Gastrointestinal Disorders and Surgeries Flashcards
Gastric outlet obstruction is also known as ____ ___
Pyloric obstruction
Gastric outlet obstruction is caused by mechanical obstruction impeding ____ ____
Gastric emptying
Gastric outlet obstruction can be caused by…
-Cancer
-Peptic ulcer disease
-Inflammation
-Congenital disorders
-Bezoar
Clinical manifestations of gastric outlet obstruction:
-Fullness, more distressing after eating
-Epigastric pain
-Nausea/vomiting
-Dehydration
-Anorexia
-Weight loss
-Malnutrition
-Electrolyte imbalances
-Metabolic alkalosis
Medical management of gastric outlet obstruction:
-Nasogastric suction
-Surgery may be necessary: pyloroplasty
MNT for gastric outlet obstruction:
-PO diet if tolerated: chew foods thoroughly, avoid tough fibrous foods; may only be able to tolerate liquids
-For severe obstruction: NPO with IVF and electrolytes
-May require JT feeding if chronic or unresectable
Upper GI bleeding is bleeding from the…
-Esophagus
-Stomach
-Duodenum
Upper GI bleeding can be caused by:
-Esophageal varices
-Peptic ulcers
-Gastritis
-Gastric cancer
-Erosive esophagitis
-Mallory-Weiss tears
-NSAIDs and aspirin
Lower GI bleeding is bleeding from the…
-Jejunum
-Ileum
-Colon
-Rectum
Lower GI bleeding can be caused by…
-Inflammatory bowel disease
-Cancer
-Diverticular disease
-Enteritis; colitis
-Polyps
-Hemorrhoids
Symptoms of acute blood loss from a GI bleed:
-Hematemesis (blood vomit)
-Melena (black, tarry stool)
-Hematochezia (bright red blood from rectum)
____ bleeding can result from chronic blood loss and is explained as small amounts of blood in the stool
Occult
Symptoms of a GI bleed:
-Decreased Hemoglobin and hematocrit
-Increased BUN
-Weakness
-Diarrhea
-Decreased BP and increased HR
-Chronic GI bleed: iron deficiency anemia
MNT for GI bleed:
-Initially NPO with IV fluids, then liquid diet, then low fiber diet, then regular diet
For someone with a GI bleed, we should provide adequate ___, ___, and ____ for healing…
-Fluid
-Protein
-Kcal
Someone with a chronic GI bleed may need supplemental iron; they should be given ____-____ mg of elemental iron per day
150-200
If someone has severe bleeding from the small intestine, they may need ____ ____
Parenteral nutrition
An ____ is a temporary lack of peristalsis
Ileus
An Ileus can be caused by…
-Abdominal surgery
-Medications (opioids, sedatives)
-Abdominal infections (peritonitis)
-Hypokalemia
Symptoms of an Ileus:
-Abdominal distention and pain
-N/V
Typically, after abdominal surgery, the small bowel resumes motility in less than or equal to ____ hours
24
Typically, after abdominal surgery, gastric motility resumes in ___-___ hours
24-48
Typically, after abdominal surgery, colonic motility resumes in ___-___ hours
48-72
Prolonged postoperative ileus occurs when symptoms persist for > ____-____ days
3-5
MNT for Ileus:
-NPO with IV fluids until resolves
When an ileus is resolved, someone’s diet should progress from ___ to ___ to ___
Clear liquids, low fiber, regular
Someone with an ileus may require parenteral nutrition if NPO for > ___ days (begin at 5 days if malnourished)
7
If someone has a prolonged gastric ileus, we can provide ______ tube feedings
Nasojejunal
Intestinal obstruction can be caused by…
-Post-surgical adhesions (scar tissue)
-Tumors
-Severe inflammation (strictures)
-Hernias
-Volvulus
-Fecal impaction
-Congenital disorders (intestinal atresia)
Clinical manifestations of intestinal obstruction:
-Severe, crampy abdominal pain that comes and goes
-Abdominal distention and bloating
-N/V
Possible complications of intestinal obstruction:
-Decreased intake
-Dehydration
-Hypokalemia
-Metabolic alkalosis
-Hypovolemic shock
-Intestinal perforation
-Peritonitis
MNT for intestinal obstruction:
-NPO with IV fluids and electrolytes
-May require parenteral nutrition
-When oral diet is appropriate, low fiber diet and then regular diet
If someone has chronic duodenal obstriction, ___ ___ feeding is indicated
Jejunal tube
Purposes of the low fiber diet:
-Reduces fecal bulk and output
-Slows intestinal transit
Guidelines for the low-fiber diet are to consume less than or equal to ___-___ grams of fiber per day
10-15
Someone on the low-fiber diet should avoid…
-All whole grains, seeds, nuts, legumes, and popcorn
-Raw fruits and vegetables, cooked corn, potato skins
Possible reasons for intestinal resection:
-Cancer
-Inflammatory bowel disease
-Obstruction
-Congenital anomalies
-Mesenteric infarct
-Diverticulitis
-Fistula
-Volvulus
-Rectal disorders
Nutritional considerations for intestinal resections:
-Site of nutrient digestion and absorption
-Digestive enzymes and secretions
-Motility
-Amount of intestine removed
-Adaptation
____ ____ and ____ enter the duodenum
Pancreatic secretions and bile
The duodenum is the preferred site of absorption for…
-Iron
-Zinc
-Copper
-Folate
A duodenal resection can cause _____ ____
Dumping syndrome
The ____ is a major site of nutrient absorption
Jejunum
If someone has had a jejunal resection, monitor for ____
Malnutrition
After jejunal resections, the ____ typically adapts to perform the functions of the jejunum
Ileum
If someone has had an ileal resection, they are at higher risk of ____ deficiency
B12
The ileum is the site of bile salt reabsorption, so resections may cause ____ ____
Fat malabsorption
Someone who has had an ileal resection may have deficiencies of what vitamins?
-Calcium
-Magnesium
-Zinc
-Fat-soluble vitamins (A, D, E, K)
Ileal resection results in rapid ____ ____, resulting in diarrhea
Intestinal transit
Ileal resections can also increase risk for _____ and _____
-Cholelithiasis (gallstones)
-Nephrolithiasis (oxalate kidney stones)
Removal of the ileocecal valve increase the emptying rate of the small intestinal contents into the colon, leading to ____
Diarrhea
Removal of the ileocecal valve increases migration of colonic bacteria into the ileum, which leads to ___ ___ ___ ____
Small intestinal bacterial overgrowth
A colonic resection decreases absorption of ____ and ____
Fluid and electrolytes
A colonic resection can cause rapid intestinal transit times, leading to ____
Diarrhea
The preoperative nutrition guidelines determined by the enhanced recovery after surgery guidelines are…
-No solid food for 6 hours before surgery
-May have clear liquids up until 2 hours before surgery
-NPO for 2 hours before surgery
Preoperative ERAS guidelines:
-Preadmission counseling
-Fluid and carbohydrate loading
-No prolonged fasting
-No/selective bowel preparation
-Antibiotic prophylaxis
-Thromboprophylaxis
-No premedication
Intraoperative ERAS guidelines:
-Short-acting anesthetic agents
-Mid-thoracic epidural anesthesia/analgesia
-No drains
-Avoidance of salt and water overload
-Maintainance of normothermia
Postoperative ERA guidelines:
-Mid-thoracic epidural anesthesia/analgesia
-No NG tubes
-Prevention of nausea and vomiting
-Avoidance of salt and water overload
-Early removal of catheter
-Early oral nutrition
-Non-opioid oral analgesia/NSAIDs
-Early mobilization
-Stimulation of gut motility
-Audit of compliance and outcomes
The MNT for intestinal resection is the traditional post-op diet advancement which is…
-Clear liquids
-Full liquids
-Low fiber
-Regular diet
No physiologic reason exists for solid foods not to be introduced as soon as the ___ ___ is functioning and a few liquids can be tolerated
Gastrointestinal tract
Therefore, after intestinal resectioning, begin with a ___ ____ diet and advance diet as tolerated to regular diet
Low fiber
Kcal recommendations for those after intestinal resection:
25-30 kcal/kg
Protein recommendations for those after intestinal resection:
1.2-2 g/kg
After intestinal resection, patients should receive high ___ and high ____ oral nutrition supplements
Protein, kcal
After intestinal resection, patients should receive ____ supplementation as needed
Micronutrient
If extensive resection or a prolonged, post-operative ileus, ____ nutrition may be indicated
Parenteral
An intestinal ____ is a surgically created opening between the intestinal tract and the skin to permit defecation from the intact portion of the intestine
Ostomy
A ____ is created when part of the colon or rectum are removed or must be bypassed
Colostomy
An ____ is created when the entire colon is removed or must be bypassed
Ileostomy
Indications for creation of intestinal ostomies:
-Colorectal cancer
-Diverticulitis
-IBD
-Bowel perforation
-Bowel ischemia
-Enterocutaneous or colocutaneous fistulae
Nutritional concerns with intestinal ostomies:
-Excessive losses of fluid and sodium (especially ileostomies)
-Obstruction of the stoma
-Gas production
-Malodorous stool
After an ostomy is placed, someone should follow a ___ ___ diet and advance diet as tolerated to regular diet after 6 weeks
Low fiber
Someone with an ostomy should receive adequate fluid, around ___-___ cups of fluid per day
8-10
Those with ostomies should get adequate ____ and ____, especially for those with ileostomies
Sodium and potassium
Someone who has had a resection of a terminal ileum should receive vitamin ___ supplementation
B12
What can be done to minimize the risk of ostomy obstruction?
-Chew food thoroughly
-Avoid foods that are incompletely digested (corn, popcorn, raw cabbage, vegetable and fruit peels, and dried fruit)
For those with ostomies, we should educate on foods that may cause odor, like…
-Cruciferous vegetables
-Beans
-Asparagus
-Garlic
-Onions
-Eggs
-Fish
What can be done if someone has excessive ostomy output?
-Provide oral rehydration solutions sipped throughout the day
-Reduce insoluble fiber and increase soluble fiber
-Avoid foods that can increase output: spicy food, high-fat foods, prunes, caffeine, alcohol, fruit juice, food high in added sugars, sorbitol
-6-8 small meals/day
____ is a clinical condition in which the normal digestion and/or absorption of nutrients is impaired
Malabsorption
Malabsorption may affect a single ____ or many of them
Nutrient
Malabsorption can lead to _____
Malnutrition
Fat malabsorption may be due to abnormalities in…
-Pancreatic secretion
-Bile salt availability
-Enterocyte function
What conditions may lead to pancreatic insufficiency?
-Chronic pancreatitis
-Cystic fibrosis
What conditions may lead to decreased bile availability?
-Cholestatic liver disease
-Biliary obstruction
-End-stage liver disease
____ disease/resection may lead to a decrease in reabsorption of bile salts
Ileal
What conditions may lead to small bowel mucosal disease/damage (and therefore fat malabsorption)?
-Celiac disease
-Crohn’s disease
-Radiation enteritis
-AIDS
Gastric resection can lead to ____ syndrome
Dumping
Bacterial overgrowth can be caused by…
-Deconjugation of bile salts
-Intestinal mucosal damage
Signs and symptoms of fat malabsorption:
-Steatorrhea
-Weight loss despite adequate intake
Excessive fat content in stool causes ____
Diarrhea
Characteristics of steatorrhea:
-Pale, greasy stools
-Oily film in toilet water
-Foul odor
Steatorrhea is diagnosed with a ___ ___ ____
Fecal fat test
Procedure of the fecal fat test:
-72 hour stool collection
-Consume 100 g fat diet
Normally, there is ___-___ grams of fat in the stool per day
2-6
Steatorrhea is diagnosed if someone has more than ___ grams of fat per day in the stool
7
Nutritional consequences of steatorrhea:
-Dehydration
-Electrolyte losses
-Weight loss and malnutrition
-Fat-soluble vitamin deficiencies
-Decreased absorption of calcium, magnesium, and zinc
-Hyperoxaluria-> nephrolithiasis
Treatment goals for steatorrhea:
-Determine and treat underlying cause
-Alleviate steatorrhea
-Correct nutritional deficiencies
MNT for fat for malabsorption is a fat-restricted diet of _____ g/day
40
The purpose of a fat-restricted diet is to decrease ____
Steatorrhea
With a fat-restricted diet, all types of fat are restricted, except ____
MCT
MNT for fat malabsorption also includes treating the _____ disease
Underlying
If fat malabsorption is due to pancreatic insufficiency, recommend ____ ____ supplements
Pancreatic enzyme
Medium-chain triglyceride oil does not require ____ ____, ____ ____, or ____ for digestion and absorption
-Pancreatic lipase
-Bile salts
-Chylomicrons
We can consider the use of MCT oil as a fat and kcal source; it provides ___kcal/g and ___ kcal/Tbsp
8.3 kcal/g; 116 kcal/tbsp
MCT oil has a low smoke point so it shouldn’t be used in ____
Cooking
MCT oil is often used in ___-____ oral supplements or enteral fomulas
Semi-elemental
MCT oil does not contain ___ ___ ___
Essential fatty acids
For someone with fat malabsorption, we should monitor for micronutrient _____ and supplement as needed
Deficiencies
For someone with fat malabsorption, they should get…
-MVI with minerals
-Water-soluble form of fat-soluble vitamins
What type of oral nutrition supplements are given to those with fat malabsorption?
-Partially hydrolyzed, peptide-based with MCT oil
What are two examples of oral nutrition supplements that would be given to someone with fat malabsorption?
-Peptamen with Prebio
-Vital Peptide 1.5 Cal
Carbohydrate malabsorption may be due to abnormalities in…
-Levels of brush border enzymes (disaccharide deficiency-> lactase deficiency)
-Pancreatic secretion (pancreatic insufficiency)
-Damaged mucosa (Celiac disease)
Carbohydrate malabsorption may also be caused by significant resections of the ___ ____
Small bowel
Signs and symptoms of carbohydrate malabsorption:
-Abdominal bloating/distention
-Flatulence
-Watery, osmotic diarrhea
-Borborygmi
-Nausea
MNT for carbohydrate malabsorption is to limit/avoid the offending ____
Carbohydrate
For someone with a lactase deficiency, someone should follow a ____-restricted diet and limit to the amount tolerated
Lactose
For someone with a lactase deficiency, we should provide alternate ____ and vitamin ____ sources
Calcium and D
Possible etiologies of protein malabsorption:
-Pancreatic insufficiency
-Small bowel mucosal damage: inflammation, Celiac disease
-Significant small bowel resections (Short bowel syndrome)
Signs and symptoms of protein malabsorption:
-Muscle wasting
-Edema
-Decrease serum albumin and prealbumin
For someone with protein malabsorption, we should recommend an high protein diet of ____ g/kg
1.5
If someone has protein malabsorption due to pancreatic insufficiency, recommend ___ ___ ___
Pancreatic enzyme supplements
Those with protein malabsorption might have a need for ____, ___-___ protein sources (enteral nutrition)
Hydrolyzed, semi-elemental
How should we monitor for symptoms of malnutrition?
-GI symptoms and stool output
-Nutrient intake
-Weight
-NFPE
-Hydration status
What labs can be used to monitor for malabsorption?
-Fecal fat test
-Serum electrolyte levels
-Serum vitamin and mineral levels
-Prothrombin time
-Serum cholesterol and triglycerides
A ____ is an abnormal connection from one organ to another organ, skin, or wound
Fistula
Fistulas can originate from anywhere in the ____ ____
Gastrointestinal tract
Fistulas can be caused by…
-Surgery
-Inflammatory bowel disease
-Radiation enteritis
-Bowel ischemia
A high output enteric fistula has over ____ mL of enteric output per day
500
A low output enteric fistula has less than ____ mL of enteric output per day
500
Complications of fistulas:
-Excessive fluid and electrolyte losses
-Micronutrient deficiencies (zinc)
-Infection, sepsis
-Malnutrition
-Mortality
Malnutrition can develop quickly and contributes to morbidity and mortality; it can also adversely affect spontaneous fistula ____
Closure
Malnutrition with a fistula can be caused by…
-Inadequate intake
-Underlying disease
-Loss of protein-rich secretion from the fistula
-Increase kcal and protein requirements due to inflammation and infection
What are the objectives for treatment of a fistula?
-Control/minimize fistula output
-Replace fluid and electrolyte losses
-Promote healing
Conservative management of a fistula includes…
-TPN
-Octreotide
____ can also be done to repair a fistula
Surgery
Someone with a fistula has high ____ needs
Energy
Someone with a fistula also has high protein needs; they should get ___-___ g of protein/kg and may even need up to ___ g/kg if high fistula output
1.5-2; 2.5
Someone with a fistula should also get ___ and ___ replacement
Fluid and electrolyte
We should monitor for losses of ____ with someone who has a fistula
Zinc
The mode of nutrition therapy is based on the ____ of the fistula and whether it is high or low output
Location
Frequently, those with a fistula are ____ with TPN
NPO
When is TPN indicated for someone with a fistula?
-High output, small bowel fistulas
How can TPN help someone with a fistula?
-Reduced GI secretions and output
-Improves nutritional status prior to surgery
Enteral nutrition for someone with a fistula may be indicated if the fistula is…
-Esophageal, stomach, or duodenal (feed distal to fistula)
-Low output
What type of tube feed formula should be used for those with fistulas?
Polymeric, high nitrogen
Oral nutrition may be indicated if someone has a _____ fistula
Colocutaneous
What type of oral diet should someone with a colocutaneous fistula receive?
Low fiber and low residue
After a fistula has healed, an oral diet should be…
-Low fiber and low residue
-Advance diet as tolerated to regular diet
The purpose of the low residue diet is to reduce ____ ____
Fecal output
Guidelines for a low residue diet:
-Low fiber: <13 grams of fiber/day
-Avoid excessive amounts of sugar alcohols, fructose, and sucrose
-Avoid alcohol and caffeine
-If lactose intolerance, limit dairy products
____-___ ____ is a rare condition that causes shedding of large amounts of protein from the gastrointestinal tract
Protein-losing enteropathy
Protein-losing enteropathy is characterized by progressive, moderate to severe _____ (<3.0 g/dL) and often ____ ____
Hypoalbuminemia and peripheral edema
Causes of protein-losing enteropathy:
-AIDS gastroenteropathy
-Inflammatory bowel disease
-Celiac disease
-Radiation enteritis
-Bacterial overgrowth
-Eosinophilic gastroenteritis
MNT for protein-losing enteropathy is the MNT for the ____ disease
Primary
Those with protein-losing enteropathy need a high protein diet and should get ___-___ g of protein/kg to achieve positive nitrogen balance
2-3
If the underlying condition is also causing fat malabsorption, we should also prescribe a ____-____ diet with MCT oil
Low-fat
For those with protein-losing enteropathy, we should monitor for and treat ____ and or deficiencies
Malnutrition
What are three things that can cause small intestine bacterial overgrowth?
-Disorders leading to impaired intestinal motility, resulting in stasis of intestinal contents
-Decreased gastric acid secretion
-Removal of the ileocecal valve
What disorders lead to impaired intestinal motility, resulting in stasis of intestinal contents?
-Intestinal obstruction
-Strictures-> Crohn’s Disease
-Surgical blind loops
-Multiple diverticula
-Scleroderma
What can lead to decreased gastric acid secretion?
-Gastric resection
-Atrophic gastritis
-Chronic use of H2-receptor blockers or protein pump inhibitors
Symptoms and consequences of small intestine bacterial overgrowth include…
-Gas cramps, abdominal bloating, and pain
-Diarrhea
-Bacterial deconjugate bile salts-> fat malabsorption
-Mucosal damage (decreased levels of brush border enzymes, malabsorption, protein-losing enteropathy)
-Metabolism of vitamin B12 and carbohydrates by bacteria
-Malnutrition
How is small intestine bacterial overgrowth diagnosed?
-Hydrogen breath test
-Small bowel aspirate and culture for bacterial count
Treatment for small intestine bacterial overgrowth:
Broad spectrum antibiotics
MNT for small intestine bacterial overgrowth:
-Adequate hydration
-Reduce highly fermentable carbohydrates (low FODMAPs diet)
-If steatorrhea, 40 g low fat diet
-Micronutrient supplementation as needed (IM vitamin B12, fat-soluble vitamins in water-soluble form)
