomes deficient
MNT- pre/pro biotics, supplementation of B12, MCT for fat mal-
                      Ileostomy and colostomy

MNT: Malodor occurs with steatorrhea, bacterial fermentation of
   food.SCFA, sulfur-containing compounds, amoonia, methane and
   other products can produce odors.
Odors depend on the gut flora, types & amounts of gases produced in an
   individual and their diets. Patients learn to observe their stools to
   determine which foods to eliminate and this differs from one to the
Foods that cause odors in a colostomy are: legumes, onions, garlic,
   cabbage, eggs, fish, some medications and some vitamin/mineral
   supplements. Odor proof pouches are now available
Normal output from the ileum to colon in a healthy person is 750 ml to 1.5
   L. Adaptation occurs with reduction in stool volume, stools become
   less liquid. Patients with ileostomies require additional salt and water

                           Adverse food reaction
               Food intolerance        Food hyper sensitivity
Food intolerance is caused by non-IgE (immunoglobulin E), toxin,
   pharmacology, metabolic
Food hypersensitivity is an IgE – mediated with immune response to
   harmless protein erraneously identified as harmful
Atopy – a child genetically predisposed to atopy meaning increased
   chances of developing food allergies
Immune system: Antigens are foreign substances such as viruses,
   bacteria, blood cells and tissue cells, cleared without an adverse
   reaction. In Allergy sensitization occurs to antigens, happens the first
   time allergen is exposed, and subsequent exposure is recognized by the
   immune system
                            Immune system

                          Antigens are recognized by
           B-lymphocytes   T-cells                      Macrophages
Originates in the stem      Originates from Stem cells
cells of the bone marrow    of the thymus
Humoral immunity            Cell-mediated
Involves antibodies         Do not produce antibodies but
Immunoglobulins             recognize antigens
IgA,IgD,IgE,IgG,IgM         Th-1 cells
IgE helps to eliminate      Th-1 is associated w/IgE
Parasites and responsible
                    Types of allergic reactions

Type – 1-Immediate hypersensitivity IgE mediated – anaphylactic, hay
         fever, occurs within seconds or upto 2 hr
Typer-2-Cytotoxic – IgG- results from transfusion of incompatible blood
Type 3- Antigen-antibody complex- IgG & IgM-occurs in food reactions
Type 4- Delayed or cell mediated hypersensitivity- T-CELLS react
   directly with antigen- graft rejection, protein loosing emteropathy
Types of food allergies:
IgE mediated occurs within minutes to 1 hr
Mixed – IgE & cell mediated – delayed onset>2 hrs
Non-IgE or cell mediated – onset>2 hrs

Page 750 Table 29-4 Skin tests
Diets: Elimination diet used in hives, angoedema and eczema. Cooked,
   raw and protein derivatives-all foods that cause any of the symptoms
   have to be removed from the diet
Eosinophilic gastroenteritis or eosinophilic esophagitis- elemental
   formulas are to consudered in severe cases. Elemental formulas are
   unpalatable. For infants they are Neocate, Elecare. For children 1-10
   years, neocate one & tolerex; E028 for teenagers and adults.
Food challenge: once symptoms subside, and anti histamines have been

Infancy: CMA (cow’s milk allergy) one of the most common allergens,
   prevalent in 2.5% in the first 3 years. Out grow by age 3
Page 752- Table 29-6
Page 757 Box 29-7
Does Pareve really mean milk free Clinical insight page 758
                         Common allergens

• Cow’s milk protein
      Eggs
      Soy
      Peanut
      Tree nuts
      Fish
      Wheat
• In older pediatric patients- berries and chocolate are included
Garcia-Careaga & Kerner, Nutrition in Clinical Practice, 2005, 20 (5)
   Oral Allergy Syndrome or Pollen-food allergy syndrome

Reaction is limited to oral cavity
 Characterized by itching, burning, erythema or tingling of the lips, tongue,
      palate, or oropharynx
 Most common proteins are those in fresh fruits and vegetables
These plant proteins can react with air-borne allergens such as birch, ragweed, and
      mugwort pollens
1. Birch allergy may react to - raw apples, pears, celery, hazelnuts, kiwi, potatoes,
      and carrots
2. Ragweed Allergy will cause reaction to eating Fresh melon and bananas
3. GrassPollen- reacts to raw tomato
Avoid the fruits and cook the vegetables to prevent allergic reactions
Garcia-Careaga.M. & Kerner, J.A (2005). Gastrointestinal Manifestations of Food Allergies in Pediatric
      Patients. Nutrition in Clinical Practice 20(5): 526-535, October
         Current recommendations in clinical practice
 Enteral formula options in different types of GI impairment

              Eosinophilic GastroenteritisTrial of Elemental formula

                           Eosinophilic Esophagitis:
       Cow’s milk, wheat, soy, peanut,and egg cause the allergic reaction
  Use hydrolyzed protein formulas in infants or elemental formulas with L AA.
         Dietary manipulation helps to reduce inflammation but does not cure.

      Garcia-Careaga & Kerner, Nutrition in Clinical Practice, 2005, 20 (5)
                    Other Eosinophilic gastroenteropathies:
           Implicated proteins are cow’s milk, egg, corn, cod and soy.
    Use hydrolyzed protein formulas for age <2 years. Authors report excellent
                               response to L-AA as well
Garcia-Careaga.M. & Kerner, J.A (2005). Gastrointestinal Manifestations of Food Allergies in Pediatric
       Patients. Nutrition in Clinical Practice 20(5): 526-535, October

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