Medical Nutrition Therapy for Gastrointestinal Tract Disorders

1. Medical Nutrition Therapy for Gastrointestinal Tract Disorders By Gaga Irawan Nugraha & Nur Fatimah Department of Medical Nutrition Faculty of Medicine, Unpad

2. Hepatic Disorder Dyspepsia/indigestion Gastritis Peptic Ulcer

3. Indigestion & Dyspepsia • Dyspepsia refers to persistent upper abdominal discomfort or pain • The discomfort may be related to organic causes such as esophageal reflux, gastri- tis, or peptic ulcer, gallbladder disease, or other identifiable pathology. • Functional dyspepsia is a term that de- scribes unexplained persistent or recurrent upper GI discomfort. It may also be described as non-ulcer dyspepsia • Symptoms of functional dyspepsia are reported in about 15%-20% of adults over a year's time and may include vague abdominal discomfort, bloating, early satiety, nausea, and belching. • May be caused by diet, stress, other lifestyle factors

4. Nutritional Recomendation • Use of well-cooked foods • Adequate amount • Small meals best tolerated • Eat slowly • Chew thoroughly • Avoid excesses: • Excess volumes of food • High fat intake • Sugar, caffeine, spices, alcohol • Stress management

5. Nutritional Recomendation • If etiology psychogenic: removing the cause often results in the disappearance of the dyspepsia • If etiology organic: soft food, low-fat diet, low fiber

6. Gastritis & Peptic Ulcer Disease Causes: disruption of mucosal integrity by infectious, chemical, neural abnormalities Infection  chronic inflammatory state + damage by cytotoxins produced by the organism Helicobacter pylori: G- bacteria with flagella. Resistant to acidic medium of stomach. Chronic inflammation of the gastric mucosa; gastric and duodenal ulcers; some forms of atrophic gastritis & gastric cancer Treatment: Medications: bismuth, antibiotics, antisecretory agents

7. Gastritis & Peptic Ulcer Disease Gastritis  • Nausea, vomiting, malaise, anorexia, hemorrhage, epigastric pain •  Atrophy & loss of stomach parietal cells, with loss of HCl secretion(achlorhydria)and intrinsic factor. • Patients may have  serum B12 levels

8. Gastritis & Peptic Ulcer Disease Medical Treatment • Endoscopy to identify problems • Eradication of pathogenic organisms • Withdrawal of provoking agents • Antibiotics, antacids, H2-receptor antagonists, proton pump inhibitors Nutritional Recommendation • Lack of acid & intrinsic factor  B12 malabsorption •  Evaluate vitamin B12 status

9. Peptic Ulcers Pathophysiology H. Pylori; NSAIDs; Corticosteroids; Stress; Alcohol; Tobacco • Gastric & duodenal mucosa protected from digestive acid & pepsin by: • Mucus • Bicarbonate • Removal of XS acid by normal blood flow • Rapid renewal & repair or epithelial cell injury Peptic Ulcer

10. Patho-physiology Algorithm: Peptic Ulcer

11. Stomach and Duodenum with Eroded Lesions • Gastric Ulcer • Duodenal Ulcer

12. Gastric vs. Duodenal Ulcers • Gastric ulcers: • Mostly along the lesser curvature of the stomach • Widespread gastritis, inflammatory involvement of oxyntic (acid-producing) cells, & atrophy of acid- and pepsin-producing cells • Antral hypomotility, gastric stasis, and duodenal reflux gastric injury severity • Higher hemorrhage and overall mortality than with duodenal ulcer.

13. Gastric vs. Duodenal Ulcers • Duodenal ulcer: • Acid secretion, nocturnal acid secretion, &  bicarbonate secretion. • Mostly within the 1st few centimeters of the duodenal bulb. • Gastric outlet obstruction: common • Duodenal ulcer related to H. pylori  gastric metaplasia may occur • H2-receptor blockers or proton pump inhibitors for acid suppression

14. Nutrition Recommendationfor Ulcers • Protein foods: • Stimulate gastrin & pepsin secretion • Food pH: • Little importance unless presence of lesions of mouth or esophagus (normal gastric pH = 1-3) • Alcohol: • May cause superficial mucosal damage. • Beers & wines  gastric secretions  Avoid • Coffee& caffeine: • Stimulate acid secretion and may  LES pressure • Spices: • Very large doses  acid secretion; small superficial erosions; mucosal lining inflammation; altered GI permeability or motility. • Spicy foods not shown to cause or affect the healing of peptic ulcer

15. Nutrition Recommendation for Ulcers • Prostaglandins from -3 & -6 FAs: • Conflicting studies: protective or harmful effects of -3 & -6 FAs. • -3: antiinflammatory properties, protective against mucosal injury by drugs and H. pylori. • Ideal dose or form of lipids in the diet has not been established. • Malnutrition: • Micronutrient deficiencies or protein-calorie malnutrition • Affect rapidly dividing cells such as in GI tract • Avoid deficiencies  protection from PUD + may help in wound healing. • Meal frequency: • Frequent small meals: comfort, acid reflux, & stimulate gastric blood flow – BUT – may  net acid output. • Avoid large meals esp. before bed to latent increases in acid secretion.

16. Nutrition Recommendationfor Ulcers • Use small feeding and frequent • High protein foods and vitamin C • Avoid personal intolerance • Limit gastric stimulant: • Caffeine • Alcohol • Pepermint, garlic, black peppr, cloves, chili • Use fewer saturated fat and more polyunsaturated fat • Supplement with vitamin C-rich foods or oral supplement. Citrus foods may not be tolareated • High intake vitamin A, vitamin C, fruits and vegetables, Soluble fiber reduce the risk • Refined sugar a risk

17. NUTRITIONAL MANAGEMENT IN HEPATIC DISORDERS

18. Metabolic function of liver • Carbohydrate, lipid and protein metabolism • Storage and activation of vitamins and mineral • Formation and excretion of bile • Metabolism of steroids Company Logo

19. Intermediate metabolism of carbohydrate • Heksose isomerization • Maintain blood glucose (glycogenesis/lysis) • Gluconeogenesis (from lactate, • glucogenic amino acid) Company Logo

20. Intermediate metabolism of lipid • Synthesis acetyl CoA from fatty acid • Synthesis and hydrolysis triglycerides, • phospholipids, cholesterol and lipoproteins • Synthesis of bile Company Logo

21. Intermediate metabolism of protein • Synthesis of visceral protein (albumin, transferin, • ceruloplasmin), coagulation factor, apolipoprotein • Gluconeogenesis • Urea cycle. • Synthesis of non essensial amino acid Company Logo

22. Acute liver disorders: • Anoreksia • Nausea • Vomitus • Depletion of glycogen storage Company Logo

23. Chronic liver disorder: • Maldigestion, malabsorption • Energy metabolism  • Hypoalbuminemia • Malnutrition • Vitamin deficiency Company Logo

24. Subjective global assessment for nutrition management in live disease • History: • Weight change •  apetite • Persistent GI problem (nausea, vomitus, diarrhea, constipation) • Physical: • Edema, ascites, muscle wasting. • Existing condition: • Hepatic encephalopathy, GI bleeding, renal insufficiency, infection Company Logo

25. Laboratory assessment: • Liver function • nutritional status: • nitrogen balance, visceral protein, immunologic parameter. Company Logo

26. Nutritional therapy • Adequate energy intake • Malabsorption: specific nutrient • Adapted protein intake • Micronutrient supplementation Company Logo

27. Nutritional therapy • Energy intake need: • Basal metabolic rate: • Harris Benedict formula: • Men : 66 + (13,7 x BW kg) + (5 x BH cm) – (6,8 x age) • Women : 665 + (9,6 x BW kg) + (1,7 x BH cm) – (4,7 x age) • Correction factor: • Thermogenic effect of food (10% BMR) • Physical activity • Stress factor TEE = BEE + PA + SDA (TEF) + stress factor Company Logo

28. Nutritional therapy • Composition: • Protein: • Branch chain amino acid (valine, leucine, isoleucine) • Lipid : • Medium chain fatty acid (MCT) • Carbohydrates : • complex carbohydrates Company Logo

29. Nutritional therapy • Consistency : • Adapted to liver capacity • Step by step to increase consistency. • Frequency: • Small frequent • Methods : • Intake >60%: per oral • Intake <60%: enteral • Contra indication via GI: parenteral Company Logo

30. Nutritional therapy with specific condition • Ascites: sodium restriction • Encephalopathy: BCAA • Glucose intolerance; adapted to blood glucose • Fat malabsorption: MCT Company Logo

31. Thank you....