From Review Flashcards
Crohn’s disease s/s:
Abdominal pain, fever, weight loss, nausea, vomiting, GI bleeding, chronic diarrhea, poor growth in children, nutrient deficiencies.
Intestinal obstruction (blockage), GI sores/ulcers, fistulas thru affected area into surrounding tissues such as bladder, vagina, or skin.
Arthritis, skin probs, inflammation in eyes or mouth, kidney stones, gallstones, or other diseases of the liver and biliary system.
ulcerative colitis s/s:
Rectal bleeding Iron deficiency Diarrhea & Abdominal cramps Weight loss in severe cases Synovitis Ankylosing spondylitis Sacroiliitis Erythema nodosum Pyoderma Aphthous stomatitis Episcleritis Iritis Uric acid renal stones thromboembolic events or syndromes Mild fever Tachycardia Dehydration Malnutrition Abdominal tenderness
irritable bowel syndrome (IBS) s/s:
gas, bloating, abdominal pain, cramps, spastic contractions, constipation and/or diarrhea, fecal incontinence, anxiety, back pain, mucous in the stool
National Dysphagia Diet (NDD)
4 levels
Level 1 - dysphagia pureed
Smooth pureed foods, cohesive, no lumps, homogeneous
Pudding like
No jello, fruited yogurt, peanut butter, scrambled eggs
Level 2 - dysphagia mechanically altered
Moist soft textured foods with some cohesion (easily form a bolus)
Tender ground or finely diced meats, soft tender cooked vegetables, soft fruit
No bread, dry cake, rice, cheese cubes, corn, peas, pineapple
Level 3 - dysphagia advanced
Nearly regular diet- no hard, crunchy, very dry, or sticky (adhesive) foods
Level 4 - regular diet
Viscosity
resistance to flow or the rate of flow per unit force. units= centipose (cP)
foods that decrease LES sphincter pressure
(or irritate the esophagus) High fat foods Alcohol Coffee/caffeine Chocolate Smoking Peppermint/spearmint! Acid foods like citrus or tomatoes Hot spicy foods mustard Pepper Red wine Carbonated beverages
meds that decrease LES sphincter pressure
Meds such as: Estrogen Progesterone Valium L-dopa narcotics
factors that increase LES sphincter pressure
High protein intake
Metoclopramide (reglan)- speed gastric emptying
pyrosis - define
heartburn
pyrosis - complications
is a s/s of GERD. burning sensation in the upper abdomen
GERD - cause/risk factors
factors that lower LES pressure (fat, alcohol, mint, spicy, soda, valium, L-dopa), gastric acidity, surgery fundoplication.
GERD - MNT
avoid overeating, large fluid intake, constipation.
do not recline 2-3 hr after meals
avoid running, aspirin in some ppl.
add factors that raise LES pressure (high pro intake)/speed gastric emptying (metoclopramide [Reglan])
GERD - decrease gastric acid OTC meds
histamine receptor blockers - nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac).
Antacids - Mylanta, Maalox Tums, Rolaids. Gaviscon-foams and decreases esophageal acid reflux.
GERD - decrease gastric acid PRES meds
PPI’s: work best to decrease acid production: esomeprazole (Nexium), lasoprazole (Prevacid), (omeprazole (Prilosec), pantoprazole (Protonix), rabeprozole (Acidphex), dexlansoprazole (Dexilant)
GERD - define
Lack of adequate LES closure and back flow of acidic gastric contents into the esophagus due to low LES pressure.
GERD - s/s
Pyrosis (heartburn) Dysphagia Pulmonary symptoms/aspiration Chest pain Burning throat bitter or sour taste of the acid in the back of the throat
define diverticulosis
small pouches in the colon that bulge outward through weak spots in the colon wall
diverticulosis - complications
may be asymptomatic or cause abdominal distress
diverticulosis - cause/risk factors
chronic constipation
low fiber diet
diverticulosis - MNT
high fiber diet to increase stool volume & softness.
stool softener meds like colase.
wheat bran as laxative but increase intake gradually to decrease gas, bloating, and discomfort.
MD prescribed fiber laxatives.
diverticulosis - avoid?
physicians recommend avoid nuts, popcorn, sunflower, pumpkin, caraway, sesame seeds. BUT no proof and 1 study found opp effect that eating these foods lessens the risk of diverticulosis.
Diverticulitis - define
pouches in colon become inflamed or infected due to trapped bacteria or irritants
Diverticulitis - s/s
abdominal pain and spasms, distension, n/v, constipation or diarrhea, chills, fever, bleeding, fistulas, obstruction
Diverticulitis - MNT
Bowel rest with IV hydration
Antibiotics
NPO, low residue or elemental diet, TPN may be used depending on nutritional status, anticipated length of time NPO, peritonitis, fistulas, and obstructions.
May need surgery to remove part of the colon.
After the acute episode is over and full recovery has occurred, the patient can gradually resume the high fiber diet.
Diverticulitis - meds
antibiotics: typically combine ciprofloxacin {flouroquinolone}, (trimethoprim-sulfamethoxazole) and metronidazole.
Amoxicillin penicillin monotherapy is acceptable as well.
Gluten sensitive enteropathy (celiac) - define
Sensitivity to gluten in wheat, spelt, triticale, kamut, rye, barley, and possibly oats that causes the pt’s immune system to damage their intestines.
Celiac (Non-Tropical Sprue) - risk factors
Usually has a childhood onset but occasionally begins in adulthood.
Genetic disorder that is highest in populations that consume wheat - 1 in 133 Americans.
unknown cause, Caucasian & Europeans, more in women.
GSE - diagnosis
Blood test for IgA endomysial antibodies (EMA), IgA tissue transglutaminase (tTG), IgG tissue transglutaminase and Total IgA antibodies.
Endoscopy and small bowel biopsy.
GSE - s/s
diarrhea, fatigue, cramping, weakness, bloating, flatus, dehydration, electrolyte depletion or acidosis, rectal prolapse, clubbed fingers. failure to grow, weight loss or failure to gain weight irritability and inability to concentrate
*Steatorrhea with foul, floating, clay-colored, light tan or gray; highly rancid and frothy stools.
GSE - refractory iron def anemia
PEM, muscle wasting, rickets, back pain as a result of a collapsed lumbar vertabrae; osteopenic bone disease; hyperparathyroidism; amenorrhea, fat soluble vitamin deficiencies
GSE - complications
dermatitis herpetiformis- skin rash with or without GI symptoms.
Stomatitis and recurrent aphthous ulcers.
Increased cancer risk (lymphomas & GI tract) especially if gluten is consumed.
GSE - risk factors
More common in people with autoimmune disorders such as Grave’s disease, type 1 diabetes, Sjogren’s disease, collagen diseases, rheumatoid arthritis, IgA deficiency.
May occur without GI symptoms and can cause osteoporosis, nervous system disorders, pancreatic or liver problems, internal bleeding.
Gluten free diet
Some doctors recommend the complete avoidance of gluten/gliadin and dairy products when this allergy is suspected in cases of Graves’ disease or other autoimmune disease.”
CONCLUSIONS: “The greater frequency of thyroid disease among celiac disease patients justifies a thyroid functional assessment. In distinct cases, gluten withdrawal may single-handedly reverse the abnormality.”
Celiac - MNT
Avoid all wheat (gliadin), spelt, triticale, kamut, rye (secalin), barley (hordein), and maybe oats
Celiac - what to eat
*Check all labels carefully as for example some cereals that say RICE WHATEVERS may have some wheat in them.
Plain meat, fish, rice, fruits, and vegetables and potato, rice, soy, or bean flour are OK. Or gluten-free bread, pasta, and other products can be bought from specialty food companies
Gluten sensitivity
diff from celiac. 6% of population. s/s: ab pain similar to IBS, fatigue, headaches, brain fog, tingling in extremities.
radiation enteritis - define
damage to the lining of the intestines (bowels) caused by radiation therapy, a type of cancer treatment.
radiation enteritis - an ex of
exudative diarrhea gut inflammation that results in excretion of blood, mucus, plasma proteins, and electrolytes.
radiation enteritis - SBS
Short Bowel Syndrome: cause for removal of part or all of the SI. other causes: thromboses/bowel necrosis, strangulated hernias, Crohn’s, trauma, cancer, necrotizing enterocolitis/infection.
Menetrier’s disease - aka
hyperplastic hypersecretory gastropathy
Menetrier’s disease - define
a rare, acquired, premalignant disease of the stomach characterized by massive gastric folds, excessive mucous production with resultant protein loss, and little or no acid production.
Menetrier’s disease - a cause of
gastritis - inflammation of stomach lining
pro rec in Menetrier’s disease or hypertrophic gastritis management
high protein diet (20% kcals) is recommended as albumin is low
gastritis - most common cause
Helicobacter pylori.
WBC appear in stomach lining in response to H. pylori bacteria, leading to gastritis.
gastritis - may be caused by
bacteria, viruses, alcohol, allergies, autoimmune rxns as in pernicious anemia, meds, chemical damage, bile reflux, Crohn’s, radiation gastritis, GVHD, Menetrier’s.
gastritis - s/s
Burning sensation, pain, n/v, burping, bloating, red or coffee ground vomit, melena (black stool due to blood), anorexia, weight loss, diarrhea
gastritis - MNT
Give antibiotics if gastritis is bacterial.
Avoid meds etc that irritate the stomach.
If pernicious anemia, give high dose oral or IM vitamin B-12.
In Menetrier’s disease or hypertrophic gastritis, a high protein diet (20% kcals) is recommended as albumin is low.
peptic ulcer disease - define
Mucosal break in the stomach or duodenum
PUD - % cases
15% gastric, 85% in duodenum
PUD - common cause
Helicobacter pylori (like in gastritis)
PUD - other causes
Helicobacter pylori - most common. NSAIDs, aspirin, Alcohol. Gastrinoma (Zollinger-Ellison syndrome). Severe stress (eg, trauma, burns), Curling ulcers. Bile reflux. Pancreatic enzyme reflux. Radiation. Staphylococcus aureus exotoxin. Bacterial or viral infection.
peptic ulcer disease - gastric s/s
pain ½ -1 hr after eating which is not relieved by food intake, vomiting, hematemesis (vomiting bright red blood), gastric cancer-rare, weight loss
peptic ulcer disease - duodenal s/s
pain 2-3 hrs after eating that is lessened by food intake, pain at night, vomiting-rare, melena ( dark to black tar like stools), weight gain
peptic ulcer disease - diagnosis
Gastroscopy/endoscopy
Barium Swallow/upper GI series
PUD - Management
Stop taking nsaids and aspirin and any other meds as directed by MD.
Stop smoking.
Take meds for the ulcer as directed by MD.
PUD - Helicobacter meds
flagyl, tetracycline, pepto bismol, PPI, carafate (Sucralfate) - coats ulcer and decreases its exposure to acid and pepsin.
PUD - Helicobacter PPI meds
esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), *Dexlansoprazole (Dexilant) or rabeprozole (Aciphex)
PUD - OTC meds
less effective.
histamine receptor blockers
antacids
PUD - OTC histamine receptor blocker meds
nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac)
PUD - OTC antacid meds
Mylanta, Maalox, Tums, or Rolaids etcGaviscon- foams and decreases acid reflux into the esophagus
PUD - adjunctive MNT
*diet does not cause & cannot cure an ulcer.
avoid irritant/acid production stimulants as for GERD.
avoid eating w/in 3 hrs of bedtime.
avoid skipping meals/eating large meals.
PUD - MNT check for
check for anemia esp if pt has had hemetemesis or melena - may need iron.
PUD - vagotomy surgery
rare, last resort if meds don’t work and ulcer perforates or hemmorages.
Cut vagus nerve to decrease stimulation, not effective
PUD - antrectomy/partial gastrectomy
The lower half of the stomach that makes most of the acid is removed with a Billroth I, II, or a Roux-en-Y gastrojejunostomy
PUD - partial gastrectomy
a portion of the stomach is surgically removed and the remainder must be reattached to the bowel
PUD - Billroth I
aka gastroduodenostomy. joining the upper stomach back to the duodenum
PUD - Billroth II
Joining the upper stomach with the jejunum and creating a “y” with the bile drainage and the duodenum forming the second branch of the “y”
Borchardt’s triad - develops from
hiatal hernias
Borchardt’s triad - s/s
chest pain, retching but unable to vomit, and inability to pass a nasogastric tube indicate gastric volvulus
Borchardt’s triad - MNT
Often requires emergency surgery
hiatal hernias - define
stomach protrudes up thru diaphragm where the esophagus enters the diaphragm and up into the thoracic cavity
hiatal hernias - types
sliding
rolling (paraesophageal)
hiatal hernias - s/s
May have no symptoms or have symptoms similar to GERD.
ulceration of the herniated stomach with resultant bleeding and anemia, obstruction, torsion, gangrene, and perforation may occur.
hiatal hernias - gastric volvulus
with strangulation. usually occurs post-prandially. is life threatening and is a surgical emergency if stomach cannot be decompressed.
in almost 30% of paraesophageal (rolling) hernias - stomach becomes twisted and angulated in its midportion.
hiatal hernias - MNT
same as GERD, may need surgery
zollinger-ellison syndrome - define
Tumors (cancerous/benign) of the delta cells in the islets of Langerhans in the pancreas (or sometimes at other sites like lymph nodes or duodenum) that produce gastrin and cause the parietal cells in the stomach to over secrete acid.
zollinger-ellison syndrome - s/s
Ulcers in the stomach and/or duodenum Pain Secretory diarrhea Diarrhea, steatorrhea, malabsorption (due to inactivation of pancreatic enzymes by the excess acid) Weight loss/poor appetite/malnutrition Vomiting blood
zollinger-ellison syndrome - MNT
Surgical removal of tumors
Proton pump inhibitors
If these do not work, a surgical resection or total gastrectomy is needed
dumping syndrome - post
gastrectomy
dumping syndrome - s/s
flushing, sweating, syncope (fainting), abdominal fullness, diarrhea, nausea & vomiting, weakness, tachycardia, hunger, tremors, anxiety
dumping syndrome - early cause
due to high osmolarity of simple carbs entering rapidly the SI and rapid distension of the SI by too much chyme entering too fast
dumping syndrome - late cause
due to reactive hypoglycemia where BG rises quickly followed by an over response with too much insulin production leading to hypoglycemia
bezoar - post
gastrectomy. risk of bezoar (fibrous blockages) in GI tract is increased
bezoar - avoid
fibrous foods: orange, coconut, persimmon, berries, green beans, apple, fig, celery, psyllium, sauerkraut, brussel sprouts, potato peel, legumes to decrease risk of a phytobezoar.
acute diarrhea
frequent evacuation of liquid stools, often severe w/rapid onset and usually caused by a GI infection.
temporary lactose intolerance may occur after an acute episode.
acute diarrhea - manage
may need rehydration, electrolytes (IV/equalyte, ricelyte, pedialyte) and maybe antibiotics.
acute diarrhea - meds
lomotil, imodium, kaopectate as directed by MD
acute diarrhea - severe
see MD if severe and not over in a couple days.
may use fecal transplant if severe infection like Clostridium difficile.
acute diarrhea - early refeeding
may help the gut recover and about 60% of intake may be absorbed
acute diarrhea - avoid
milk products, greasy, high-fiber, very sweet foods (aggrevate diarrhea).
progress to soft, bland foods like banana, rice, boiled potato, toast, cracker, cooked carrot, baked chicken w/out skin and fat.
acute diarrhea - children diet
BRAT diet - bananas, rice, applesauce, toast
chronic diarrhea
required a thorough workup and evaluation such as endoscopic exam and stool test for malabsorption, bacteria, etc.
treatment will vary w/cause of diarrhea.
types of diarrhea
- osmotic
- exudative
- steatorrhea/small intestinal disorders/lack of digestive enzymes.
- osmotic diarrhea - examples
lactose intolerance
dumping syndrome
- osmotic diarrhea - cause
poor digestion and absorption resulting in osmotically active solutes in the GI tract causing water to be pulled into the GI tract causing diarrhea
- osmotic diarrhea - relieved by
fasting/avoidance of the substance that cannot be digested
- exudative diarrhea - examples
radiation enteritis, ulcerative colitis, severe infection like C. diff
- exudative diarrhea
inflammation of gut results in excretion of blood, mucus, plasma proteins, and electrolytes
- steatorrhea/SI disorder/lack of dig enzy diarrhea
inadequate exposure of chyme to the intestinal epithelium, lack of or inactivation of pancreatic enzymes, SI damage, post-gastrectomy
- steatorrhea/SI disorder/lack of dig enzy diarrhea - examples
lack of pancreatic/biliary excretions, pancreatitis, CF, enterohepatic recirculation problems, bacterial overgrowth.
PUD -total gastrectomy
entire stomach is removed and esophagus is anastomosed to the duodenum
ileostomy
SI is brought to the surface of the abdomen to form a stoma. Have the ileum form the stoma if entire colon is removed.
ileostomy - stoma
many pts will have to wear pounch/bag to collect feces, control odor and protect skin.
traditional ileostomy
as there is no colon to absorb fluid and electrolytes, ensure adequate intake.
if part of the ileum was removed in surgery, there may be some malabsorption of fat, pro, cobalamin.
ileostomy MNT
As the stoma is higher in the ileum (more ileum removed), there may be malabsorption of fat, bile acids, cobalamin, water, sodium, potassium, and protein.
MNT similar to pouch.
For all ileostomy pts it is a good idea to take a multi vit/min supplement.
colectomy
surgical removal of the colon to cure UC
reasons for colectomy
cancer, familial polyposis, ulcerative colitis, ischemic bowel, trauma, severe diverticulosis, etc.
colectomy internal pouch
pt may elect to have an internal pouch connected to a stoma on the abdomen or the anus to store feces instead of wearing a bag.
colectomy BCIR
a Kock pouch or Barnett Continent Intestinal Reservoir (BCIR) may be created after a colectomy
ileoanal reservoir
an internal pouch is created using part of the ileum and is pulled thru the rectal wall and attached to the anus.
ileoanal reservoir - pouchitis
imodium is often taken to decrease diarrhea. pouchitis may cause pain, fever, bleeding. fecal leakage.
ileoanal reservoir MNT
eat slowly, small freq meals.
increase fluid & electrolyte intake.
limit simple sugars and caffeine.
soluble fiber like spyllium or guar gum may help stools be more solid.
foods reported to increase output or cause discomfort include nuts, corn, chocolate, lettuce, oranges, milk, alcohol, tomatoes.
ileoanal reservoir - avoid
insoluble fiber foods like fruit peels, mushroom, corn, celery, lettuce, bean sprouts, coleslaw, coconut, pineapple, nuts, seeds, tough meat shrimp or lobster may cause mechanical bowel obstruction.
ileoanal reservoir - gas & odor causing foods
asparagus dried beans and peas mustard cabbage family onions carbonated beverages eggs radishes pickles beer fish cucumbers strong flavored cheeses melons spiced foods fatty foods (pastries/deep fried foods) whips and meringues
ileoanal reservoir - anal irritation foods
certain raw fruits and vegetables (e.g., oranges, apples, coleslaw, celery and corn) popcorn Chinese/oriental vegetables nuts coconut dried fruits (e.g. raisins, figs) food with seeds spicy foods
ileoanal reservoir - pouch output decreasing foods
applesauce bananas boiled rice, pasta cheese creamy peanut butter tapioca pudding potatoes (without skins)
