Definitions

1. Endoscopy: a nonsurgical procedure used to examine a person’s digestive tract. Using an endoscope, a flexible tube with a light and camera attached to it, your doctor can view pictures of your digestive tract on a color TV monitor
2. Steatorrhea: the excretion of abnormal quantities of fat with the feces owing to reduced absorption of fat by the intestine
3. Bacterial Translocation: the passage of viable bacteria from the gastrointestinal (GI) tract to extra-intestinal sites, such as the mesenteric lymph node complex (MLN), liver, spleen, kidney, and bloodstream
4. Ileus: the temporary absence of the normal contractile movements of the intestines

Pathophysiology

What laboratory values would most likely be changed in a patient with dehydration due to severe diarrhea?

Albumin, BUN, creatinine, hematocrit and osmolality would be increased, and sodium, potassium and bicarbonate would be decreased.

For each of the following disorders, describe the etiology, clinical symptoms, medical management, and diet therapy:

Hiatal Hernia

• Etiology: Occurs when weakened muscle tissue allows your stomach to bulge up through your diaphragm. The exact reason why it happens is not always clear, but it may be caused by:
  • Age-related changes in your diaphragm
  • Injury to the area, for example, after trauma or certain types of surgery
  • Being born with an unusually large hiatus
  • Persistent and intense pressure on the surrounding muscles, such as while coughing,vomiting, straining during a bowel movement, exercising or lifting heavy objects
• Clinical symptoms: Heartburn, regurgitation of food or liquids into the mouth, backflow of stomach acid into the esophagus (acid reflux), difficulty swallowing, chest or abdominal pain, shortness of breath, vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding
• Medical management: Medications that may be recommended include antacids that neutralize stomach acid (Mylanta, Rolaids, and Tums), H-2-receptor blockers (Pepcid, Axid, and Zantac), or proton pump inhibitors (Prevacid 24HR, and Prilosec). Surgery may be required; a smaller opening in the diaphragm is created or the hernia sac is removed
• Diet therapy:
  • Individuals identify the foods that irritate them and avoid intake of those foods
  • To reduce gastric acidity:
    • Avoid foods that stimulate gastric acid production – chili powder, pepper, coffee and alcohol
    • Small, frequent feeding – large meals increase acid production, delay gastric emptying and increase risk of reflux
  • Avoid foods that can reduce LES pressure – chocolate, mint, and high-fat foods
  • When esophagus is inflamed, low pH foods like citric juices and soft drinks may cause pain

Gastroesophogeal Reflux Disease (GERD)

• Etiology: Occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.
• Clinical symptoms: A burning sensation in your chest (heartburn), usually after eating, which might be worse at night, chest pain, difficulty swallowing, regurgitation of food or sour liquid, and/or the sensation of a lump in your throat. If you have nighttime GERD, symptoms may also include chronic cough, laryngitis, new or worsening asthma, and/or disrupted sleep
• Medical management: Over the counter include antacids that neutralize stomach acid, H-2-receptor blockers, and proton pump inhibitors. Prescriptions medications include prescription-strength H-2-receptor blockers, prescription-strength proton pump inhibitors, and medication to strengthen the lower esophageal sphincter (Baclofen). If medications don’t help, or if you want to avoid long-term medication use, there are two surgery options: (1) Fundoplication – surgeon wraps the top of your stomach around the lower esophageal sphincter, to tighten the muscle and prevent reflux, and (2) LINX device – a ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus; the magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through
• Diet therapy:
  • Individuals identify the foods that irritate them and avoid intake of those foods
  • To reduce gastric acidity:
    • Avoid foods that stimulate gastric acid production – chili powder, pepper, coffee and alcohol
    • Small, frequent feeding – large meals increase acid production, delay gastric emptying and increase risk of reflux
  • Avoid foods that can reduce LES pressure – chocolate, mint, and high-fat foods
  • When esophagus is inflamed, low pH foods like citric juices and soft drinks may cause pain

Diabetic Gastroparesis

• Etiology: The muscles of the stomach and intestines stop working due to vagus nerve damage and the movement of food is either slowed or stopped (also known as delayed gastric emptying)
• Clinical symptoms: Vomiting, nausea, feeling of fullness after eating just a few bites, vomiting undigested food eaten a few hours earlier, acid reflux, abdominal bloating, abdominal pain, changes in blood sugar levels, lack of appetite, and/or weight loss and malnutrition
• Medical management: Prokinetics and anti-emetic drugs. Enteral nutrition via jejunum
• Diet therapy:
  • Small, frequent meals – larger volumes of food that create stomach distension can delay gastric emptying and increase satiety
  • Reduced fat intake – although fat delays gastric emptying, liquid fatis tolerated by many patients
  • Physical activity, such as walking, after meals may increase gastric emptying rates
  • Foods with soft or liquid consistency may be more easily digested – but hypertonic enteral formulas should be avoided because they further delay gastric emptying
  • Avoid high fiber
  • Adjust insulin dose and timing to better match delayed nutrient absorption and postprandial rise in glucose levels – for example, administer regular insulin after meals instead of before meals

Crohn’s Disease

• Etiology: Unknown cause – it’s an inflammatory bowel disease that causes inflammation of the digestive tract (can occur from the mouth to the anus and does not have to be continuous) which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition
• Clinical symptoms: When the disease is active – diarrhea, fever, fatigue, abdominal pain and cramping, blood in your stool, mouth sores, reduced appetite and weight loss, and/or pain or drainage near or around the anus due to inflammation from a tunnel into the skin (fistula). People with severe Crohn’s disease may also experience – inflammation of skin, eyes and joints, inflammation of the liver or bile ducts, and/or delayed growth or sexual development
• Medical management: It depends on the severity of the disease. Drug treatments include antibiotics, immunosuppressive medications (6-mercaptopurine, azathioprine cyclosporine), immunomodulators, and biologic therapies (infliximab). Surgical treatment may be necessary if the person is not responding to treatment or if any acute complications arise, such as perforation, obstruction or abscess – only the affected area is removed, this may include may ileocolic resections, segmental resections, total proctocolectomy and ileostomy
• Diet therapy
  • Affects normal digestion and absorption, may increase calorie, protein, and micronutrient requirements
  • Inflammation increases protein requirement
  • During acute exacerbations of the disease weight loss and nutritional deficits may occur
  • Diet therapy during acute exacerbation of disease:
    • Enteral nutrition
    • Parenteral nutrition with bowel rest is not necessary in a lot of cases (no improvement in remission)
      • Parenteral nutrition may be necessary for extensive intestinal involvement or short bowel syndrome
    • Strict I/Os.
    • Monitor ostomy output
    • Maintain electrolytes and fluid balance
    • Energy need: Harris-Benedict equation x (1.3~1.5 stress factor)
    • Protein requirement: based on lean body mass wasting and biochemical parameters measuring – protein need may be as high as 1.5- 1.75 g/kg for adults
    • Fiber is restricted.
  • Diet therapy during recovery:
    • When oral intake is initiated, start with a low-residue, lactose-free diet with small, frequent meal as tolerated
    • If steatorrhea is present, reduced total fat with medium chain fatty acids (MCT) added
      • * MCT is absorbed via portal blood, easier to be absorbed
    • Slowly add fiber then lactose back to diet
    • Nutrient supplement, e.g. B12 and iron

Drug Therapy

Discuss the use of the following drugs; include classification, mechanism of action, indications for use, and nutrient/drug interactions.

	Reglan	Flagyl	Immodium (Loperamide)	Lactulose	Solumedrol
Classification	Prokinetic agent	Antibiotic	Antidiarrheal	Laxative	Corticosteroid
Mechanism of Action	Dopamine receptor antagonist	Inhibits nucleic acid synthesis	Acts on receptors along the small intestine to decrease muscle activity and slow down transit time	Lactulose metabolites draw water into the bowel, causing a cathartic effect through osmotic action	Anti-inflammatory glucocorticoid
Indications for use	Diabetic gastroparesis   Symptomatic GERD (short-term therapy for adults who don’t respond to conventional therapy)	Bacterial infections   Parasitic infections   Used as a component of multidrug antibiotic combinations to heal stomach and duodenal ulcers caused by H. pylori infections	Diarrhea	Chronic constipation	Allergies, asthma, adrenal gland problems, blood problems, skin rashes, and swelling problems
Nutrient/drug interactions	Avoid alcohol – it can increase the sedative side-effect of the drug	Avoid alcohol and foods that contain propylene glycol for at least 3 days after finishing this medicine, otherwise severe stomach upset/cramps, nausea, vomiting, headache, and flushing may occur	Avoid alcohol – it can increase the sedative side-effect of the drug   Avoid tonic water	Avoid if lactose intolerant   Medication contains different sugars – can affect blood sugar levels	Avoid grapefruit juice   Restrict dietary sodium intake

Nutritional Management

Describe the nutritional management of the following problems:

Diarrhea

• Review fluid and beverage intake, energy and mineral intake, medication and herbal supplement use, weight change and biochemical data
• Stimulating the GI tract by feeding the patient can speed up the recovery of damaged cells
• Avoid high-sugar beverage and foods high in simple carbohydrates
• Avoid caffeine and alcoholic-beverages
• Avoid gas-producing foods
• Soluble fibers may help thicken the consistency of stool
• Introduce solid foods beginning with a low-residue diet, e.g. refined starch, then slowly adding other foods to diet
• Prebiotics and probiotics increase the amount of short-chain fatty acids produced, which promote water and electrolyte absorption in the colon, which reduces the incidence of diarrhea
• Probiotics – live bacteria
  • “Good bacteria” that can displace harmful bacteria in the gut, e.g. lactobacillus, bifidobacterial
  • Used for C. diff diarrhea

Constipation

• Ensure adequate fiber intake – 25-35 g dietary fiber/d
  • Begin slowly with adding one to two high-fiber foods each day
• Ensure adequate fluid intake – minimum of 2,000 mL/d (~8-10 cups/d)
• Probiotics and prebiotics can help relieve constipation

Dumping Syndrome

• Fat and protein are better tolerated than carbohydrates as their digestion to hyperosmolar molecules is slower
• Simple carbohydrates should be limited – complex carbohydrates can be included in diet
• Lactose is often not tolerated
• Liquids should be consumed between meals
• Soluble fibers, such as pectin or gums can form gel with carbohydrates and delay GI transit
• Vitamin D and calcium supplements may be needed when intake is inadequate
• When steatorrhea (> 7% of dietary fat excreted in stool) exists, reduced fat or pancreatic enzymes may be beneficial
• Small, frequent meals (5-6 meals/day) – lie down after meals if necessary
• Monitor for iron, B12 and folate deficiency

Early Satiety

• Eat small, frequent meals that are nutrient dense
• Encourage consumption of energy-dense beverages between meals – want to avoid beverages with meals so as not to add to the feeling of fullness
• Avoid consumption of raw vegetables, such as salads, and other high-fiber foods

Lactose Intolerance

• Avoid lactose-containing foods – found in milk and other dairy products
• If eating a lactose-containing food, take lactase enzyme beforehand to help avoid symptoms
• Hard cheeses, yogurt, and cottage cheese contain lower amounts of lactose and may be tolerated

Describe the role of pre-biotics and pro-biotics in the management of GI disorders.

Probiotics and prebiotics support the growth of healthy flora and/or repopulate the intestinal tract with healthy bacteria. They increase the amount of undigested substrates that are fermented to short-chain fatty acids, and this increased amount of SCFA can help reduce the incidence of diarrhea. Research has also shown that they can improve the mucosal defense in the GI tract and may also reduce the growth of harmful bacteria. Studies have also shown that probiotics can help prevent flares of ulcerative colitis, but more research is needed. Probiotics have also been shown to help with the treatment of IBS. However the extent of their ability to help manage these GI disorders is still being researched.

How do dietary changes affect the microbiome?

In humans, the most significant modifier of the gut microbiome observed so far is caloric restriction. Because the adult microbiome is stable over time, the influence of short-term dietary intervention is drastic in the first 24-48 hours but becomes subtler later. Altering the microbiome requires long-term dietary changes. Increasing dietary fiber and eating a variety of fruits and vegetables can improve our gut microbiomes.