Upper GIT Flashcards
Body’s initial response to stress, trauma, or injury
Inflammation
Adverse physical effects of undernutrition and their consequences
- impaired immune response: predisposes to infection
- reduced muscle strength and fatigue: Inactivity, inability to work effectively, and poor self-care
- reduced respiratory muscle strength: poor cough pressure, delay recovery from chest infection
- Inactivity, especially in bed-bound patient: predisposed to pressure, sores, thrmboembolism
- impaired thermoregulation: hypothermia
- Impaired wound-healing: failure of fistulae to close, un-united fractures, increased wound infection, prolonged recovery, increased hospital stay
- fetal and infant programming: predisposed to common chronic illness
- growth failure: stunting, delayed sexuao devlopment, reduced muscle mass
Adverse psychosocial effects of undernutrition
- impaired psychosocial function: even when uncomplicated by disease, undernutrition causes apathy, depression, self-neglect, hypochondriasis, loss of libido, social interaction deterioration; effects in personality and impairment in mother-child bonding
organs used for ingestion (4) and their functions
- oral cavity: mechanical breakdown,
moistening, and mixing of food with saliva - salivary glands: release a mixture of water, mucus, and enzymes
- pharynx: propels food from the back of the cavity to the esophagus
- esophagus: unique because transport system from external source to internal system
organs used in digestion and their functions
- small intestine: can help digestion and utilization (main character); major site of enzymatic nutrient digestion and absorption
- stomach: (more main character than intestine); muscular contractions mix food w/ acid and enzymes –> physical and chemical breakdown of food
- liver: produces bile (important secretion for lipid digestion)
- gall bladder: stores and releases bile (needed for lipid digestion)
- pancreas: releases pancreatic juice to neutralize acidic chyme; contains enzymes for CHO, CHON, and fat digestion
organs used in utilization and their functions
small intestine: nutrient absorption
large intestine: undigested food to be eliminated by body as feces
What happens in secretion of the IDU?
enzymes and digestive fluids secreted by the digestive tract and its accessory organs facilitate chemical digestion
What happens in the elimination of the IDU?
undigested material will be released through the rectum and anus by defecation
What happens in the absorption of the IDU?
passage of end-products (nutrients) of chemical digestion from digestive tract into blood or lymph for distribution to tissue cells
Common Symptoms of Gastrointestinal Disease
- ingestion of solid food causes distress but liquids do not
- difficulty swallong; food sticks in throat
- epigastric pain when eating
- pain 2-5 hours after a meal; pain relief after eating
- abdominal pain several hours after ingesting fatty meal
- cramps, distention, flatulence 18-24 hours after drinking milk
- heartburn after large or fatty meal
possible disorder for the symptom: ingestion of solid food causes distress, but liquids do not
esophageal stricture or tumor
possible disorder of the symptom: difficulty swallowing; food sticks in throat
esophageal spasm; achalasia
possible disorder of the symptom: epigastric pain when eating
gastric ulcer
possible disorder of the symptom: pain 2-5 hours after a meal; pain relief after eating
duodenal ulcer
possible disorder of symptom: abdominal pain several hours after ingesting a fatty meal
pancreatic or biliary tract disease
possible disorder of the symptom: cramps, distention, and flatulence 18-24 hours after drinking milk
lactose intolerance
- due to lactase deficiency or rapid transit time
possible disorder of the symptom: heartburn after eating a large or fatty meal
esophageal reflux
term for prolonged vomiting
hyperemesis
effects of prolonged vomiting
- loss of nutrients, fluids, electrolytes
- dehyration, electrolyte imbalance, weight loss
medications for nausea and vomiting
- antinauseants
- antiemetics
goals of MNT in nausea/vomiting
- decrease frequency and severity of nausea and/or vomiting
- maintain optimal fluid balance and nutritional status
- prevent development of anticipatory nausea, vomiting, and learned food aversions
MNT for Nausea/Vomiting
● When vomiting stops, introduce ice chips if older than 3 years of age. If tolerated, start with rehydration beverage or clear liquids
- 1tsp every 10 minutes.
- Increase to 1 Tbsp every 20 minutes.
- Double amount of fluid every hour.
If diarrhea is present, use only rehydration beverage.
○ Apple juice
○ Sports drink
○ Warm or cold tea
○ Lemonade
● When there has been no vomiting for at least 8 hours, initiate oral intake slowly with adding one solid food at a time in very small increments.
● Choose the following types of foods;
1. Without odor
2. Low in fat
3. Low in fiber
4. Take prescribed antiemetics and other medications on a regular schedule to assist in prevention of nausea and vomiting. Take all other medications after eating.
Food and Feeding Issues of Vomiting and Nausea
● Keep patient away from strong food odors
● Provide assistance in food preparation to avoid cooking odors
● Eat foods at room temperature
● Keep patient’s mouth clean and perform oral hygiene tasks after each episode of vomiting
● Offer fluids between meals
● Patient should sip liquids throughout the day
● Cold beverages may be more easily
tolerated
● Keep low-fat crackers or dry cereal by the bed to eat before getting out of bed
Lifestyle issues of Nausea and vomiting
● Relax after meals instead of moving around
● Sit up for 1 hour after eating
● Wear loose-fitting clothes
● Provide fresh air with a fan or open window
● Limit sounds, sights, and smells that may trigger nausea and vomiting
● Other complementary and alternative medicine interventions that have anecdotal evidence (though clinical trials have not been conducted):
○ Relaxation techniques
○ Acupuncture
○ Hypnosis
causes of eating difficulties associated with cancer in the oral cavity, pharynx, esophagus
- tumor mass
- obstruction
- oral infection
- ulceration
- alcoholism
T or F: Cancer in the Oral Cavity, Pharynx, Esophagus affects the chewing, swallowing, salivation, and taste acuity
TRUE
T or F: weight gain is common in Cancer in the Oral Cavity, Pharynx, Esophagus
FALSE; weight loss is common
this refers to the inability to safely transfer food and liquid from the oral cavity to the esophagus
dysphagia
occurence (in percentage) of dysphagia in the ICU
3 to 62% of those patients who have been intubated
percentage of mortality
9.2%
Risks associated with dysphagia
● Increases risk of aspiration pneumonia
● Increased likelihood of malnutrition
● Prolongs ICU stay
● Prolongs hospital stay
● Still present on discharge in 60% of cases
● Increased morbidity and mortality
how is dysphagia assessed on the ICU?
- bedside swallowing assessment
- Flexible Endoscopic Evaluation of Swallowing (FEES)
Explain the graph on consequences of dysphagia
- aspiration pneumonia –> immuno-compromise
- aspiration pneumonia –> malnutrition & dehydration
- immunocompromise –> poor wound healing
- immunocompromise –> increased risk of infections
- immunocompromise –> malnutrition & dehydration
- increased risk of infections –> increased risk of skin breakdown
- increased risk of infections –> immunocompromise
- ## increased risk of skin breakdown –> poor wound healing
- malnutrition & dehydration –> poor wound healing –> immunocompromise (refer to previously mentioned effects of immunocompromise)
- malnutrition & dehydration –> muscle breakdown
- muscle breakdown –> decreased functional status
- muscle breakdown –> decreased swallowing ability
- decreased swallowing ability –> malnutrition & dehydration
- decreased swallowing ability –> dysphagia
[refer to the actual graph for better comprehension]
This diet is of different levels of allowable consistencies and modified according to the capacity of the patient to swallow
Diets for Patients with Dysphagia
this established standard terminology and practice applications of dietary texture
modification in dysphagia management
The National Dysphagia Diets, published in 2002 by the American Dietetic Association
Objectives of MNT for dysphagia
- To attain and maintain optimal nutritional status for patients with dysphagia
- To provide adequate calories and nutrients by a variety of food items included in the meals
this can affect any part of the head and neck area
head and neck cancers
this disease finds surgical treatment to have a profound effect on ability to take food orally
head and neck cancers
what are utilized to aid patients with head and neck cancers in obtaining nutritional needs at the time of surgery
feeding tubes
where should tube be connected for immediate nutrition if with neck cancer
stomach
where should tube be connected for immediate nutrition if with stomach cancer
jejunum intestine
MNT in head and neck cancers (7)
● Address nutritional consequences of
disease and treatments (radiation therapy, surgery)
● Radiation therapy can alter taste sensation, result in dry mouth, loss of appetite, mucositis and dysphagia
● Malnutrition is reported to affect 30 to 50% of patients with head and neck cancers.
● Goal is to maintain adequate intake to promote healing and allow aggressive treatment
● May involve enteral feedings, liquid oral supplements, dietary changes (liquid, moist, soft-textured foods and smalll, frequent meals)
● Artificial saliva solutions, increased fluids, topical anaesthetics to relieve pain
● Aggressive oral hygiene, fluoride, treatment of fungal infections
Steps in the Malnutrition Universal Screening Tool (MUST)
Step 1: BMI score
Step 2: Weight loss score
Step 3: Acute disease effect score
Step 4: Overall risk of malnutrition
Step 5: Management guidelines
Etiology of acute esophagitis
- viral infection
- ingestion of irritating agents
- intubation
etiology of chronic esophagitis
- increased abdominal pressure
- reduced lower esophageal sphincter (LES) pressure
- recurrent vomiting
- delayed gastric emptying
- hiatal hernia
Pathophysiology of esophagitis
reflux of gastric acid and/or intestinal contents through the lower esophageal sphincter and into the esophagus
Management of esophagitis
behavioral modification
*avoid:
- eating within 3-4 hours of bedtime
- lying down after meals
- tight-fitting clothing
- cigarrete smoking
- excess stress
medical/surgical management
- proton pump inhibitors
- histamin-2 receptor antagonists
- antacids
-
-
nutrition management
goal: decrease exposure of esophagus to gastric contents
avoid: large meals, excess intake of dietary fat, alcohol, mint, coffee, chocolate
goal: decrease acidity of gastric secretions
avoid: coffee, alcohol
goal: prevent pain and irritation
avoid: any food that the patient feels exacerbates symptoms, especially hot and spicy foods
this chemical relaxes both upper and lower esophageal sphincters
nicotine
tube from pharynx to stomach
esophagus
this part of the esophagus is closed except when swallowing
upper esophageal sphincter (UES or cardial sphincter)
this part of the esophagus closes entrance to stomach
lower esophageal sphincter (LES)
part of the esophagus that prevents reflux of stomach contents back into esophagus
lower esophageal sphincter (LES)
Defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
Gastroesophageal Reflux Disease (GERD)
Symptoms of GERD
Symptoms: Burning sensation after meals; heartburn, regurgitation or both, especially after meals
what actions can aggravate symptoms of GERD
recumbency or bending over
what relieves symptoms of GERD
antacids
An outpouching of a portion of the stomach into the chest through the esophageal
hiatus of the diaphragm
Hiatal hernia
Symptom of hiatal hernia
Heartburn after heavy meals or with
reclining after meals
this condition may worsen GERD symptoms
hiatal hernia
Complications of GERD
● Esophagitis, stricture or ulcer
● Barrett’s Esophagus (premalignant state)
a precancerous condition in which the
normal squamous epithelium of the
esophagus is replaced by abnormal
columnar-lined epithelium known as
specialized intestinal metaplasia (similar to the intestinal lining)
Barrett’s Esophagus
what replaces the normal squamous epithelium in Barrett’s Esophagus
abnormal columnar-lined epithelium
what is the abnormal columnar-lined epithelium called in BE
specialized intestinal metaplasia
How is GERD diagnosed?
● Empirically, via symptoms (symptoms don’t always correlate with the degree of damage)
● Endoscopy - to confirm Barrett’s Esophagus and dysplasia (a negative endoscopy does not rule out the presence of GERD)
● Ambulatory reflux monitoring
what are the clinical symptoms associated with GERD?
- dental corrosion
- dysphagia
- heartburn (pyrosis)
- odynophagia
- regurgitation
- noncardiac chest pain
- extraesophageal symptoms
slow, progressive tooth surface loss associated with acid regurgitation
dental corrosion
difficulty initiating a swallow (oropharyngeal dysphagia) or sensation of food being hindered or “sticks” after swallowed
dysphagia
difficulty initiating a swallow
oropharyngeal dysphagia
painful, burning sensation that radiates up behind the sternum of fairly short duration
heatburn (pyrosis)
another word for heartburn
pyrosis
painful swallowing
odynophagia
backflow of gastric content into the mouth not associated with nausea or retching
regurgitation
unexplained substernal chest pain resembling a myocardial infarction without evidence of coronary artery disease
noncardiac chest pain
chronic cough, hoarsness, reflux-induced laryngitis, asthma
extraesophageal symptoms
Goals of Nutrition Intervention in GERD
● Increasing lower esophageal sphincter competence
● Decreasing gastric acidity, which results in decreasing severity of symptoms
● Improving clearance of contents from the esophagus
● Identification of drug-nutrient interaction
● Prevention of obstruction if esophageal stricture present
● Improvement of nutritional intake if appropriate
Nutrition Prescription for GERD
● Initiate weight-reduction program if
overweight
● Initiate smoking cessation (lowers LES pressure)
● Improve clearing of materials from
esophagus
● Remain upright after eating
● Avoid eating within 3 hours of bedtime
● Wear loose-fitting clothing
● Raise the head of bed for sleeping
● Reduce gastric acidity by eliminating the following:
○ Black and red pepper
○ Coffee (caffeinated and
decaffeinated)
○ Alcohol
● Substitute smaller more frequent meals
● Restrict foods that lessen lower esophageal sphincter pressure by eliminating the
following:
○ Chocolate
○ Mint
○ Foods with a high fat content
● Spicy, acidic foods may be irritating if esophagitis is present
● Limitation of these foods should be based on individual tolerance
T or F: Evidence reflecting the true efficacy of the Nutritional Care for Patients with Reflux and Esophagitis is almost completely lacking
True; Evidence reflecting the true efficacy of these maneuvers in patients is almost completely lacking
- American College of Gastroenterology Guidelines, 2005
What are Nutrition Recommendations based on the Nutrition Care Guidelines for Reducing Gastroesophageal Reflux and Esophagitis
- avoid large, high-fat meals and decrease greasy foods
- avoid eating 2 to 3 hours before lying down
- avoid chocolate, mint, tomatoes, and tomato products
- avoid caffeine-containing foods and beverages
- avoid acidic and highly spiced foods
- consume a well-balanced diet with adequate fiber
- consider weight loss if overweight or obese
- choose smaller, more frequent meals rather than three larger meals each day
What are Lifestyle Recommendations based on the Nutrition Care Guidelines for Reducing Gastroesophageal Reflux and Esophagitis
- elevate head of bed by 6-8 inches for individuals who have reflux episodes at night
- quit smoking and avoid secondhand smoke and alcoholic beverages
- reduce overall stress levels when possible
- wear losse-fitting clothing around the stomach area, as tight or constricting clothing can worsen reflux
Drugs Commonly Used to Treat Gastrointestinal Disorders
- antibiotics
- antacids
- proton pump inhibitors
- histamine-2 receptor antagonists (cimetidine, ranitidine)
- sucralfate
this drug eradicates Helicobacter pylori and prevents or treats infection after abdominal wounds or surgery
Antibiotics
this drug neutralizes gastric acid in acid reflux, peptic ulcer
antacids
this drug decrease gastric acid secretion
Proton pump inhibitors
this drug inhibits gastric acid
secretion
Histamine-2 receptor antagonists
(cimetidine, ranitidine)
this drug protects stomach lining and may increase mucosal resistance to acid or enzyme damage
Sucralfate (sulfated disaccharide)
Medications Used to Tx GERD
- antacids
- gaviscon
- H2 receptor antagonists
- proton pump inhibitors
- promotility agents
examples of antacids as medications for GERD
- mylanta
- maalox
a medication for GERD that functions as a barrier between gastric contents and esophageal mucosa
Gaviscon
examples of H2 receptor antagonists as medications for GERD
- cimetadine
- ranitidine
- famotidine
- nizatidine
examples of proton pump inhibitors as medications for GERD
- Omeprazole (Prilosec)
- lansoprazole
- rabeprazole
- pantoprazole
- esomeprazole
examples of promotility agents as medications used to treat GERD
- cisapride
- bethanechol
this drug enhances esophageal clearing and gastric emptying
promotility agents
what is the mainstay therapy for GERD? (main goal of medication)
acid suppression
drug that provide the most rapid symptomatic relief and heal esophagitis in the highest percentage of patients
PPI
less effective than PPIs but effective in divided doses for persons with less severe GERD
Histamin-2 receptor
may be used in selected patients, especially as an adjunct to acid suppression BUT not ideal monotherapy for most patients with GERD
Promotility agents
Fundus of stomach is wrapped around lower esophagus to limit reflux
Fundoplication
this surgical procedure requires that there be another conduit in place to transport food from the oropharynx to the rest of the GIT for digestion and absorption
esophagectomy
this procedure is usually indicated for patients with esophageal cancer
esophagectomy
Diseases of the Stomach
- Indigestion/Dyspepsia
- Acute gastritis
causes of acute gastritis
- H. pylori
- tobacco
- chronic use of drugs (alcohol, aspirin, nonsteroidal anti-inflammatory agents)
symptoms of dyspepsia
- Abdominal pain
- Bloating
- Nausea
- Regurgitation
- Belching
Dyspepsia Treatment
- Avoid offending foods
- Eat slowly
- Chew thoroughly
- Do not overindulge
What protects the gastric and duodenal mucosa in gastritis?
- mucus
- bicarbonate
- rapid removal of excess acid
- rapid repair of tissue
pertains to the erosion of mucosal layer
gastritis
pertains to the exposure of cells to gastric acid secretions and bacteria
gastritis
pertains to inflammation and tissue damage
gastritis
what is the full scientific name of H. pylori and its four characteristics
Helicobacter Pylori
- Bacteria; resistant to acid
- Damages mucosa
- Treat with bismuth, antibiotics, antisecretory agents
- Causes ~92% duodenal ulcers; 70% gastric ulcers
characterized by loss of parietal cells in the stomach
atrophic gastritis
characterized by gastric or duodenal ulcers
peptic ulcer disease (PUD)
this disease can be asymptomatic or may cause symptoms similar to gastritis and dyspepsia
Peptic Ulcer Disease
Danger of hemorrhage, perforation, penetration into adjacent organ or space
Peptic Ulcer Disease (PUD)
characterized by melena
peptic ulcer disease (PUD)
black tarry stools from GI bleeding
melena
differentiate gastric ulcers and duodenal ulcers
Gastric ulcer
- inflammatory involvement of acid-producing cells
- usually occurs with low acid secretion
Duodenal ulcers
- high acid and low bicarbonate secretion
T or F: Duodenal ulcers are associated with increased mortality and hemorrhage
False; Increased mortality and hemorrhage are associated with gastric ulcers
Etiology of Petic Ulcer
- H. pylori infection
- aspirin
- stress
- gastritis
pathophysiology of peptic ulcer
erosion through muscularis mucosa into submucosa or muscularis propria
Medical management of peptic ulcer
- if H. pylori is positive, use antibiotics
- reduce or withdraw use of NSAIDs
- use sulcrafate antacids
- suppress acid secretion with PPIs or H2 receptor antagonists
behavioral management of peptic ulcer
- avoid tobacco products
nutrition management of peptic ulcer
decrease consumption of:
- alcohol
- spices (red and black peppers when inflammed)
- coffee and caffeine
increase consumption of:
- omega-3 and omega-6 fatty acids which may have a protective effect
T or F: Nutrition cannot prevent H. pylori complications
False; Good nutrition helps defend against H. pylori complications
Surgical treatment of GERD
Fundoplication
