GASTROINTESTINAL

DISORDERS

 Nutritional implication of diseases

that impact the stomach, small
intestine, large intestine, colon and
rectum
THE GI TRACT
Management of GI disorders
depends on your understanding
of the system. If you know
• Where the GI system is
damaged
• What type of damage
has occurred
• Cut / removed
• What is digested at the
site of damage
Then you can manage ANY
disease. MNT is all dependent
on those 3 principles!!
MANAGING GI SYMPTOMOLOGY
Complaint Cause Medical treatment MNT

Dry Mouth Medications Commercial washes Add lemon/lime to water

Sjogrens Syndrome Frequent dental care Gum/candies
Chemotherapy Add flavor to food
Nausea Acid/osmolarity Anti-emetics (Zofran) Avoid high acid foods
Hormones Small, frequent meals
Medications Bland, soft foods
Limit liquids
GERD Varied Proton pump inhibitors Avoid acidic foods
Flundoplication Smaller meals
Gastritis Unknown Antibiotics Avoid acidic foods
(Generalized pain) Virus/bacteria Anti-inflammatories Encourage yogurt/probiotics
Vomiting Varied Nelms Table 14.13 (pg 360) Soft, bland foods
Fundoplication Small, frequent feeds
Separate food/water
Ulcers Ibuprofen overuse Antibiotics Avoid acidic foods
Bacteria Surgery Yogurt, dairy
Constipation Slowed motility Laxatives Fiber supplements
Medications Prune juice
Limit grain and dairy
Diarrhea Medications Anti-diarrheals Low residue diet
Bacteria/virus Manage fluids
(Not tube feed) Probiotics
Dumping syndrome High sugar or electrolyte None Reduce osmolarity
content of feeds Avoid salt, sugar
Slow down feedings
Specific Diet recommendation for c/o:
Mouth Sores Nausea
Dry mouth Occasional Diarrhea (1x/ week)
Weight Loss (unintentional)

Increase protein foods Fluids

- Chicken - Lemon/ Lime ice water
- Pork - Smoothies/ wet foods

Fiber
- Soluble (oats, pectin, gums)
- Low FODMAPS (low fermentability)
- Prebiotics
- Increased F/V (low FODMAP)

Increase calorie
- Small, frequent meals
- Pasta, potatoes, breads
FOODS TO AVOID (COMMONLY)

High Acid Foods Inflammatory Foods

 Carbonated beverages  Fried Foods
 Beef
 Caffeine
 Pastries
 Cocoa  Processed meats
 Citrus (including strawberries)  Full fat desserts (?)
 Peppers  Depends if the patient can tolerate
cream
 Lettuce or crude fiber (?)
 Depends on fiber tolerance
 Nuts & seeds (?)
LACTOSE INTOLERANCE

Pathophysiology Management
 Most common CHO intolerance  Avoidance of lactose containing
 African Americans, Asians, South
Americans symptoms
 Intermittent in GI disorders  Most can consume 6-12 g/day
 Lactose that is not hydrolyzed into  12 g = 240 ml of full-lactose milk
galactose and glucose passes into
colon  Calcium and vitamin D
 Bacteria ferment lactose to SCFAs and
gases supplementation
 Small amounts readily absorbed  Lactase & lactase-treated
 Larger amounts (> 12 g) may be more
than can be disposed of products
 Acts osmotically and increase
fecal water
MANAGING GENERALIZED GI C/O
Questions to Ask
 Where is the pain?
 When does the pain occur?
 Within 15 minutes – stomach
 1-4 hours – small intestine
 4-8 hours – large intestine
 After 6 hours - colon
 What can you tolerate?
Diet Modifications
 Sympathy vs. advice
 Manage pain aggressively
 Avoid insoluble fiber, nuts/seeds
 Keep the lumen open
 Avoid quackery
 Must resolve the medical issue
– food will not cure
NON-TRADITIONAL TREATMENTS

Safe Less Safe

 Many disruptions in GI function are  Brewer’s yeast (HTN), Buchu (liver),
the focus of herbal meds Caraway (liver), Chamomile (anti-
 See chart at end of Ch. 14, pg 371 for a coagulants), evening primrose (seizures),
discussion on common herbal agents
grapefruit seed extract (DNI), Turmeric
 Good agents to recommend
(anti-coagulants)
 Ginger is safe & effective
 Peppermint relieves nausea, but worsen  Caution in pregnancy ALWAYS!
GERD
 Milk thistle can reduce pain
 Should not be used with children unless
 Probiotics closely monitored by a doctor (who
 Turmeric understands herbal medicine)
 Nutmeg
 Encourage use in foods rather than
supplements
CONTROVERSIAL TREATMENTS
 Lactose & fructose restriction
 High anecdotal evidence but not confirmed in blinded studies

 FODMAPS: Fermentable oligo-, di-, and monosaccharides, and Polyols

 This has become the basis of many fad diets & beauty queen regiments for that
elusive “flat stomach”
 Eliminates a wide range of fruits
 Gas-causing vegetables eliminated
 Legumes, honey, and wheat eliminated
 While not directly indicated, dairy is generally avoided as well due to perceived
“lactose” bloating
 May contribute to poor nutrition if adopted as a lifestyle – but not likely to be
followed for long
FRACTURED JAW

Pathophysiology Diet modifications

 Trauma  Similar to a dysphagia 1
 Surgery w/ fixation  Add flavorings

 Usually disrupts chewing &  Non-dairy Protein, vit/min &

requires all food to be taken
through a straw
fiber likely inadequate
 Liquid multivitamin
 Protein additives or supplements
 Fiber powders
 Pasteurized egg product
 Limit ice cream
IRRITABLE BOWEL SYNDROME (IBS)
 Occurs in about 15% of women and 10% of men
 Characterized by chronic symptoms of:
 Abdominal discomfort, altered intestinal motility, bloating, feelings of incomplete
evacuation, mucus in stool, straining or increased urgency, GI distress with
psycohsocial distress
 Diagnosed based on ROME I or II criteria
 Must have symptoms for at least 12 weeks in past year
 Personally, I haven’t ever seen MDs put this much diagnostic thought into it – it’s a
benign diagnosis that tends to be given to anyone with non-pathological GI c/o
IBS MANAGEMENT

Pathophysiology Medical & Nutrition Management

 May be related to abnormal  Management of symptoms

secretion of peptide hormones  Education, counseling, medications,

and diet
or signaling agents
 Ensure adequate intake
 Altered intestinal gas and
 Tailor the diet for specific GI patterns
microflora, bacterial
 Explain the potential roles of food
overgrowth, etc may also
 Avoid large meals
contribute  Avoid excess fat, sugar, caffeine
 Moderate alcohol use
 Adequate fiber and fluid
EOSINOPHILIC ESOPHAGITIS
 Allergic inflammatory condition
 Symptoms: swallowing difficulty, food impaction, heartburn
 Requires hypoallergenic foods/formulas for treatment
GI STRICTURE/OBSTRUCTION
Medical management
 Resolve inflammation
 Surgery

Medical Nutrition Therapy

 Nutrition support
 Feed the gut if possible

 Low fiber diet

TROPICAL SPRUE (NON-BENIGN)

Pathophysiology Medical Treatment

 Broad-spectrum antibiotics
 Acquired diarrheal syndrome
 Restoration of fluid and electrolyte balance
with malabsorption  WHO Rehydration Solution
 Nutritional deficiency, anemia  2.6 g/L NaCl
 13.6 g/L Glucose
 May include bacterial  1.5 g/L KCl

overgrowth, changes in GI  2.9 g/L Trisodium citrate

motility, and cellular changes in

 May need to adjust osmolality for children,
the GI tract malnourished
 Macro- and micronutrient supplementation
 Intestinal villi altered  Folate and vitamin B12
 Not as severe as celiac disease
INFLAMMATORY BOWEL DISEASES
 Anemia
 Dietary restrictions (prescribed and
perceived)
 GI narrowing and strictures
 Bloating, nausea, bacterial overgrowth,
diarrhea
 Food aversions
 Immune system disruption & chronic
inflammation
 Malabsorption: abdominal pain, N/V,
bloating, diarrhea
 Impact of surgical resections
 Drug-nutrient interactions
 Malnutrition: growth failure, weight
loss, micronutrient deficiencies
Overview of MNT
 Restore and maintain nutrition
status
 Energy needs not generally
increased
 Protein needs may be increased
 Supplementation of nutrients
 MCT oil in steatorrhea
 Fat reduction well-tolerated but
risky due to malnutrition
 Nutrition support as necessary
 Enteral vs. parenteral
 Pre- and probiotics?
Crohn’s disease
• Transmural mucosal involvement
• May involve any portion of the GI tract
• 50-60% of cases involve the distal ileum
and colon
Characterized by: abscesses, fistulas, fibrosis, sub
mucosal thickening, localized strictures, narrowed
segments of the bowel, partial/complete obstruction
of the intestinal lumen

• See Table 15.17 on pg 419 Nelms for staging

• Surgical intervention is primary treatment for
Crohn’s and ulcerative colitis
CROHN’S DISEASE
Ulcerative colitis
 Disease process is continuous
 Rectum involved

 Normally limited to the mucosa

 Characterized by:
 Bleeding/hematochezia
 Diffuse ulceration
 Abscesses, pseudocrypts

 20% of cases of ulcerative colilitis

will require a colectomy
 Resolves disease
ULCERATIVE COLITIS
  Intestines pulled through the layer of

OSTOMIES
skin to create an external pathway
• Colostomy has minimal impact on
nutrition
• Ileostomy & jejunostomy have potential
to impact nutrition
• Increase salt
• MVI supplementation as needed
• Consume small, frequent meals
• Chew foods thoroughly
 Odor is a major problem
 Foods that cause odor:
 Legumes, onions, garlic, cabbage, eggs, fish,
 Some medications and vit/min supplements
 Deodorants available
 Pouch appliances are odor proof
 Hygiene is critical

 Patients should consume at least 1 L of

fluid more than their ostomy
output/day
DIVERTICULAR DISEASE

Saclike herniations of
the colonic wall

Sigmoid involvement

Result of long-term
constipation?

Can lead to sepsis and

systematic inflammation
DIVERTICULAR DISEASE

Medical Management Nutrition Management

 Antibiotics  Diverticulosis – high fiber diet
 Modified diet  Diverticulitis – low fiber diet
 Bowel rest
 Bowel resection/removal of
diverticuli
Polyps and colon cancer
• Third most common cancer in adults
and second most common cause of
cancer death
• Risk factors: Family history, IBD,
familial polyposis, adenomatous ,
polyps, diet, etc.
Medical Management
• Micronutrient supplementation
• Medication
• Radiation
• Chemotherapy
• Surgery
• Nutrition Support, if needed
SHORT-BOWEL SYNDROME (SBS)
Pathophysiology Medical Management
Complications:  Medications
 Malabsorption  Antibiotics
 Pre- and probiotics
 Frequent diarrhea
 Bowel resections – loss of 70-
 Steatorrhea
80% of bowel
 Growth failure
 Most digestion/absorption takes
 Weight loss place in the first 100 cam of the small
bowel
 Electrolyte imbalances
 Ileum can compensate with
adaptation
 Distal ileum : Vitamin B12, bile salts
CONTINUOUS
ADVANCEMENTS
MNT FOR SHORT BOWEL SYNDROME
General management
 Most require TPN initially
 May be life long
 Enteral nutrition
 Gradual introduction
 Regular diet if intact ileum and
colon
 Small meals, avoidance of lactose,
concentrated sweets, caffeine
 MCT oil
 Micronutrient supplementation
 Vitamin B12
 Iron
 Pre- and probiotics
Special considerations
 Malabsorption of bile acids
 Malabsorption of fats and fat-
soluble vitamins
 Malabsorption of calcium,
magnesium, and zinc
 Soap formation
 Risk for oxalate stones
 Blind Loop Syndrome
 Characterized by bacterial
overgrowth from stasis of GI tract
 Fat malabsorption/steatorrhea
 CHO malabsorption
 Micronutrient deficiency
GI DISEASE: GENERAL PRINCIPLES
 These principles apply to disease or surgery – any impact
 If stomach involved:
 Vitamin B12 and iron

 If small intestine involved:

 Malnutrition due to poor absorption
 High-dose MVI w/ water-soluble vitamins

 If colon involved:
 Fluid is main concern

 If all areas impacted:

 Unlikely to maintain nutrition on enteral feeds

 Elevated protein needs

 Watch nutrient deficiencies closely