Gastrointestinal Disorders & Surgeries Flashcards
What Gastric Outlet Obstruction (GOO)
pyloric obstruction impeding gastric emptying
GOO is Caused by ?
cancer
PUD (peptic ulcer disease)
inflammation
congenital disorders
bezoar
what is a bezoar ?
can be hair or undigested fiber material stuck in the stomach
Clinical Manifestations of GOO
Fullness, more distress after eating
Epigastric pain
Nausea/Vomiting
Dehydration
Anorexia
Weight loss
Malnutrition
Electrolyte imbalances
Metabolic alkalosis
Metabolic alkalosis
pH too basic bc too much acid loss
Medical Management of GOO
gastric enzymes first
nasogastric suction
surgery - pyloroplasty (largen the sphincter)
pyloroplasty may cause
dumping syndrome
MNT for GOO
PO diet if tolerated=> _______ & ________
may only be able to tolerate liquids=> _________
For severe obstruction=> __________
May require _______ if chronic or unresectable
chew foods thoroughly & avoid tough fibrous foods
blenderized diet
NPO with IVF & electrolytes
JT feeding
Upper GI bleeding (UGIB) is bleeding from the ___________
esophagus, stomach, or duodenum
Upper GI bleeding (UGIB) can be caused by:
Esophageal varices
Peptic & stress ulcers
Gastritis
Gastric cancer
Erosive esophagitis
Mallory-Weiss tears
NSAIDS and aspirin (ibuprofen)
Lower GI Bleeding (LGIB) is bleeding from the ________
jejunum, ileum, colon, or rectum
Lower GI Bleeding (LGIB) caused by:
Inflammatory bowel disease
Cancer
Diverticular disease
Enteritis or colitis
Polyps
Hemorrhoids
Symptoms of a GI Bleed (GIB)
Acute blood loss
Chronic blood loss
Decreased Hgb & Hct
Increased BUN (from high pro of blood)
Weakness
Diarrhea
Decreased BP and increased HR
Chronic GIB=> _____________
iron deficiency anemia
Acute blood loss from GIB? (3)
Hematemesis=>bloody vomit
Melena=>black, tarry stools (digested)
Hematochezia=>bright red blood from rectum (BRBPR) (lower GI)
chronic GIB ?
Occult bleeding=>small amounts of blood in stool
MNT for GIB
If acute bleeding:
Initially ______ then=>______=>______ diet=> ______ diet
Provide adequate _____; _____ and _____ for healing
____ supplement if needed (chronic bleeding)
NPO with IVF
liquids
low fiber
regular
fluid
protein & kcal
Iron
___ mg of elemental iron daily for adults with GIB
Note: ________ contains 20% elemental iron
If severe bleeding from small intestine, may need=> _____
iron taken _______
120 mg
taken without food
Ferrous sulfate
parenteral nutrition (PN)
without eating food
what is ileus
temporary lack of peristalsis
illeus can be caused by
abdominal surgery
medications (opioids or sedatives)
abdominal infections
hypokalemia
symptoms of ileus
Abdominal distention, pain, N/L
Intestinal obstruction is caused by…?
Post-surgical adhesions
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 bloating & distention
N/V
Possible Complications of Intestinal Obstruction
Decreased intake
Dehydration
Hypokalemia
Metabolic alkalosis
Hypovolemic shock
Intestinal perforation=> peritonitis
MNT for Intestinal Obstruction
__________________.
May require ________.
When oral diet appropriate=>____ diet=>_____ diet
If chronic duodenal obstruction=> _________
NPO with IVF & electrolytes
May require PN
low fiber
regular
JT feeding
Low fiber diet is consuming <______ grams fiber per day
Avoid?
10-15
whole grains, nuts, seeds, legumes, popcorn
raw fruits & veggies, cooked corn, and potato skins
resection ?
remove
Reasons for Intestinal Resections
MAINLY - Cancer
Inflammatory Bowel Disease
Obstruction
Congenital anomalies
Mesenteric Infarct
Diverticulitis
Fistula
Volvulus
Rectal disorders
Nutritional Considerations of intestinal resection
Site of nutrient digestion & absorption
Digestive enzymes & secretions
Motility
Amount of intestine removed
Adaptation
Pancreatic secretions & bile enter the ___________
duodenum
Duodenum is Preferred site of absorption for ____, ____, ____, and ____ however the _____ can take over some absorption
iron, zinc, copper, & folate
jejunum
Duodenal resections can cause __________
dumping syndrome
______ is the Major site of nutrient absorption, so Monitor for _____________
After resections, the______ typically adapts to perform the functions
Jejunum
malabsorption
ileum
________ slows down gastric emptying
cholecystickinase
ONLY place B12 is absorbed
end of ileum
ileum is where we reabsorb ____________
why is this important for resections?
bilesalts
can cause fat malabsorption which can further cause Ca, Mg, and Zn excretion
some side effects of ileum resection
malabsorption
diarrhea
cholelithiasis due to decreased bile salt pool
nephrolithiasis (oxalate stones)
how does cholelithiasis happen
low bile salts
high cholesterol doesn’t get bonded to bile
how does nephrolithiasis happen
Not enough calcium to binds to oxalates and takes them away bc the calcium is bonded to fat
can something take the job of ileum
no
Ilealcecal Valve (ICV):
- what is it?
- ## what does it do when removed?-
- connects ileum to ascending colon
- Increases the emptying rate of small intestinal contents into the colon=> diarrhea
- Migration of colonic bacteria into the ileum=> small intestinal bacterial overgrowth (SIBO)
Colonic resection can lead to Decreased absorption of _______
and _______
resection can lead to ________
fluid & electrolytes
diarrhea
where is fluid and electrolytes absorbed
colon and ileum
Per Enhanced Recovery After Surgery (_____) Guidelines:
No solid food for ____ before surgery
May have clear liquids up until_____ before surgery
NPO for _____ before surgery
ERAS
6 hrs
2 hours
2 hrs
high fluid in surgery can result in
ileus and inflamed bowel
MNT for Intestinal Resections
Traditional post-op diet advancement=> ?
However, there is no reason for solid foods and liquids to not be introduced as soon as the GIT is functioning. Soooo, new recommendation is _________
clear liquids=>full liquids=> low fiber=> regular
low fiber diet and ADAT (advance diet as tolerated) to regular diet
FOR INTESTINAL RESECTIONS
Provide ____ kcal/kg
Provide ________ g/kg of protein
Provide high protein, high kcal ONS
Micronutrient supplementation ?
If extensive resection or prolonged, patient can get _______=> and in this case we recommend ____________
25-30
1.2-2.0
as needed
post-operative ileus
parenteral nutrition
A surgically created opening between the intestinal tract and the skin to permit defecation from the intact portion of intestine
Intestinal Ostomies
created when part of the colon or rectum are removed or must be bypassed
Colostomy
created when entire colon is removed or must be bypassed
Ileostomy
Indications for Creation of Intestinal Ostomies
Most common is Colorectal cancer & Diverticulitis
Also…
IBD
Bowel perforation
Bowel ischemia
Enterocutaneous or colocutaneous fistulae
intestine cut and the rest is gone, ostomy type is _____
looks like ?
end stoma
turtleneck folded over
ostomy type that is more a bypass situation
loop ostomy
MNT for Ostomies
Post-op: ______________
Provide adequate fluid=> _________ of fluid/d
Adequate ____________________
Supplementation
Resection terminal ileum=> _____________
Low fiber diet=> ADAT to a Regular diet after ~6 weeks
8-10 cups
Na & K+ (especially for ileostomies)
vitamin B12 supplementation
MNT for ostomy longterm for as long as they have the ostomies
Minimize risk of stoma obstruction:
Chew food thoroughly
Avoid foods that are incompletely digested=> corn, popcorn, seeds, nuts, coconut, raw cabbage, veg & fruit peels, dried fruit
If excessive ostomy output..
Particularly a concern with _______
Provide a __________________
Avoid foods that can increase output=> foods high in ________, ____ food, high ___ foods, prunes, caffeine, alcohol, fruit juice, foods high in __________, _______
______ insoluble fiber and _____ soluble fiber
_____ small meals/day
ileostomies
oral rehydration solution (ORS) sipped throughout the day
insoluble fiber
spicy
fat
added sugars
sorbitol
Reduce
increase
6-8
soluble fiber foods
bananas
oats
carrots
Educate on foods that may cause odor=> _________
cruciferous vegetables
beans
asparagus
garlic
onions
eggs
fish
If excessive gas, limit=> ____________
cruciferous vegetables, garlic, onions, fish, eggs, legumes
carbonated beverages, chewing gum, alcohol
dairy products (if lactose intolerant)
Clinical condition in which the normal digestion and/or absorption of nutrients is impaired
Malabsorption
Malabsorption May be a _______ or ____________
Can lead to _______________
single nutrient
multiple nutrients
malnutrition
where is alcohol absorbed
stomach
colon can make some ___
vitamin K
can also absorb ____ in colon
oxalates and short chain fatty acids
Fat Malabsorption can be from abnormalities in _______, __________, or _________
Pancreatic secretion (pancreatic lipase deficiency)
Bile salt availability
Enterocyte function (damaged spot of absorption)
what can cause Pancreatic insufficiency
CF
chronic pancreatitis
Bile salt function
breaks down globs of fat (emulsifying)
form around globs to transport them
what cause decrease bile availability ?
what decreases reabsorption of bile?
Cholestatic liver disease
biliary obstruction
ESLD
ileal disease or resection
what can cause small bowel mucosal disease/damage
Celiac disease
Crohn’s disease
radiation enteritis
AIDS
what can cause dumping syndrome
gastric resection because doesn’t have time to mix
bacterial overgrowth can cause ?
deconjugation of bile salts
intestinal mucosal damage
Signs & Symptoms of Steatorrhea
Excessive fat content in stool causes diarrhea
Pale, greasy stools, oily film in toilet water, foul odor
Weight loss despite adequate intake
diagnosis of fat malabsorption
Fecal Fat Test
Fecal Fat Test
____ hr stool collection
Consume a _____ g fat diet
Normally _____ g fat in stool per day
>___ g/day=> malabsorption
72
100
2-6 g
>7 days
Nutritional Consequences of Steatorrhea
Dehydration
Electrolyte losses
Weight loss and malnutrition
Fat-soluble vitamin deficiencies
Decreased absorption of Ca, Mg, & Zn
Hyperoxaluria=> nephrolithiasis
Vitamin deficiency consequences of fat soluble vitamins
A - night blindness and bitots spots
D - osteoporosis and malabsorption Ca
E - peripheral neuropathy (nerve pain)
K - clotting factors so if someone is bruising
Treatment Goals for Fat Malabsorption
Determine & treat underlying cause
Alleviate steatorrhea
Correct nutritional deficiencies
Fat-Restricted Diet: ____ g/d
Purpose=> decrease _______
Note: All types of fat are restricted except _____
If due to pancreatic insufficiency=> _______
40
steatorrhea
MCT
pancreatic enzyme supplements
MCT do not require _____, ____, or _____ for digestion & absorption
pancreatic lipase, bile salts, or chylomicrons
Can consider MCT oil use of as a fat & kcal source
____ kcal/g; ____ kcal/Tbsp
Used for cooking?
Often used in __________ or __________
Does not contain ____
8.3
116
no bc it has low smoke point
semi-elemental oral supplements
enteral formulas
EFA
For Fat-Malabsorption, Monitor for micronutrient deficiencies & supplement as needed
- __________
- ___________
Oral nutrition supplements
- ____________________
MVI w/minerals
Water-soluble form of fat-soluble vitamins
Partially-hydrolyzed, peptide-based with MCT oil
examples of oral nutrition supplements for fat malabsorption
Peptamen with Prebio
Vital Peptide 1.5 Cal
How can CHO malabsorption occur?
- abnormalities in __________ such as ________ leading to _______ deficiency
- abnormalities in ___________ leading to __________
- damaged _______ from ________
- significant resections of the ________
- brush border enzymes
disaccharide deficiency
lactase deficiency - pancreatic secretions
pancreatic insufficiency - mucosa
celiac disease - small bowel
Signs & Symptoms of CHO Malabsorption
Abdominal bloating/distention
Flatulence
Watery, osmotic diarrhea
Borborygmi (gurgling noise)
Nausea
MNT for carb malabsorption
_____________
If Lactase deficiency __________ and _________
Also provide ____________
Limit/avoid the offending CHO
Lactose-restricted diet and Limit to amount tolerated
Provide alternate Ca & vitamin D sources
Etiology of Protein Malabsorption
Pancreatic insufficiency
Small bowel mucosal damage
- inflammation, Celiac disease
Significant small bowel resections
- Short Bowel Syndrome (SBS)
Signs & Symptoms of Protein Malabsorption
Muscle wasting
Hair loss
Decreased serum albumin, prealbumin
Edema
MNT for Protein Malabsorption
Increase protein intake=> ______ g/kg
If due to pancreatic insufficiency=> _________
Possible need for _____________ sources
(oral nutrition supplements or enteral nutrition)
1.5
pancreatic enzyme supplements
hydrolyzed, semi-elemental protein
Monitoring for protein Malabsorption
GI symptoms & stool output
Nutrient intake
Weight
Nutrition-Focused Physical Examination
Hydration status
Lab Assessment for protein malabsorption
Fecal fat test
Serum electrolyte levels
Serum vitamin & minerals levels
Prothrombin time
Serum cholesterol & TG
What is a fistula?
Abnormal connection from one organ to another organ, skin, or wound
where can a fistula happen
from anywhere in the GIT
fistula can be cause by
Surgery (mostly)
Inflammatory Bowel Disease
Radiation Enteritis
Infection (e.g., diverticulitis)
Cancer
Injury
Bowel ischemia
Classification of Enterocutaneous Fistulas (ECF)
High output: >500 ml of enteric output/day
Low Output: <500 ml
Fistula Complications
Excessive fluid & electrolyte losses
Micronutrient deficiencies (Zn)
Infection; sepsis
Malnutrition
Mortality
Malnutrition from fistula Can develop quickly and contributes to morbidity & mortality
- Adversely affects spontaneous ECF closure
Caused by:
_______
________
________
________
Inadequate intake
Underlying disease
Loss of protein-rich secretions from the fistula
Increased kcal & protein requirements due to inflammation & infection
objectives of medical treatment for fistula
management and treatment?
Control/minimize fistula output
Replace fluid & electrolyte losses
Promote healing
Conservative management: TPN, octreotide
Surgical repair
fistula nutritional needs
kcal ?
pro ?
fluid/electrolytes/vit/min ?
High calorie
High protein: 1.5-2.0 g/kg
May need up to 2.5 g/kg if high fistula output
Fluid & electrolyte replacement
Monitor for Zn losses
Mode of nutrition therapy based on location of fistula and whether it is _____ or _______
high or low output
Esophageal, stomach, duodenal fistulas=> provide _________ and ________
Use a ___________ formula
enteral nutrition
feed distal to the fistula
polymeric, high nitrogen EN
Colocutaneous fistula=> _______ and ______ diet
oral low fiber & low residue diet
For high output, ECF…
provide _________
Reduces _________ which increases the chances of spontaneous closure
Improves nutritional status prior to surgery
NPO with TPN
GI secretions & output
Low output ECF=> can try _________
enteral nutrition
MNT After Fistula Has Healed
provide an ___________ diet and _________
oral low fiber, low residue diet
ADAT regular diet as tolerated
Purpose of low residue diet
reduce fecal output
low residue diet guidelines
fiber?
what to avoid?
Low fiber: <10-15 grams fiber per day
Avoid excessive amounts of sugar alcohols, fructose, sucrose
Avoid alcohol & caffeine
If lactose intolerant=> Limit dairy products
what is Protein-Losing Enteropathy (PLE) ?
how common?
characterized by ______ and _______
Shedding of large amounts of protein from the GIT
Rare condition
progressive, moderate to severe hypoalbuminemia (<3.0 g/dL)
often peripheral edema
Causes of Protein-Losing Enteropathy
AIDS enteropathy
Inflammatory bowel disease (IBD)
Celiac disease
Radiation enteritis
Bacterial overgrowth
Eosinophilic gastroenteritis
MNT for Protein-Losing Enteropathy
High protein=> may require 2-3 g/kg to achieve positive nitrogen balance
If underlying condition is also causing fat malabsorption,
Rx a 40 g low-fat diet with MCT oil
Monitor for and treat malnutrition &/or micronutrient deficiencies
What is (SIBO) ?
Small Intestine Bacterial Overgrowth
Small Intestine Bacterial Overgrowth (SIBO) is caused by ?
Disorders leading to impaired intestinal motility resulting in stasis of intestinal contents
Decreased gastric acid secretion
Removal of the ileocecal valve (ICV)
Disorders leading to impaired intestinal motility resulting in stasis of intestinal contents (causing SIBO)
Intestinal obstruction
Strictures - Crohn’s disease
Surgical blind loops
Multiple diverticula
Scleroderma
Decreased gastric acid secretion (causing SIBO) can come from ?
Gastric resection
Atrophic gastritis
Chronic use of H2-receptor blockers or proton pump inhibitors
Symptoms and Consequences of Small Intestine Bacterial Overgrowth (SIBO)
Gas cramps, abdominal bloating & pain
Diarrhea
Bacteria deconjugate bile salts=>fat malabsorption
Metabolism of vitamin B12 & CHO by bacteria
Mucosal damage:
- Decreased levels of brush border enzymes
- Malabsorption
- Protein-losing enteropathy
- Malnutrition
SIBO Diagnosis
Hydrogen breath test
Small bowel aspirate & culture for bacterial count
SIBO Treatment
Broad-spectrum antibiotics
MNT for SIBO
Adequate ________
Reduce highly fermentable CHO=> _______ diet
If steatorrhea __________
Micronutrient supplementation as needed:
- _________
- _________
hydration
low FODMAPs
40 g Low Fat diet
- IM vitamin B12
- Fat-soluble vitamins in water-soluble form
