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Medical Nutritional Therapy II > MNT II: Exam 1 (Upper Gastrointestinal (GI) Disorders) > Flashcards

MNT II: Exam 1 (Upper Gastrointestinal (GI) Disorders) Flashcards

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USMLE® Step 1 flashcards
1
Q

Barium swallow- drink barium and have an x ray taken

Endoscopy- swallow a lighted tube with a camera so MD can look at GI tract

A

aids in the diagnosis of Upper Gastrointestinal (GI) disorders

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2
Q

Any problem swallowing food, beverages, or medications

A

Dysphagia

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3
Q

anorexia and weight loss
food sticking in the throat
choking on food, liquid or saliva
Coughing or discomfort in the throat or chest when swallowing
heartburn or acid reflux
the patient finds fluids and/or solids difficult to swallow

A

Signs and Symptoms of Dysphagia

part 1

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4
Q

symptoms indicating aspiration, such as recurrent chest infection
Need for repeated swallowing
Drooling or rocking the tongue
Pockets of food pooling in the mouth or throat
Difficulty chewing
Gurgling or wet voice quality
Hoarse breathing

A

Signs and Symptoms of Dysphagia

part 2

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5
Q 
Bedside Swallow Evaluation 
Usually a Speech & Language Pathologist will carry this out
A. important considerations
1. Oral mechanism exam
2. Mental status exam 
Can stay alert for 30 min
3. Activities of daily living
4. Medical diagnosis

B. if patient shows adequate skills, various food consistencies are presented for a swallow test
Liquid, Paste, Puree, Solid

A

(Diagnosis of Dysphagia)

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6
Q

Food or beverages enter the respiratory tract
Can cause immediate respiratory distress, block the airway, or lead to aspiration pneumonia
May occur only with certain consistency foods or all foods

A

Aspiration

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7
Q 
VISCOSITY = resistance to flow or the rate of flow per unit force units= centipose (cP)
COHESIVENESS= degree to which a food deforms instead of shears when compressed
ADHESIVENESS= the attraction between a food and another surface
A

Terms for Dysphagia

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8
Q

Smooth pureed foods, cohesive, no lumps, homogenous
Pudding like
No jello, fruited yogurt, peanut butter, scrambled eggs

A

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 1- DYSPHAGIA PUREED

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9
Q

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

A

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 2- DYSPHAGIA MECHANICALLY ALTERED

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10
Q

Nearly regular diet- no hard, crunchy, very dry, or sticky (adhesive) foods

A

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 3- DYSPHAGIA ADVANCED

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11
Q

Regular diet
www.beckydorner.com
specific info and tips on diet

A

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 4- REGULAR DIET

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12
Q

Thin liquids are usually the most difficult for the patient to swallow and present the highest risk of aspiration so many patients will be required to drink thickened liquids
1-50 cP

A

NDD TERMS FOR VISCOSITY LABELS FOR LIQUIDS

Dysphagia

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13
Q 
NECTAR-LIKE consistency of thicker fruit juices like apricot nectar
51-350cP
HONEY-LIKE
351-1750 cP 
SPOON-THICK 
like pudding
>1750 cP 
Prethickened liquids at nectar and honey consistency are available commercially
Water, juices
Tea, coffee, hot choc
milk
A

Dysphagia

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14
Q 
THICKENERS ARE AVAILABLE TO ADD TO LIQUIDS
Some are fortified with nutrients
Resource thickenup 
Thickit 
Thick & easy
nutrathik
A

Dysphagia

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15
Q

an esophageal motility disorder characterized by failure of a LES to relax and the absence of esophageal peristalsis
This causes a bag like distension of the esophagus
Caused by defective nerves or maybe a virus

A

Achalasia

ESOPHAGEAL AND LOWER ESOPHAGEAL SPINCTER (LES)

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16
Q 
Dysphagia for solids and liquids
Weight loss/ malnutrition
Substernal chest pain
Fullness in the chest
Nausea & vomiting
Regurgitation and burning
A

Signs and Symptoms of Achalasia

ESOPHAGEAL AND LOWER ESOPHAGEAL SPINCTER (LES)

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17
Q

Will not alter disorder but may help lessen discomfort
May need dysphagia diet
Frequent small feedings and eat slowly
Dietary fat may help relax the LES so include fat in feedings
Avoid extremes of temperature
Avoid foods that cause discomfort such as spicy, hot, acid, or very fibrous foods
Similar recommendations for esophageal strictures

A

Medical Nutritional Therapy for Achalasia

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18
Q

Weakened esophageal wall causing a pouch in the esophagus

Signs & Symptoms
Dysphagia
Fetid breath
GERD

MANAGEMENT
surgical removal

A

ESOPHAGEAL (Zenker) DIVERTICULUM

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19
Q

Low LES pressure results in a lack of adequate LES closure and back flow of acidic gastric contents into the esophagus

Unlike the stomach the esophagus is very sensitive to acid

Long term chronic GERD can lead to esophagitis or Barrett’s esophagus which may increase risk of esophageal cancer especially in genetically susceptible individuals

A

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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20
Q 
Pyrosis (heart burn)
Dysphagia
Pulmonary symptoms/aspiration
Chest pain
Burning throat
bitter or sour taste of the acid in the back of the throat
A

SIGNS & SYMPTOMS of GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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21
Q

A. avoid factors that may lower LES pressure and increase those that make it higher
B. decrease gastric acidity
C. surgery fundoplication

A

MANAGEMENT of GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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22
Q

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 such as: Estrogen, Progesterone, Valium, L-dopa, narcotics

A

A. FACTORS THAT MAY DECREASE LES PRESSURE or IRRITATE THE ESOPHAGUS

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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23
Q

High protein intake
Metoclopramide (reglan)-speed gastric emptying

Other
Avoid obesity and overeating
Do not recline during or after (2-3 hrs) meals
Avoid large fluid intake with meals
Avoid constipation
A

FACTORS THAT MAY INCREASE LES PRESSURE or SPEED GASTRIC EMPTYING

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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24
Q

OVER THE COUNTER MEDS

Histamine receptor blockers
nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac)

Antacids
Mylanta, Maalox,Tums, or Rolaids etc

proton pump inhibitors(PPI’s)
Prescription meds
esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec)

A

B. Decrease gastric acid

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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25
Q

Any of these meds (previous flashcard) may have side effects (which are reviewed in the food drug interaction section of you notes) for example

Antacids may decrease absorption of iron, thiamin, phosphorus, and vitamin A

PPI’s and Hist blockers may cause a decrease in vitamin B-12 absorption

Lower stomach acid may decrease calcium, magnesium, and iron absorption

A

B. Decrease gastric acid

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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26
Q

LINX Reflux Management System (Torax Medical Inc)
Magnetic sphincter augmentation (MSA)
implantable device for treatment of GERD refractory to drug therapy
Restore sphincter like function
May cause dysphagia
Nissen fundoplication
May be done endoscopically (transoral endoscopic fundiplication)- lessens reflux

A

C. Surgery

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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27
Q

The stomach protrudes up through the diaphragm where the esophagus enters the diaphragm and up into the thoracic cavity

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

gastric volvulus with strangulation which usually occurs post-prandially is a surgical emergency if the stomach cannot be decompressed it is life threatening

A

Hiatal Hernias

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28
Q

chest pain, retching but unable to vomit, and inability to pass a nasogastric tube indicate gastric volvulus

A

Borchardt’s triad

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29
Q

Borchardt’s triad: chest pain, retching but unable to vomit, and inability to pass a nasogastric tube indicate gastric volvulus

Often requires emergency surgery

MANAGEMENT
Same as for GERD
Surgery may be needed

A

Hiatal Hernias

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30
Q

Inflammation of the esophagus

May be acute or chronic

A

Esophagitis

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31
Q

Symptoms similar to heartburn, cough, dysphagia, hoarseness, sore throat
Infections like candida albicans, HIV, Epstein Barr virus, CMV, TB etc
Trauma
Bulimia/frequent vomiting
Chemotherapy or radiation exposure as in cancer therapy

A

Esophagitis

32
Q 
Drug side effect
Ingestion of caustic materials
Crohn's disease
Graph vs host disease
eosinophilic (may be related to food allergies)
Alcohol or smoking
other
A

Esophagitis

33
Q

dysphagia, upper esophageal webs, difficulty swallowing and iron deficiency anemia, glossitis, koilonychia (spoon nails),pallor

treat with iron supplements

A

Plummer-Vinson syndrome

ESOPHAGITIS

34
Q

May lead to Barrett’s esophagus which may increase risk of esophageal cancer

May lead to Mallory Weiss Syndrome (tears in the esophagus with bleeding) which in a few cases require surgical repair

ESOPHAGEAL VARICES

A

ESOPHAGITIS

35
Q

MANAGEMENT
Treat condition causing it if possible
Correct iron deficiency in Plummer-Vinson syndrome
Otherwise treatment is similar to GERD

A

ESOPHAGITIS

36
Q

Etiology: Increased blood pressure in the portal vein caused by liver disease

Can lead to increased pressure and dilation of veins in the stomach and esophagus

A major upper GI bleed will cause hematemesis (vomiting blood) or melena (black, tarry stool)
May result in shock and death
If it happens enough, you can become anemic

A

ESOPHAGEAL VARICES

ESOPHAGITIS

37
Q

When the route of the blood is blocked due to congestion in the liver, pressure increases and the blood tries to find a new way back to the heart

It starts bypassing the liver creating small blood vessels called varices

Varices are small and delicate and there is a significant risk of internal bleeding when or if the varices may rupture

Portal hypertension
Results in esophageal varices

A

ESOPHAGEAL VARICES

ESOPHAGITIS

38
Q

Most often squamous cell carcinoma or adenocarcinoma

Risk is increased by tobacco or alcohol use, Barrett’s esophagus, other irritant exposure, viruses, high meat & low F & V intake

A

Esophageal Cancer

39
Q

STAGES
I (localized)-IV(metastisized)

SIGNS & SYMPTOMS
Difficult or painful swallowing 
Severe weight loss 
Pain in the throat or back, behind the breastbone or between the shoulder blades 
Hoarseness or chronic cough 
Vomiting 
Coughing up blood
A

Esophageal Cancer

40
Q

MANAGEMENT
Esophagectomy-removes the tumor along with all or a portion of the esophagus, nearby lymph nodes, and other tissue in the area

The remaining healthy part of the esophagus may be anastamosed to the stomach (B) or a plastic tube or part of the intestine may be used to replace the esophagus (D & E)

May need radiation and/or chemotherapy and /or laser therapy

A

Esophageal Cancer

41
Q

ESOPHAGEAL REPLACEMENT SURGERY

If there is no esophagus, the patient must have a gastrostomy tube or jejunostomy tube for feeding and is not able to eat

So replacement surgery is an option to restore a more normal function

part of the colon or SI or a tube may be with to replace the esophagus

A

Esophageal Cancer

42
Q

ESOPHAGEAL REPLACEMENT SURGERY

Often a jejunostomy tube is placed at the time of the surgery and the patient is weaned from tube feeding to oral food intake in frequent small feedings

This may take weeks

Liquid supplements may be helpful

Patients may experience dysphagia,some lactose intolerance, GERD, poor taste, or bad tastes

A

Esophageal Cancer

43
Q

nausea, retching, & emesis

A

3 components of Vomiting

44
Q

Nausea- unpleasant sensation that you feel sick to your stomach which often precedes vomiting

Retching- “dry heaves” and spasms in the upper GI tract, may have gagging

Emesis- the act of vomiting or forceful removal of gastric contents up and out of the mouth, “throwing up”

A

Nausea and Vomiting

45
Q

CAUSES
Viruses, bacteria, motion sickness, morning sickness, diabetic ketoacidosis, PUD, brain tumors, Meniere’s disease, bowel obstruction, chemotherapy and other medications etc

Psychogenic- food aversions, self induced- manually or with ipecac, erotic

A

Nausea and Vomiting

46
Q

POSSIBLE CONSEQUENCES
Usually none unless vomiting is very severe or prolonged or the patient is at high risk of aspiration

Can lead to sodium and/or potassium depletion , dehydration, alkalosis

Black or coffee ground vomit or bright red blood in the vomit- go to ER

Repeated vomiting can cause tears in the esophagus, esophagitis, tooth deterioration etc

A

Nausea and Vomiting

47
Q

MANAGEMENT

Some Antiemetic Meds include:

Antivert (Meclizine) and bonine (Cyclizine)- antihistamines

Phenergan (promethazine)

A

Nausea and Vomiting

48
Q

HG is intractable nausea & vomiting (N&V) during pregnancy
@2% of pregnancies
It is a conditions that makes a pregnancy in the high risk category

A

HYPEREMESIS GRAVIDARUM (HG)

49
Q

ETIOLOGY
Not clear but may be related to: hormonal changes, allergies or immunological factors, metabolic abnormalities, psychosomatic as in AN/bulimia, genetic incompatibilities, GERD, Helicobacter pylori, stomach abnormalities, vitamin deficiencies such as B-6 or Mg ?????

A

HYPEREMESIS GRAVIDARUM (HG)

50
Q

Signs and Symptoms
Severe N&V, dehydration, electrolyte depletion, ketosis, weight loss or poor weight gain, poor oral intake and appetite, multiply nutritional deficiencies, ptyalism (excessive salivation), esophagitis, esophageal tears, liver damage, kidney damage, encephalopathy, brain or retinal hemorrhage, injury or death of mother or baby

A

HYPEREMESIS GRAVIDARUM (HG)

51
Q

give anti-emetics that are safe for pregnancy, restore fluid and electrolyte balance and nutritional status

If anti-emetics don’t work, the patient will need either jejunostomy feedings or TPN until normal oral intake can be maintained

It may be weeks to months in some cases

Good outcome for mother & baby as long as it is adequately treated

A

HYPEREMESIS GRAVIDARUM (HG)

52
Q

Inflammation of the stomach lining

A

Gastritis

53
Q

May be caused by bacteria, viruses, alcohol, allergies, autimmune reactions as in pernicious anemia, medications, chemical damage, bile reflux, Crohn’s, radiation gastritis, GVHD, Menetrier’s disease hyperplastic hypersecretory gastropathy) etc

HELICOBACTER PYLORI IS A VERY COMMON CAUSE

A

Gastritis

54
Q

SIGNS & SYMPTOMS
Burning sensation, pain, nausea & vomiting, burping, bloating, red or coffee ground vomit, melena (black stool due to blood), anorexia, weight loss, diarrhea

A

Gastritis

55
Q

MANAGEMENT
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

A

Gastritis

56
Q

Mucosal break in the stomach or duodenum

@15 % gastric (in the stomach) and 85 % in the duodenum

A

Peptic Ulcer Disease (PUD)

57
Q 
Possible 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
A

Peptic Ulcer Disease (PUD)

58
Q

SIGNS AND SYMPTOMS
Gastric: pain ½ -1 hr after eating which is not relieved by food intake, vomiting, hematemesis (vomiting bright red blood), gastric cancer-rare, weight loss

Duodenal: 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

A

Peptic Ulcer Disease (PUD)

59
Q

DIAGNOSIS
Gastroscopy/endoscopy
1) View GI with a lighted scope and take pictures or videos

Barium Swallow/upper GI series

1) Drink chalky liquid and get X-rayed
2) Generally NPO overnight as the stomach should be empty for either procedure

A

Peptic Ulcer Disease (PUD)

60
Q

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 which may include:

Take therapy (flagyl, tetracycline, & pepto bismol, proton pump inhibitor) if helicobacter test is positive

proton pump inhibitors-esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), Dexlansoprazole (Dexilant)or rabeprozole (Aciphex)

A

Peptic Ulcer Disease (PUD)

61
Q

MANAGEMENT
Carafate (Sucralfate) - coats ulcer and decreases its exposure to acid and pepsin

OVER THE COUNTER MEDS- less effective
Histamine receptor blockers
nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac)

Antacids
Mylanta, Maalox,Tums, or Rolaids etc
Gaviscon- foams and decreases acid reflux into the esophagus

A

Peptic Ulcer Disease (PUD)

62
Q

ADJUNCTIVE MNT
Diet does not cause and can not cure an ulcer

Avoid irritant and acid production stimulants as for GERD

Avoid eating within 3 hrs of bedtime

Avoid skipping meals or eating very large meals

Check for anemia especially if pt has had hemetemesis or melena- may need iron

RARE, LAST RESORT IF MEDS DO NOT WORK , ULCER PERFORATES or HEMORRHAGES IS SURGERY

A

Peptic Ulcer Disease (PUD)

63
Q

VAGOTOMY

1) Cut the vagus nerve to decrease stimulation
2) Not very effective

Antrectomy or partial gastrectomy
The lower half of the stomach that makes most of the acid is removed with a Billroth 1, II, or a Roux-en-Y gastrojejunostomy

Pyloroplasty
Opening up the valve at the outlet of the stomach to speed gastric emptying

A

Peptic Ulcer Disease (PUD)

64
Q

TOTAL GASTRECTOMY
Entire stomach is removed and esophagus is anastomosed to the duodenum

PARTIAL GASTRECTOMY
a portion of the stomach is surgically removed and the remainder must be reattached to the bowel

BILLROTH I- joining the upper stomach back to the duodenum is called a or gastroduodenostomy.

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.”

A

Peptic Ulcer Disease (PUD)

65
Q

Tumors of the delta cells in the islets of Langerhans in the pancreas (or sometimes at other sites like lymph nodes or duodenum and may others) that produce gastrin and cause the parietal cells in the stomach to over secrete acid

Tumors may be cancerous or benign

A

Zollinger-Ellison Syndrome

66
Q 
SIGNS & SYMPTOMS
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
A

Zollinger-Ellison Syndrome

67
Q

MANAGEMENT
Surgical removal of tumors

Proton pump inhibitors

If these do not work, a surgical resection or total gastrectomy is needed

A

Zollinger-Ellison Syndrome

68
Q

MNT POST GASTRECTOMY
Do a complete nutritional assessment prior to surgery

If pt has PEM, try to start improving nutritional status prior to surgery

Pt will usually need TPN or jejunostomy feeding after surgery

Will need to be NPO the night before surgery

A

Gastric Cancer

69
Q

Generally the larger the portion of the stomach removed the more difficult recovery will be for the pt

For a total gastrectomy due to cancer or Zollinger-Ellison, it is best to have a surgical jejunostomy inserted at the time of surgery as it will be a slow process for the patient to ease back into being able to eat a normal amount
Early post-op nutrition may be given via the J tube

Start trying PO intake of small amounts of water then noncarbonated sugar free or diluted clear juices progress slowly as per patient tolerance

Progress to soft bland foods in at least 6 small feedings per day

A

Gastric Cancer

70
Q

Monitor protein and kcal intake , plasma proteins and wt- supplements or feeding via J tube

Generally, drink liquids before or after meals, eat slowly, chew all foods thoroughly

If steatorrhea develops, decrease fat intake, try MCT oil, pancreatic enzyme capsule may be helpful, give water miscible forms or larger doses of fat soluble vitamins if the condition is chronic

As many or all of the cell that produce gastric intrinsic factor are removed in the surgery B-12** absorption will be lessened

Large doses PO (500 to 2000 mg/day) or IM vitamin B-12 will be needed to prevent macrocytic/megaloblastic** anemia

A

Gastric Cancer

71
Q

Remember folate will also treat the anemia, but will not prevent nerve damage from cobalamin deficiency so it is critical that the pt get adequate B-12**

IRON DEFICIENCY* may occur due to blood loss from bleeding prior to and during surgery

1) Microcytic anemia is most often due to iron deficiency
2) Plasma iron and ferritin will be low and TIBC will be elevated in iron deficiency

CALCIUM AND VITAMIN D malabsorption may result in osteomalacia

Check plasma 25-OH vitamin D levels

A

Gastric Cancer

72
Q

Plasma calcium levels are not usually a good indicators of calcium status and a bone density test is needed to detect osteomalacia

Give calcium and vitamin D supplements daily

Risk of BEZOAR (fibrous blockages) in the GI tract is increase

May need to avoid high intake of very fibrous foods such as: oranges, coconut, persimmons, berries, green beans, figs, apples, celery, psyllium, sauerkraut, Brussel sprouts, potato peels, legumes to decrease risk of a phytobezoar

A

Gastric Cancer

73
Q

This is a risk of ________ syndrome with Gastric Cancer.

A

Dumping Syndrome

74
Q

Early dumping is caused by the high osmolarity of simple carbohydrates entering rapidly into the SI and rapid distension of the SI by too much chyme entering too fast

Late dumping is due to reactive hypoglycemia where BG rises high quickly followed by an over response with too much insulin production which then leads to hypoglycemia

A

Dumping Syndrome

75
Q

SIGNS & SYMPTOMS

flushing, sweating, syncope (fainting), abdominal fullness, diarrhea, nausea & vomiting, weakness, tachycardia, hunger, tremors, anxiety

A

Dumping Syndrome

76
Q

MANAGEMENT
Don’t drink fluids with meals
Recline after eating
Small frequent feedings
Cut down on rapid acting CHO’s if they cause distress
Try new foods in small amounts and one at a time to assess tolerance, try again tolerance may improve over time
Really hot or cold liquids bother some people

A

Dumping Syndrome

Medical Nutritional Therapy II (1 decks)

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