Upper GI Flashcards
which types of reflexes produce saliva?
- Autonomic = pressure exerted by food in mouth (i.e., oral stimulation)
- Acquired = sight or smell of food
name a condition resulting from altered salivary gland function
Xerostomia (reduced saliva and dry mouth)
nutrition intervention with xerostomia?
• Small, frequent meals may be tolerated best
• Soft, moist foods
• Liquids with all meals sips intermixed with bites, so liquid
• Blended foods can act as saliva
• Use of gravies,sauces
• Cold foods sometimes preferred
• Avoid foods that are dry, crunchy, sharp
edges, extreme temperatures
• Mouthcare after each meal/snack
• Rinse mouth to get rid of food particles (1/4tsp baking soda in 1 cup water)
• Saliva substitutes (e.g., biotene) put not every pt
• Maybehelpful:spraymouthwithlikwesatietr,suck on ice chips or mints, lemon, sugar-free beverages containing citric acid (e.g., lemonade)
complications/problems with xerostomia
- Foods may be difficult to swallow
- Tasteless
- Increased risk of mouth infection
xerostomia is associated with cancer
complications are specific for the location of the cancer
e.g. head and neck> xerostomia is very common
what is dysgeusia and ageusia?
causes?
dysgeusia:
- common in head/neck radiation
- pts and elderly pts (due to meds)
- usually related to a metallic taste (usually red meats)
- Medications E.g., methotrexate strong
metallic taste
ageusia
- can’t taste anything all
- usually due to zinc deficiency, however it is not specific
Dysgeusia/Ageusia nutrition interventions
- Zinc supplementation if needed
- Avoid use of metallic utensils
- Avoid foods that taste metallic or bitter: red meats, coffee, tea
- Encourage chicken, fish, dairy, eggs, cheese instead of red meats
- Eat meat with something sweet (e.g., pork and applesauce)
- Encourage vegetarian proteins
- Add seasonings or spices (not salt)
- Cold temperature foods
swallowing phases
- Preparatory: Food is chewed and mixed with saliva
- Transit: Voluntary movement of bolus from front of oral cavity to back
- Pharyngeal
- Bolus is directed into esophagus and prevented from entering trachea
- Uvula seals off nasal passage so food does not enter nose
- Laryngeal muscles contract and seal off entrance to larynx (voice box)
- Epiglottis folds backwards to seal off entrance to larynx
• Esophageal
- Upper esophageal sphincter, opens and allows bolus to enter esophagus
- Lower esophageal sphincter (LES) controls passage into stomach & prevents stomach acid from refluxing into esophagus
Factors that can lower LES pressure and lead to incompetence of LES
- Increased secretion of gastrin, estrogen, progesterone
- Hiatal hernia, obesity
- Cigarette smoking
- Use of medications (e.g., morphine)
- Foods high in fat, chocolate, spearmint, peppermint, alcohol, caffeine
Diagnosis of gerd
most frequent method of diagnosis: give meds-> if symptoms go away-> GERD
• Sx: Difficult swallowing, heartburn, increased saliva, belching
treating GERD
- Goal: increase LES competence, decrease acid secretion & protect esophageal mucosa, clear contents from esophagus
Modify lifestyle factors
• Smoking, obesity, wear loose-fitting clothing, remain upright after eating
• Medications to reduce acidity Surgery
• Fundoplication: Laparoscopically performed-> Fundus of stomach is wrapped around the lower esophagus
nutritional implications of GERD
- Nutritional deficiency and/or weight loss if avoid food groups
- Long-term use of GERD medications can impair absorption of calcium, iron and B12
Nutrition and Lifestyle Therapy for GERD
• Smaller meals
- Large quantity = greater gastric distention = greater acid production
• Avoid high fat meals
- Delays gastric emptying; prolongs gastric secretions
• Avoid spicy food (e.g., pepper), coffee, alcohol
- Stimulates gastric acid production
• Avoid smoking
• ID foods that cause problems
• May include chocolate, mint, fried foods, alcohol, coffee (lower LES pressure)
• Remain upright at least 45 minutes after eating
• Elevate HOB 45-degree angle at night
• Avoid eating or drinking three hours before bed
what can esophagectomy be used to treat?
- Uncontrolled GERD
- Cancer
- Hiatal Hernia
- Achalasia oesophagus
- Zenkers diverticulectomy
diet progression after esophagectomy
NPO-> fluids-> soft diet-> regular diet
hwo long does diet progression after esophagectomy take place
6-8 weeks
what classifies as soft foods?
- Most cereals soaked in milk
- Scrambled eggs and omelets
- Canned or cooked fruits.
- Finely ground beef, chicken, turkey, and pork with sauces/gravies
- Mashed potatoes, squash, carrots
- Cooked or pureed vegetables
- Yogurt
Long term nutritional considerations with esophagectomy
- Early satiety
- GERD
- Weight loss
- Dumping syndrome
- Swallowing difficulties
- Nutrient deficiencies
which method of swallowing assessment will be used Post-Esophagectom
barium contrast leakage is more prone to causing infection vs gastrografin
thus gastrografin will be used
when can EN be discontinued after surgery?
when PO >60% for 2+ days
which parts of stomach are responsible for mixing/ storage?
mixing- antrum
storage- body/corpus
cells found in the stomach and their functions
- Mucous cells: Protect lining of stomach
- Chief cells: Gastric lipase and pepsinogen
• Parietal cells
- HCl and intrinsic factor
- HCl activates pepsinogen and denatures proteins
• ECL cells: Assist in control and production of gastric juices
what controls gastric secretions?
- Chemical messengers stimulate secretin: acetylcholine, histamine, gastrin
- Act to increase H+ available for HCl formation in parietal cells
- Chemical messengers inhibit secretion: somatostatin
- Basal secretions
what are the phases of gastric release?
- Cephalic phase: Release of HCl and Pepsinogen when stimulated by tasting, smelling, seeing food
- Gastric phase: Food enters stomach and stimulates gastric juices
- Other factors that contribute to stimulation of gastric secretions
- Presence of protein
- Distension of the stomach
- Caffeine
- Alcohol
• Intestinal phases: Slows gastric secretions and prepares small intestine for acidic chyme
Absorption in the stomach
• Limited - no food, small amounts of water
• Alcohol and some meds (e.g., aspirin) are exceptions
- Alcohol is absorbed in gastric mucosa and enters bloodstream through capillaries of stomach
- Presence of food slows this process
consequences of prolonged vomiting
- Rupture
- Hematemesis (bleeding)
- Dehydration
- Acid-base imbalances
- Malnutrition
- Aspiration pneumonia
Which acid-base disturbance is common with vomiting?
A. Metabolic acidosis
B. Metabolic alkalosis
B. Metabolic alkalosis
Tips for managing nausea
eat crackers
- Small frequent meals
- Avoid being too hungry or too full
- Eat slowly
- Eat plain foods
- Eat cold foods
- Drink liquids 30-60 minutes after or before meals
- Wear loose fitting clothing
- Try ginger (like ginger popsicle: hydration + nausea help; ginger ale)
tips after prolonged vomiting
1: Liquids to avoid: water, apple juice, sports drink, warm or cold tea, lemonade
Suck on ice chip first, if tolerated-> 1 teaspoon every 10min.
Increase to 1 tbsp.
Double the amount of lfid every hour. If diarrhea-> only use rehydration beverage
- Solid food intro: add one solid food at a time if no vomiting for at least 8h
Avoid high fiber and fat foods
Recommended foods:
- Crackers, grains, milk and dairy products, meat and poultry, dry toast, yogurt, clear broth
where are ulcers most commonly found?
duodenum and antrum
what are the causes of ulcers
• H.Pylori- main cause
- lives under mucus layer of stomach; attached to mucus-secreting cells
- Produces proteins that damage mucosa and cause inflammation
• Decreased mucosal integrity:
- Use of NSAIDs (e.g., ibuprofen) or steroids
- Alcohol abuse
• May be a genetic link
• Reduced blood supply caused by shock, stress, smoking
• Exacerbation of symptoms with certain foods and stress
what is similar and different between GERD and ulcers?
both ulcer and GER show a sign of pain
the difference between GERD and peptic ulcer is that with ulcers pain will go away after eating
signs and symptoms of ulcers
• Epigastric pain that occurs 90min- 3 hours after eating and is usually relieved by eating or use of antacids - Rebound gastrin • Presence of blood in vomit or stool > bleeding ulcer
ulcer treatment
• Dx: Endoscopy and tissue biopsy;
Urea breath test
• Triple/quadruple therapy for H.
Pylori (disgusting, thus important to motivate the pt to finish the course)
• Meds to reduce acid secretion (e.g., proton pump inhibitor)
• Surgical resection if disease is refractory or complications develop
diet that may cause ulcer
no evidence that diets can cause ulcers
micronutrients of concern with PUD
iron, B12 and calcium
what are the reasons for gastrectomy
- Complications of peptic ulcer disease (PUD)->hemorrhage, perforation, obstruction of pyloric sphincter
- Malignancy
- Weight loss
types of gastrectomy
• Gastrectomy- stomach resection
• Selective Vagotomy: eliminate innervations from the vagus nerve to parietal cells in order to decrease gastric acid production poor gastric emptying
• Total Vagotomy with pyloroplasty: innervations to parietal cells severed + portion of vagus nerve controlling gastric emptying no acid production
• Reconstruction with Billroth I (gastroduodenostomy- stomach connected to duodenum) & II (gastrojejunostomy- stomach connected to jejunum), Roux-en-Y:
- reconstruction always has to be performed with gastrectomy
Gastrectomy - Nutrition Implications
• Nutritional risk related to:
1) Reduced capacity of stomach-> early satiety
2) Changes in gastric emptying & transit time (could either lead to dumping or gastroparesis_
• Food normally remains in stomach 1-3 hrs in order to liquefy and partially digest. Chyme should enter duodenum slowly via pyloric sphincter and is neutralized by pancreatic bicarb
3) Components of digestion altered or lost
• E.g., Reduction in intrinsic factor secretion (required for B12 absorption)
• Standard practice to prescribe prophylactic B12 injections
• Most common deficiencies documented: B12, thiamin, vitamin D, iron, copper
• Common nutritional problems: dumping
early vs late dumping
early dumping (75%)
- 10-30 min after eating
- fluid gets moved from blood to intestine in an attempt to dilute food
- bloating, nause, vomiting, diarrhea
- due to decreased blood volume: reapid heart rate, dizziness
late dumping:
1-3 hours
- rapid increase of insulin production in an attempt to prevent hyperglycemia
- result in overproduction of insulin and hypoglycemia (-> weakness, sweating, confusion, tremors)
may experience both late and early
Post gastrectomy or “anti-dumping” diet
• Prophylactic B12 injection • Liquid multivitamin/mineral • 5-6 small meals per day • May need to lie down after eating for early dumping • Nutrient dense • Limit simple sugars to prevent hyperosmolality and hypoglycemia- late dumping • Avoid sweetened beverages esp. • Lactose is often not tolerated • Do not restrict unless have to! • Liquids in between meals - Liquids facilitate quick movement through GI • Soluble Fibre, Pectin
what is gastroparesis?
syndrome of objectively delayed gastric emptying in the ABSENCE of mechanical obstruction. Cardinal symptoms including early satiety, postprandial fullness, nausea, vomiting, bloating, and upper abdominal pain
gastroparesis DX and sx
- Dx: when gastric retention of food continues after 4 hours
* Sx: nausea, vomiting, early satiety
what are the causes of gastroparesis
Gastric emptying is complex and involves:
• Hormones
• Muscles
• Nervous system
Abnormalities in any of the above can lead to delayed gastric emptying
• E.g., autonomic nerve damage d/t diabetes or surgery
implications of gastroparesis
- High risk of malnutrition d/t intolerance of oral intake and subsequent reduced intake
- Dehydration
- If DM, glycemic control is difficult d/t unpredictable absorption of food
gastroparesis nutritional treatment
• 5-6 small meals per day
• Avoid lying down after eating, try to be active instead.
• Low in fat (<3-5g/serving) and low in fiber (<3g/serving)
• Modular supplements may be needed to enhance nutrient density
• ONS may be needed
• Chew well
• Avoid carbonated beverages and gas- producing foods legumes, cruciferous foods
• If enterally fed, may need post-pyloric
feeding
