CNS MNT GI Disorders Part 2 (mixed upper and lower GI)

Which of the following is NOT the etiology of SIBO -Chronic use of medications that suppress gastric acid -Liver diseases or chronic pancreatitis can decrease the production or flow of bile and pancreatic enzymes that control bacterial growth, into the bowel. -Gastroparesis, narcotic medications, or bowel dysmotility disorders decrease peristalsis and can impair the ability to propel bacteria to the distal bowel. -eating too much fiber in the diet

-eating too much fiber in the diet

Treatment for diverticulosis includes a diet that is a. Bland b. Low in fiber c. High in fiber - void of foods that may cause gas or intolerance, and low in fat d. A full liquid diet

. High in fiber - void of foods that may cause gas or intolerance, and low in fat

. Dietary advice that may help treat GERD includes: a. avoiding alcohol. b. avoiding gas-forming foods. c. eating large servings. d. sucking on a peppermint after a meal.

A

Should Mr. Fruge develop diverticulitis in the future, how would the dietary recommendations change?

A clear liquid diet is indicated initially, with progression to solid foods as tolerated. In severe cases, bowel rest may be necessary and fluids will be given intravenously. Oral intakes are gradually reintroduced as the condition improves

Long-term use of proton pump inhibitor pharmaceuticals may lead to decreased absorption of all of the following except: a. Vitamin B12 b. Iron c. Vitamin C d. Magnesium

ANS A Most B-vitamins, iron, magnesium, and calcium require acid for absorption. Vitamin C does not.

When the pH of the stomach is increased to avoid GERD, over time the stomach may not be acidic enough. Which of the following might occur? a. lack of carbohydrate digestion b. decreased protein digestion c. destruction of bacterial in the stomach d. gastric ulcer

ANS B

All of the following decrease lower esophageal sphincter tone and can lead to increased GERD EXCEPT: a. Peppermint (Mentha piperita) b. Cow's milk c. Smoking d. Bland foods

ANS C The nicotine from tobacco relaxes the valve between the esophagus and stomach (lower esophageal sphincter). This can allow stomach acid and juices, the chemicals that break down food in the stomach, to back up (reflux) into the esophagus, which causes heartburn

Which of the following contributes to nighttime GERD? a. Delayed gastric emptying b. Increased swallowing c. Decreased digestive secretions d. Increased saliva production

ANS: A Nighttime GERD is distinguished from daytime GERD by changes in physiology during sleep. Stomach emptying is delayed, saliva production and swallowing decrease, chyme is exposed to stomach acid for longer periods of time, and other gastrointestinal digestive secretions increase. These changes are partly explained by the supine or recumbent position that a person is in during sleep.

Which of the following contributes to nighttime GERD? a. Delayed gastric emptying b. Increased swallowing c. Decreased digestive secretions d. Increased saliva production

ANS: A Nighttime GERD is distinguished from daytime GERD by changes in physiology during sleep. Stomach emptying is delayed, saliva production and swallowing decrease, chyme is exposed to stomach acid for longer periods of time, and other gastrointestinal digestive secretions increase. These changes are partly explained by the supine or recumbent position that a person is in while sleeping.

Which of the following surgeries would be used to treat a patient with GERD? a. Billroth I b. Billroth II c. Fundoplication d.Roux-en-Y procedure

ANS: C In a fundoplication surgery, the fundus of the stomach is wrapped around the lower esophagus to limit reflux. Billroth I, Billroth II, and the roux-en-Y procedure are different gastric surgeries that involve either gastrectomy or gastric partitioning.

Which of the following is a condition involving the cells lining the distal esophagus becoming abnormal and premalignant? a. Gastroesophageal reflux disease b. Esophageal stricture c. Hiatal hernia d. Barrett esophagus

ANS: D Barrett esophagus is partly responsible for the development of adenocarcinoma of the esophagus, although esophageal cancer may develop in the absence of Barrett esophagus. GERD is also a risk factor for esophageal cancer; however, the condition does not necessarily involve the histologic changes seen in Barrett esophagus. An esophageal stricture may result from a variety of conditions that lead to decreased esophageal tone and narrowing of the esophageal lumen. Hiatal hernia involves an outpouching of the stomach through the diaphragm.

What type(s) of foods should be avoided in a patient with GERD because it(they) decrease(s) LES pressure? a. High-acid foods b. Low-fat milk and yogurt c. High-protein foods d. Peppermint

ANS: D Peppermint is known to decrease the lower esophageal sphincter pressure, contributing to the development of esophageal reflux. High-acid foods may cause pain in the esophagus when it is already inflamed. Milk, yogurt, and high-protein foods may temporarily buffer gastric secretions, but they also stimulate the secretion of gastrin, pepsin, and acid.

People with GERD should avoid foods and beverages such as: Mint, tomatoes, mustard Caffeine, alcoholic drinks, pepper Oranges, grapefruit and vinegar All of above

All of above

The GI effects of smoking include: Reduction of LES pressure Lower duodenal pH Inhibition of pancreatic bicarbonate secretion All of the above

All of the above

Nutrient deficiencies in Tropical sprue

Anemia (iron, folic acid, B12) Nutritional deficiency increases susceptibility to infectious agents, aggravating the condition.

Which of the following dietary modifications is suggested for gastroesophageal reflux disease (GERD)? 1. Consuming a small glass of wine with meals 2. Taking mint lozenges after meals 3. Planning small, frequent meals that include protein 4. Substituting decaffeinated coffee for regular

Ans: 3 Wine (alcohol) should be avoided to prevent relaxation of the lower esophageal sphincter. Peppermint and spearmint should be avoided to prevent relaxation of the lower esophageal sphincter. Small frequent meals with normal amounts of protein are appropriate for GERD.

Which of the following types of gastritis is associated with H.pylori and duodenal ulcers? Erosive (hemorrhagic) gastritis Fundic gland gastritis (type A) Antral gland gastritis (type B) Aspiring-induced gastric ulcer

Antral gland gastritis (type B)

Nutrient impact in GERD

B6, B12, B9, L-tryptophan, methionine, betaine and melatonin

Complications of GERD

Barrett's Esophagus (BE) ● Esophagitis and esophageal ulcers ● Laryngopharyngeal reflux ● Bleeding ● Strictures - narrowing of the esophagus due to chronic scaring ● Swallowing problems due to strictures ● Respiratory problems including asthma ● Cancer of the esophagus

The nurse understands that a patient with GERD will benefit from education on managing the disease. All of the following suggestions would be included in the education except: a. Avoid eating at bedtime. b. Limit chocolate, high-fat foods, coffee, and tea. c. Consume liquids with meals. d. Avoid alcohol.

C

Which type of SIBO is harder to treat, and it may take longer to respond to treatment. Rifaximin plus neomycin is typically used for these cases. H predominant CH4 predominant recurrent SIBO none of the bottom

CH4 predominant

. Most often, GERD develops as a consequence of: a. aging. b. drugs. c. feeding tubes. d. pregnancy.

D

Tropical sprue

Damage to small bowel villi due to an unknown organism resulting in malabsorption Symptoms: Diarrhea and malabsorption, anorexia, abdominal distention, nutritional deficiency as evidenced by night blindness, glossitis, stomatitis, cheilosis, pallor, and edema.

_____ is a condition of discomfort in the digestive tract. Esophagitis Hiatal hernia Dyspepsia Peptic ulcer

Dyspepsia

Diverticulitis is a relatively mild, non-life-threatening condition. a. True b. False

False

The development of diverticulosis is influenced by the type of dietary protein one consumes. a. True b. False

False

Which of the following surgeries would be used to treat a patient with GERD? Billroth I Billroth II Fundoplication Roux-en-Y procedure

Fundoplication

What is the major difference between gastric and duodenal ulcers? Gastric ulcers can develop with low acid output and duodenal ulcers develop with high acid secretion. Gastric ulcers develop with high acid secretion, and duodenal ulcers develop with low acid output. H. pylori is the primary cause of gastric ulcers. Gastric ulcers are treated with proton pump inhibitors and duodenal ulcers are treated with H2-receptor antagonists.

Gastric ulcers can develop with low acid output and duodenal ulcers develop with high acid secretion.

Associated Disorders of GI strictures and obstruction

Gastroparesis (delayed gastric emptying), adhesions, hernias, metazoic cancers, dysmotility, or volvulus, IBD/Crohn's, diverticulitis

Which of the following statements is NOT associated with H.Pylori? H.pylori increases the risk of atrophic gastritis and gastric cancer. H. pylori is a viral infection found in the intestine. H. pylori is a bacterial infection found in the gastric mucosa. H. pylori infection may be treated with antibiotic and acid suppression therapies.

H. pylori is a viral infection found in the intestine.

What type of amino acid supplement can be recommended to a client suffering from gastritis? L-arginine L-lysine L-glutamine Creatine

L-glutamine

What surgical procedure is indicated for refractory GERD?

Nissen Fundoplication

How can dyspepsia be related to a physical cause? Overeating Diabetes Stress Prolonged eating times

Overeating

Which type(s) of foods should be avoided in a patient with GERD because it(they) decrease(s) LES pressure? High-acid foods Low-fat milk and yogurt High-protein foods Peppermint

Peppermint

Reflux is an alternative term for: Vomiting Acid erosion Regurgitation Salivating

Regurgitation

Mr. Fruge tells the dietitian that his mother had diverticulosis and he remembers that she was told to avoid nuts, seeds, and popcorn. How should the dietitian reply to this comment?

The dietitian should tell Mr. Fruge that there is no scientific evidence to justify this recommendation.

. one of the most common symptoms of SIBO is chronic diarrhea from fat maldigestion True False

True

A high fiber diet increases stool weight and fecal water content. a. True b. False

True

Daily exercise can help treat constipation if it stimulates peristalsis. a. True b. False

True

Types of Hiatal Hernia

Type 1 (sliding hiatal hernia) - most common type; gastroesophageal junction is pushed above the diaphragm causing a symmetric herniation of the proximal stomach Type 2 (true para-esophageal hernia) - Fundus slides upward and move above the gastroesophageal junction Type 3 (mixed para-esophageal hernia) - Combines sliding and para-esophageal herniation Patients may present with severe chest pain, vomiting and hematemesis (vomiting of blood) because the hernias can twist and cause strangulation in the chest which would be considered a medical emergency. Some patient can present with iron deficiency anemia without acute bleeding, because the diaphragm becomes so irritated that the patient may develop chronic blood loss Type 4 (complex para-esophageal hernia) - Less common form; intrathoracic herniation of other organs, such as the colon and the small bowel into the hernia sac

Mr. Fruge is 60 years old. After performing a routine colonoscopy, his gastroenterologist tells him everything is normal except that she noticed the presence of several diverticula in his colon. The physician suggested he speak with the clinic dietitian regarding dietary recommendations. 18. What causes diverticula to develop? (Short answer) Differentiate between diverticulosis and diverticulitis. (short answer) Why was Mr. Fruge unaware of his condition until now? What dietary recommendations should the dietitian discuss with Mr. Fruge?

What causes diverticula to develop? (Short answer) a. Diverticula are caused by low-fiber diets, which require more vigorous muscle contractions, increasing pressure within the segments immediately adjacent to the circular muscles. This increase in pressure may induce small areas of intestinal tissue to weaken and balloon outward over time. 19. Differentiate between diverticulosis and diverticulitis. (short answer) a. Diverticulosis refers to the presence of diverticula, or pebble-sized herniations or outpockets in the intestinal wall. Diverticulitis refers to inflammation or infection in the area around a diverticulum. 20. Why was Mr. Fruge unaware of his condition until now? a. Most people with diverticulosis have no symptoms until complications develop 21. What dietary recommendations should the dietitian discuss with Mr. Fruge? a. The dietitian should recommend that Mr. Fruge increase his fiber intake to help prevent progression of the disease. He should emphasize insoluble fiber in his diet and increase his fiber intake gradually to ensure tolerance. Bulk-forming agents, such as psyllium, can help to increase fiber intake if he has trouble getting enough fiber from food sources

Gastroparesis

a condition in which the muscles in the stomach slow down and work poorly or not at all, preventing the stomach from emptying normally

Nissen fundoplication

a surgical technique used to suture the fundus of the stomach around the esophagus to prevent reflux

A patient with a history of diverticulosis who complains of severe, left lower quadrant pain with diarrhea, nausea, and vomiting should be evaluated for a. Diverticulitis - develops when diverticula become infected b. Obstruction c. Appendicitis d. Celiac disease

a. Diverticulitis - develops when diverticula become infected

What pain is typical of diverticulitis? a. Lower left quadrant b. Lower right quadrant c. Sharp, colicky, periumbilical d. Lower abdominal pain, radiating into the groin

a. Lower left quadrant

Diverticular disease often occurs with a. Bacterial infection b. Aging c. Constipation d. Food intolerances

b. Aging

Diet therapy for clients with diverticulitis may begin with a. Low-residue diet b. Clear liquid diet c. High-fiber diet

b. Clear liquid diet

Which disease is associated with advanced age? a. Crohn disease b. Diverticulitis - is one of the most common medical conditions in industrialized countries and incidence increases with age. More common in people over 50. c. Ulcerative colitis d. Tropical sprue

b. Diverticulitis - is one of the most common medical conditions in industrialized countries and incidence increases with age. More common in people over 50.

The nurse is instructing a patient with diverticular disease on appropriate foods to include in his diet in order to prevent progression of the disease. She will tell him to consume all of the following except: a. Whole-grain breads b. Enriched pasta c. Legumes d. Fresh vegetables

b. Enriched pasta

A patient is newly diagnosed with diverticulosis and voices concern about future complications. What is the nurse's most appropriate response a. Follow a low-fiber diet b. Follow a high-fiber diet c. Avoid nuts, popcorn, and foods with seeds d. Drink plenty of fluids.

b. Follow a high-fiber diet

mall outpouchings in the lower gastrointestinal tract are called a. Hernias b. Lesions c. Diverticula d. Epiploic appendages

c. Diverticula

What is the name of the intestinal disorder characterized by little pockets in the sides of the large intestine? a. Diverticulitis b. Pancreatitis c. Diverticulosis d. Ulcerative colitis

c. Diverticulosis

The incidence of diverticulosis may be reduced by recommending a diet: a. Low in dietary fiber and residue b. High in dietary fiber and fat c. High in dietary fiber d. High in dietary protein

c. High in dietary fiber

What is characteristic of a high-fiber diet? a. 20-30g soluble fiber b. 30g or more of soluble fiber c. 30g or more of insoluble fiber d. 30g or more of dietary fiber

d. 30g or more of dietary fiber

Dietary strategy for SIBO includes all except low FODMAP elemental diet avoiding probiotics that produce D-lactate eating frequent meals

eating frequent meals

Prolonged acid exposure can result in :

esophagitis, esophageal erosions, ulceration, scarring, stricture, and in some cases dysphagia

For reflux to take place, pressure in the proximal stomach must be greater than the pressure in the _____________. Good _______________ function is an important defense mechanism against GERD as prolonged acid clearance correlates with the severity of esophagitis and the presence of complications such as Barrett's esophagus.

esophagus, peristaltic

Achalasia

failure of the lower esophagus sphincter (LES) muscle to relax

· You shouldn't use ____________ if you're taking diuretics, corticosteroids, or other medications that lower your body's potassium levels.

licorice Licorice can amplify the effects of these medications and cause your potassium levels to become dangerously low.

A definite relationship with Gerd and ____________ exists.

obesity There is also an association with BMI, waist circumference, weight gain, and the presence of symptoms and complications with GERD.

Gastroparesis

partial paralysis of the stomach

hiatal hernia

protrusion of a part of the stomach upward through the opening in the diaphragm

Which of the following are nutrient impacts of SIBO? vitamins A, D, E, B12, and iron B12, B6, B1, B5 only fat soluble vitamins iron, vitamin C, vitamin D, vitamin K

vitamins A, D, E, B12, and iron

a failure of esophageal neurons, resulting in a loss of ability to relax the LES and have normal peristalsis.

● Achalasia:

Pathophysiology of Tropical Sprue

● Acquired diarrheal syndrome with malabsorption that occurs in many tropical areas. ● Anemia might result from iron, folic acid, vitamin B12 deficiency. ● Diarrhea of tropical sprue appears to be infection though precise cause and sequence of pathogenic events unknown ● My include bacterial overgrowth, changes in GI motility, cellular changes in GI tract. ● Identified intestinal organisms may differ from one region of the tropics to the next ● As with celiac, villi may be abnormal, but cell alterations are much less severe. ● Gastric mucosa atrophied and inflamed, with diminished secretion of hydrochloric acid and intrinsic factor.

MNT for GERD

● Begin with portion control. Smaller meal sizes will reduce gastric reflux probability. ● Avoid eating 2-3 hours before lying down ● Nighttime reflux: keep the head of the bed 6-8 in elevated ● Work on weight loss if overweight. ● Avoid smoking ● Limit bending over ● Wear loose-fitting clothing around the stomach area

The main factors that trigger reflux symptoms are:

● Caffeine ● Alcohol ● Tobacco ● Stress ● Foods to Avoid: ● Highly acidic foods: citrus juices, tomatoes ● Large, high-fat meals ● Fermented, carbonated, alcoholic beverages ● Caffeinated drinks or foods ● Avoid highly spiced foods when inflammation present

Herbs /supplements GERD

● Chamomile - tea, may have soothing effect on the digestive tract (do not use if there's a ragweed allergy) ● Ginger root-· The root of the ginger plant is another well-known herbal digestive aid. It has been used for centuries as a folk remedy for heartburn. ● Licorice - said to increase the mucous coating of the esophageal lining. Deglycyrrhizinated licorice or DGL is available in pill or liquid form. · Vitamin A and E - inhibit development of stress ulcers in rats and help maintain integrity of mucosal barrier. · L-Glutamine · Zinc increase mucin production in vitro and has a protective effect on PUDs in animals and curative effect in human beings. · Melatonin - pineal hormone also has antioxidant properties. Melatonin mitigates gastric lining breakdown and ulcer formation. · Garlic and Onions - high intakes of garlic and onions reduces the risk of stomach cancer. Garlic inhibits growth of H.pyloria. · Catnip, fennel, marshmallow root, and papaya tea have all been said to aid in digestion and stop heartburn. Some people eat fresh papaya as a digestive aid.

Medical Nutrition Therapy (Dietary & Lifestyle) of GI strictures and obstruction

● Chew food thoroughly ● Avoid excessive fiber intake (limit to foods with less than 3g of fiber for serving, no more than 10g/day) ● Partial bowel obstruction —> may be able to tolerate a restricted fiber diet and liquids, depending on the location of the stricture or obstruction in GI tract ○ Proximal (closer to the mouth) —> might require liquid or semisolid diet ○ The more distal (closer to anus) —> the less likely diet will help

Mechanisms involved in GERD

● Decreased salivation ● Transient LES relaxation ● Reduced LES pressure ● Impaired esophageal acid clearance ● Increased esophageal sensitivity ● Acid pocket ● Increased intraabdominal pressure ● Delayed gastric emptying

Clinical Findings: Symptoms of GERD

● Dental corrosion - slow, progressive tooth surface loss associated with acid regurgitation ● Dysphagia - difficulty initiating a swallow or sensation of food being hindered or "sticks" after swallowed ● Heartburn (pyrosis) - painful, burning sensation that radiates up behind the sternum of fairly short duration ● Odynophagia - painful swallowing ● Regurgitation - backflow of gastric content into the mouth not associated with nausea or retching ● Noncardiac chest pain - unexplained substernal chest pain resembling a myocardial infarction (MI) without evidence of coronary artery disease ● Extraesophageal symptoms - chronic cough, hoarseness, reflux-induced laryngitis, or asthma

GERD (gastroesophageal reflux disease)

● GER is usually associated with transient relaxation of the lower esophageal sphincter (LES) independent of swallowing. Gastroesophageal reflux disease (GERD) is more serious, chronic or long lasting form of GER and is defined as symptoms or complications resulting from the reflux or gastric contents into the esophagus or beyond or even the mouth or lung. Some experience it only in the evenings (nocturnal GERD) which is associated significantly with severe esophagitis and intestinal metaplasia (Barrett's esophagus) and can lead to sleep disturbances

Risk factors for GERD

● Hypersensitivity to acid primarily due to impaired mucosal barrier function ● Slow peristalsis + the development of acid pockets ● Hiatal Hernia: if the attachment of the esophagus to the hiatal ring becomes compromised, a portion of the upper stomach can move above the diaphragm. The most common symptom of hiatal hernias is heartburn. ● Food intolerances: usually triggered by small-molecular weight chemical substances and biologically active components of food, which can create GI symptoms, amongst cutaneous, respiratory, and neurological manifestations. ● Obesity: contribute to intragastric pressure

Affected populations of tropical sprue

● Living in or traveling to tropical locations ● More common in certain countries within this tropical area, including India, Southeast Asian countries, Haiti, Cuba, Puerto Rico and the Dominican Republic. ● The condition afflicts residents of the affected countries as well as travelers, though usually it affects only travelers who stay for a month or longer.

Pathophysiology of GI strictures and obstructions

● Patients with gastroparesis (delayed gastric emptying), adhesions, hernias, metazoic cancers, dysmotility, or volvulus (twisting of stomach or intestine) can result in partial or complete blockage of movement of food or stool through the intestines ● Can be partial or complete ● Obstructions ● Can lead to progressive dehydration, electrolyte imbalance, systemic toxicity Risk Factors: ● Abdominal or pelvic surgery, Crohn's, Cancer in abdomen

Pharmacological Treatments for GERD

● Proton Pump Inhibitors (PPI's): decrease acid production by the gastric parietal cells, which have been associated with superior healing rates and decreased relapses. Usage only meant for short term, as chronic usage can create negative GI outcomes. ● GABA antagonist, although long-term data not yet published regarding efficacy. ● Nissen Fundoplication: the most commonly performed anti-reflux surgery. Surgical therapy is considered for individuals who have failed medical management, those who opt for surgery despite successful medical management, or those with GERD complications or asthmatic, chest pain extraesophageal manifestations. · Antacids (Alka-Seltzer, Maalox, Mylanta, Rolaids) · Foaming agents - cover stomach with foam (Gaviscon) · H2 Blockers - ↓ acid production (Cimetidine, Famotidine, Nizatidine, Ranitidine) Prokinetics - strengthen sphincter and ↑ gastric emptying (Bethanechol, Metoclopramide

MNT for Tropical Sprue

● Restoration and maintenance of fluids, electrolytes and macronutrients and micronutrients. ● Introduction of a diet that is appropriate for extent of malabsorption due to diarrhea ● B12 and folate supplementation if deficiency identified Medical treatment: 3 to 6 months tetracycline antibiotic, and folic acid supplements. People with vitamin B12 deficiency should receive vitamin supplements as well.

Barrett's Esophagus (BE):

● 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 intestinal lining tissue). Unknown cause, but GERD is a risk factor, and are at a heightened risk for cancer called esophageal adenocarcinoma, which has a dramatic rise in incidence over the past 40 years.