Diseases of Upper GI Tract Flashcards
1
Q
Describe the function of the GI tract
A
Transfers nutrients and water from the external environment to the internal environment, where the circulatory system delivers nutrients to the cells
2
Q
Define GI absorption
A
Passage of end products of digestion from the GI tract into the blood or lymph
3
Q
Name and describe the three phases in the swallowing process
A
- ORAL PHASE - sucking, chewing, and moving food/liquid into the throat (voluntary)
- PHARYNGEAL PHASE - Starting the swallow, squeezing food down the throat, epiglottis closes off and protects airway from aspiration & prevents choking
- ESOPHAGEAL PHASE - relaxing & tightening the sphincters at top (UES) and bottom (LES) of esophagus; peristalsis
4
Q
What is the chief function of the esophagus?
A
Motility
5
Q
Describe the difference between Primary and Secondary Peristalsis
A
- PRIMARY - occurs with swallowing; travels the full length of the esophagus which secretes mucus (normal)
- SECONDARY - occurs in response to esophageal distention or irritation caused by gastric reflux
6
Q
What are the two main sites of absorption in the GI tract?
A
Duodenum and Jejunum
7
Q
Describe the sympathetic nervous system’s role in digestion
A
**Carried by SPLANCHNIC NERVES
•Slows secretion and motility
•Prepares body for sudden stress, increases HR and blood flow
•Constantly active at basal level
•”Fight or flight” response
*Neurotransmitters: Primarily NOREPINEPHRINE
8
Q
Describe the parasympathetic nervous system’s role in digestion
A
**Carried by the VAGUS NERVE
•Primarily uses ACETYLCHOLINE as neurotransmitter
•Vagal activity increases esophageal activity (secretion and motility)
-Swallowing is triggered by a signal transmitted by the vagus nerve
9
Q
Summarize the functions of the parasympathetic nervous system (using an acronym)
A
SLUDD: •Salivation •Lacrimation •Urination •Digestion •Defecation
10
Q
Describe the Lower Esophageal Sphincter (LES) and its role in digestion
A
Ring of thickened, circular, smooth muscle of the esophagus
•At rest, LES maintains a high-pressure zone
•Relaxes before the esophagus contracts, allowing food to pass to stomach
•After food passes, LES constricts to prevent regurgitation
11
Q
_____ and _____ are the reservoir function of the stomach
A
FUNDUS and BODY are the reservoir of the stomach
12
Q
Contractions are great in the _____ of the stomach
A
ANTRUM
13
Q
Name three important hormones of the GI tract
A
- Gastrin
- Cholecystokinin
- Secretin
14
Q
_____ in the gastric pit secrete mucus
A
MUCOUS CELLS
15
Q
G cells secrete ______.
Where?
A
GASTRIN
Released in: stomach, duodenum, and the pancreas
16
Q
Describe gastrin
A
A peptide hormone that stimulates HCl secretion by the parietal cells of the stomach and aids in gastric motility.
17
Q
Chief cells secrete ______ and ______
A
PEPSINOGEN and GASTRIC LIPASE
18
Q
Intrinsic factor is needed for the absorption of ______ and is secreted by __________
A
Intrinsic factor is needed for the absorption of VITAMIN B12 and is secreted by GASTRIC MUCOSA - PARTIETAL CELLS
19
Q
_________ secrete HCl
A
PARIETAL CELLS
20
Q
What 3 things stimulate the parietal cells secretion of HCl?
A
- Gastrin
- Acetylcholine
- Histamine
21
Q
Seeing, smelling, tasting, and chewing food triggers the _________ to stimulate ________, causing increased acid production
A
Seeing, smelling, tasting, and chewing food triggers the VAGUS NERVE to stimulate PARIETAL CELLS, causing increased acid production
22
Q
_____, ________, and ______ send neural messages to increase gastrin release, which increases ________.
A
STOMACH DISTENTION, HIGH PH, AND PEPTIDES send neural messages to increase gastrin release, which increases HCl PRODUCTION
23
Q
Name and describe the three phases of gastric secretions
A
- CEPHALIC PHASE - before food enters stomach; from sight, smell, etc of food
- GASTRIC PHASE - stimulated by presence of protein, stomach distension, alcohol and caffeine; produces gastric secretions
- INTESTINAL PHASE - Inhibitory phase; slows gastric secretions; Stomach distention, increased fat, acid, osmolality releases 2 hormones: cholecystokinin and secretin - act on smooth muscle to slow motility
24
Q
Acid reflux induces _______ of the esophagus which returns ~90% of the acid and food to the stomach
A
SECONDARY PERISTALSIS
25
What is the pH of saliva? Why is this important?
7.8-8.0
Is rich in bicarbonate, which neutralizes residual acid coating the esophagus after second peristaltic wave
26
Describe the body's two-step method for impaired esophageal clearance
1. Peristalsis clears gastric fluid from the esophagus
| 2. Swallowing saliva neutralizes any remaining acid
27
Give the six points in the etiology of GERD
1. Decreased salivation
2. Impaired esophageal clearance
3. Impaired tissue resistance
4. Transient LES relaxation
5. Delayed gastric emptying
6. Decreased resting tone of LES
28
Describe Impaired Tissue Resistance in the etiology of GERD
* The ability of the esophageal mucosa to withstand injury can determine if reflux disease will develop; influenced by AGE and NUTRITIONAL STATUS
* Tissue resistance protects against acid injury by limiting the rate of H ions diffusing into epithelium
* The esophagus produces BICARBONATE and MUCUS which forms a protective barrier on epithelial surface
* PEPSIN in acid refluxate damages esophagus by digesting epithelial protein (esophageal mucosa is less resistant to acid damage than stomach)
29
_______ is the dominant cause of reflux. Explain.
Transient LES Relaxation (TLESR)
* cause of ~82% of reflux episodes
* vagal nerve mediates noncholinergic inhibitory reflex in LES
* TLESRs are short lived (<30s)
* Not nexessary to treat GERD that exists from TLESR
30
Describe how Delayed Gastsric Emptying can be a cause of GERD
When gastric emptying is delayed the gastric fluid volume is increased, thus increasing amount of fluid available for reflux
31
Describe how Decreased Resting Tone of LES can be a cause of GERD
* Low-pressure LES allows reflux every time pressure in stomach>LES
* Usually associated with severe ESOPHAGITIS
32
Name and describe the symptoms of GERD
* HEARTBURN - most common GERD symptom; caused by reflux of gastric contents into the esophagus
* DYSFUNCTIONAL SWALLOWING - DYSPHAGIA - impairment in movement of swallowed material from pharynx to stomach; may occur b/c abnormal peristalsis, inflammation, or a stricture
* ODYNOPHAGIA - Sharp pain beneath sternum that occurs when swallowing; result of erosive esophagitis; may inhibit eating due to pain
* REGURGITATION - bitter/acid taste in mouth from acid refluxing; not vomiting b/c lack of abdominal wall & GI contraction
* CHEST PAIN - may be sharp or dull
33
Describe the pulmonary symptoms of GERD
If refluxed material gets past UES it can aspirate into larynx and tracheobronhial tree
Symptoms: asthma, chronic coughing, bronchitis, wheezing, aspiration pneumonia, interstitial fibrosis
~45-65% of adult asthmatics have GERD
34
Describe the oral symptoms of GERD
* Waterbath - spontaneous appearance of high volumes of saliva in mouth; caused by vagally mediated reflex initiated by acid in esophagus
* Gingivitis & Tooth Decay - caused by contact with acidic refluxate
35
Describe the throat symptoms of GERD
Damage to larynx due to acidic refluxate which can result in hoarsness, laryngits, sore throat, or globus sensation (tightness in throat like when about to cry)
36
Describe the Endoscopy process
Uses and endoscope (thin, lighted tube with camera on end). Is eased into mouth, down esophagus, into stomach and duodenum.
•can visualize lining of upper GI and take photos of areas or tissue for biopsy
37
_______ is the most common complication of GERD; ________ is most common symptom
Esophagitis - complication
Heartburn - symptom
38
Describe Barrett's Esophagus
* Normal epithelium is replaced with a columnar epithelium (stiffer)
* Is a marker of severe reflux & potential precursor of esophagial cancer (DYSPLASIA - changes in the esophagus)
39
What is a treatment for Barrett's Esophagus. Why is this important?
Ablation Therapy - damages lining of esophagus with heat or laser and have normal cells develop in low acid environment
40
How is Barrett's esophagus recognizable in an endoscope?
Salmon colored esophageal mucosa which contrasts with normal pearly white appearance of normal esophageal squamous mucosa
41
List factors that exacerbate GERD symptoms
* Smoking - nicotine decreases LES and tobacco compromises GI integrity
* Fat - lowers LES resting tone and delays gastric emptying; increases acid production
* Carminatives (peppermint and spearmint) - lower LES pressure
* Coffee, beer & wine - stimulate secretion of gastric acid
* Obesity - increases intragastric pressure
* Tight clothes - may increase reflux
* Pregnancy - decreases LES pressure temporarily
42
What Nutritional Therapy is recommended for GERD?
* Avoid large, high fat meals esp 3-4 hours before bedtime
* Avoid chocolate, alcohol and caffeine, peppermint and spearmint
* Sit upright and avoid vigorous activity soon after eating
* Avoid tight fitting clothes
* Avoid spiced foods if inflammation exists
* The pH of foods has little importance, most are less acidic than gastric pH 1-3
43
What is a hernia?
Any time an internal body part pushes into an area where it doesn't belong
44
Describe a hiatal hernia
The stomach bluges up into the chest through the hiatus (muscular wall separating the chest cavity from the abdomen)
45
What are the two main types of hiatal hernias?
* Sliding - goes up and down constantly. Can be untreated because doesn't always present problems
* Paraesophageal
46
Compare and contrast Hiatal Hernias and GERD
•People with hiatal hernia often also have GERD
- Same medical and nutritional treatment
•One condition does not cause the other
47
What is the cause of a hiatal hernia?
* may develop after trauma/injury to the area
* may be born with weak/large hiatus
* may occur from increased pressure in abdomen from coughing, straining bms, pregnancy & delivery, or large weight gain
48
Who is at risk for a hiatal hernia?
* >50 yo
| * overweight people (esp women and smokers)
49
How are hiatal hernia's diagnosed?
Endoscopy with a barium swallow or with an X-ray
50
What are hiatal hernia treatment options?
* Most people don't have symptoms so no treatment is necessary
* Laparoscopic surgery
51
Where is peptic ulcer disease (PUD) found?
On the lining of the stomach (antrum) or duodenum
52
Describe the causes of PUD
* Bacterial infection - 92% of duodenal and 70% gastric ulcers caused by H pylori)
* Long-term NSAID use
* Cancerous tumors in the stomach or pancreas
* Chronic gastritis
* Patients with Zollinger-Ellison Syndrome
••NOT caused by daily stress or spicy foods
53
How do stress ulcers occur?
Complications of severe burns, trauma, surgery, shock, renal failure, or radiation therapy
54
Describe the common symptoms of peptic ulcers
Epigastric pain
•**dull, gnawing ache (most common)
•comes and goes for days/weeks
•occurs 2-3 hours after a meal
•occurs in middle of night (when stomach is empty)
•relieved by eating (dilutes irritants)
•relieved by antacid medication but then rebounds and stimulates gastrin release
55
What are some less common symptoms of PUD?
* weight loss
* poor appetite
* bloating
* burping
* nausea
* vomiting
* blood
* black tarry stools (melena)
56
Which type of peptic ulcer (gastric or duodenal) has a higher risk of complications of hemorrhage and perforation assoc with morbidity and mortality?
Gastric ulcer
57
What may have a protective effect on peptic ulcers?
Intake of n-3 and n-6 fatty acids
58
Where does a gastric ulcer occur?
In the smaller curvature of the stomach
59
Where does a duodenal ulcer occur?
Within the first few cm of the duodenal bulb, immediately below the pylorus. Increased acid secretion and decreased bicarbonate secretion
60
Describe nutrition therapy for PUD
* Restrict foods that may increase gastric secretion or cause irritation to the ulcer (restrict fat)
* Restrict foods not tolerated by individual
* Timing and size of meals is important (small, frequent meals)
* Micronutrients of concern: iron, calcium, B12
61
Describe Helicobacter pylori
* gram negative infectious bacterium
* small curved or spiral rod-shaped
* fastidious bacteria, difficult to grow in lab
* found on surface epithelium mucus of most patients with active gastritis
* plays major role in causing ulcers
* can be eliminated in most patients w/antibiotics and bismuth combo
62
How common is H plyori? Is it deadly?
* 30-60% people in developed countries are H. Pylori +
* most common bacterial infection in humans
•Class-1 Carcinogen - same category as cigarette smoking
63
Describe how H. pylori affects the stomach and duodenum
Can survive in stomach environment b/c secretes enzymes that neutralize the acid allowing it to make its way to the protective mucous lining. Once there, the bacterium's spiral shape helps it burrow through the lining, allowing acid to get beneath and cause ulcer
64
Name some factors that decrease mucosal integrity
* reduction of protective prostaglandins due to use of NSAIDs
* alcohol
* excessive glucocorticoid secretion or steroid medication
* factors that decrease blood supply (eg: smoking, stress or shock)
65
What types of damage can H. pylori cause?
* superficial gastritis
* chronic gastritis
* ulceration of stomach and/or duodenum
* MALT B cell lymphoma (mucosal-associated lymphoid tissue)
* gastric adenocarcinoma
66
How is H. pylori diagnosed?
* Endoscopy - tissue samples (invasive)
* Upper GI series - x-ray of esophagus, stomach, and duodenum. Drink barium to make the organs and ulcers show up clearly on x-ray
* If ulcer is found, test for H pylori to differentiate from ulcers caused by NSAIDs, stress, gastritis
* Test for H. pylori ulcers: blood, breath, and stool tests done before tissue tests b/c less invasive
67
Name and briefly describe the noninvasive tests for H. pylori
* SEROLOGICAL TESTS - detect H. pylori antibodies through blood test; not used after treatment b/c may result in positive still
* C-UREA BREATH TESTS - used to diagnose and to check after treatment; patient drinks urea solution w/marked carbon atom. If H. pylori is present it breaks down the urea, releasing the carbon which is released as CO2 on exhalation; Most accurate test
* H. Pylori STOOL ANTIGEN (HpSA) TEST - tests fecal matter; also accurate
68
Give the three arms of H. pylori treatment. How effective is it?
A.) Kill the bacteria - antibiotics
B.) Reduce stomach acid - Acid-suppressing drugs
C.) Protect the stomach lining - Bismuth subsalicylate (also kills H. pylori; can cause side effects)
86%-98% eradication rates
69
What tests can be used to determine if H. pylori has been eradicated?
* Breath tests
* stool tests
* endoscopy/biopsy
**not blood tests b/c antibody will always be there if you've ever had it
70
How can gastric carcinoma be treated?
With partial or total gastrectomy
71
What can develop prior to gastric carcinoma?
* achylia gastrica (reduced HCl and pepsin)
| * achloryhydria (absence of HCl in gastric juices
72
List the potential complications of gastric surgery
* diarrhea after meal
* dumping syndrome 15-30 min after meal (diarrhea, fullness, sweating, ab pain, vomiting, flushing, dizzy, light-headed)
* Hypoglycemia, lactose intolerance, fat malabsorption after a meal
* Alkaline reflux gastritis (high pH due to low HCl) - ab pain, vomiting bile, low apetite, iron-deficiency anemia
* Recurrence of an ulcer
* Malabsorption of necessary nutrients in patients who have had all or part of their stomach removed (fat)
73
Describe a Billroth I
Joining the upper stomach back to the duodenum after removing a piece of stomach.
*Also called a gastroduodenostomy
74
Describe a Billroth II
Attaching remainder of stomach with the jejunum, creating a "y" with the bile drainage and the duodenum forming the second branch of the "y"
*Also called a gastrojejunostomy
75
Describe laparoscopic sleeve gastrectomy. What are the benefits?
Sleeve surgery where stomach is cut and creates a long vertical tube but sphincters are left intact, so still have hormones and neurotransmitters that are not completely removed.
No malabsorption. Ghrelin is drastically reduced resulting is less food pangs
Pylorus and antrum are still in place
76
Describe partial vagal denervation
* Vagus nerve is responsible for motility of the stomach but also stimulates the parietal cells in the proximal stomach to secrete acid
* Vagal denervation decreases cholinergic stimulation of parietal cells and reduces response - gastrin
* Affects only proximal stomach area of gastric secretion
* Antrum and pylorus remain innervating by vagus nerve, so gastric emptying is normal
* Difficult, time-consuming surgery
77
Describe total vagal denervation
* TRUNCAL VAGOTOMY WITH PYLOROPLASTY (enlargement of the pyloric sphincter) - no motility, so nothing leaves the stomach, so have to widen pyloric sphyincter (pyloroplasty)
* This interrupts the innervation of the parietal cells and makes antral and pyloric areas dysfunctional with poor peristalsis
78
Describe nutrition therapy postoperatively gastric surgery
* Prescribe adequate energy and protein intake to assure appropriate healing and recovery postoperatively
* Initiate slow progression of low lactose, low sugar, isotonic liquid (soup, cooked cereal) to solid foods to prevent onset of early and late dumping syndrome
* Diarrhea w/dumping sydrome is thought to be precipitated by high intake of liquids at meal
* 5-6 small meals daily w/liquids between meals
* Patients should lie down after eating
* Liquids 30-60 min before or after meals
* Consider functional fiber (BRAT diet) to delay gastric emptying and help slow diarrhea
79
How do you help to prevent development of nutrient deficiencies after gastric surgery?
* Liquid multivitamin and mineral supplements initiated to meet DRIs
* Vitamin B12 injections may be indicated
80
Describe what a patient should eat/how often while recovering from gastric surgery
* High PRO foods at every meal
* Choose soft, well-cooked foods (no skins or seeds)
* Fewer carbs/grain foods
* <2g fiber/serving
* Introduce 1-2 solid foods per meal after surgery
* During recovery slowly add more foods (one at a time in small amounts) to daily eating plan. In time will be eating 6 very small meals and snacks/day
81
Give the three etiological reasons for malabsorption after gastric surgery
1. Decreased transit time prevents sufficient mixing of food with digestive enzymes and bile salts (esp in total gastrectomy or Billroth II)
2. Decreased enzyme production reduces enzyme:food ratio
3. Larger than normal food particles empty into the jejunum, making enzyme attack more difficult - due to loss of antrum, and hence its sieving function
82
What is the most common complication after gastric surgery? Explain.
Dumping Syndrome
* Complex response to greater than normal amounts of hypertonic foods & liquids in the proximal small bowel.
* Occurs as a result of loss of normal regulation of gastric emptying
* Results in cramping, abdominal pain, hypermotility and diarrhea
83
What diet modifications would you suggest for the treatment of Dumping Syndrome?
* Eat slowly and chew thoroughly
* 6+ small, frequent meals & snacks a day
* Avoid concentrated sweets (soda, juices, desserts, etc) - sugar sub is OK, complex CHO tolerated
* High protein (20%), higher fat (35-45%)
* Liquids 30-60 min between meals
* Soluble fiber will increase viscosity & slow GI transit
* Lactose free/lactase enzyme needed
* Avoid activity one hour after eating to prolong gastric emptying
84
Describe Gastroparesis. How is it diagnosed?
| What are the signs and symptoms?
Most commonly associated with autonomic nerve damage from diabetes or a complication of gastric surgery or idiopathic
* Diagnosed when gastric retention of food continues after 4 hours
* S/S: N/V, early satiety, fullness
85
Describe Clear Liquid Diets
When are the used?
What do they contain?
Used for preparation for endoscopic or colonoscopic evaluations and in GI disorders
* Only liquids you can "see" through: tea, broth, soda, apple juice, and gelatin
* No milk, fruit juices with pulp, nectar
* Provides ~500-600 kcals, 5-10 gm protein, little fat; 120-130 gm CHO - a little Na, K, no fiber and minimal micronutrients
86
Describe Full Liquid Diets
When are the used?
What do they contain?
Used for people that can't chew, swallow or digest sold food
* Foods that are liquid or semi-liquid at room temp;
* Best tolerated when foods are isotonic, low sugar, low lactose
* Milk, ice cream, gelatin, eggnog, butter, margarine, oil, etc. (typically higher dairy)
* Can be designed to meet nutritional needs - contain ~1500 kcal/45-50gm pro, 50-65 gm fat, 150-170 gm CHO
