DIET THERAPY FOR DISEASES OF THE GASTROINTESTINAL TRACT AND ACCESORY

ORGANS

A healthy digestive system is necessary for a normal life. The needed transformation of
ingested food into simpler, diffusible substance is carried on within the gastrointestinal tract
(GIT). Digestive process involves both physical and chemical changes. The organs in which
these changes takes place form the digestive system, or alternatively, gastrointestinal system.
For better appreciation, students must review the anatomy and physiology of the GIT. If any
organ of the GIT is diseased, nutrient utilization is compromised. Exposure to toxins, intestinal
permeability defects and parasitic infections are examples of common conditions associated
gastrointestinal dysfunction that can lead to malnutrition. Gastrointestinal disorders are
characterized by changes in secretory activity and motility of the GI tract. A number of factors
including diet are believe to influence these changes are summarized in Table 14.1

Table 14.1. Factors that Modify Acid Secretion, Gastrointestinal Motility and Tone

Increased Flow of Acid and Enzyme
Production
1.Chemical stimulation-meat extractives,
seasoning, certain spices, alcohol, acid foods
2. Attractive, appetizing, well-liked foods
3.State of happiness and contentment
4.Plasant surroundings for meals
Increased Tone and Motility
1.Warm foods
2.Liquid and soft foods
3.Fibrous foods, as in certain fruits and
vegetables
4.High carbonate low-fat intake
5.Seasoning; concentrated sweets
6. Fear, anger, worry, nervous tension
Decreased Flow of Acid and Enzyme
Production
1. Large amounts of fats, especially as
fried foods, pastries, nuts etc
2. Large meals
3. Poor mastication of foods
4. Foods of poor appearance, flavor or
texture
5. Foods acutely disliked
6. Worry, anger, fear, pain
Decreased Tone and Motility
1. Cold foods
2.Dry,solid foods
3.Low-fiber foods
4. High fat intake. especially as fried foods.
pastries, etc
5Vitamin B complex deficiency, especially B1
6.Sedentary habits
7.Fatigue
8. Worry, anger, fear, pain

Lying adjacent to the intestinal tract are three major accessory organs- liver, pancreas and
gallbladder. They play a vital role in the production of the digestive absorptive agents. Basically,
the liver and pancreas are capable of producing and storing enzymes for specific nutrients for
future use. The gallbladder on the other hand, serve as the concentrating unit and reservoir for
bile assisting in the enzymes interrelated actions with the GIT, such that a disorder of any of
which, affect gastrointestinal functions in digesting food and utilization of nutrients.
Factors involved in diet therapy will be considered in relation to the successive sections of the
GI tract: mouth and esophagus, stomach and duodenum and intestines. Also involved, are the
accessory organs: liver, gallbladder and pancreas.

Diet therapy for various gastrointestinal problems will depend on the following:

1.Chemical secretions- the secretory functions that provide the necessary environment and
agents for chemical digestion.

2.Muscle activity and structural integrity- the neuromuscular functions and their structures that
provide the necessary motility and mechanical actions for digestion.

3.Absorbing mucosa- the absorptive functions which enable the end-product of digestion(the
nutrients) to enter the body’s circulation and nourish the cells.

4.Psychologic factors- the person itself and his/her coping mechanism

5.Bacteria or microflora- as found in the oral cavity, throat, stomach, and the gut.

Of recent concern are bacteria in the mouth related to dental caries; bacteria causing peptic
ulcer disease; food- borne bacteria in the intestines; and the friendly ones called probiotics.
The last group is being credited with helping digestion and absorption; enhancing the immune
system and regulating hormone balance thus, protecting us from food-borne illnesses and
developing allergies. Medications and poor diet are among the factors that will decrease the
population of good bacteria in our bodies. Some foods( like yogurt, kefir, tempeh, miso,
kimchi,sauerkraut, buro,and other fermented foods) contain these healthy bacteria and are
called probiotic foods. Prebiotic are foods and nutrients that these probiotics like to eat. These
are oatmeal, flax and barley. By eating prebiotic foods, the good bacteria are nourished and by
eating probiotics foods, the ones lost are replaced. One must bear in mind that taking
antibiotics kills both the bad and the good bacteria, hence the need to eat probiotic and
prebiotic foods.

Although more research is needed, there’s encouraging evidence that probiotics may help; 1)
Treat diarrhea especially following with certain antibiotics; 2) Prevent and treat vaginal and
yeast infections and urinary tract infections; 3) Treat irritable bowel syndrome; 4) Reduce
bladder cancer recurrence; 5) Speed treatment of certain intestinal infections; 6) Prevent and
treat eczema in children;7)Prevent or reduce the severity of colds and flu.

Nutrition counseling for various gastrointestinal problems will depend on normalizing the
chemical secretion, physical and neuromuscular structure of the GIT. Diet therapy for the liver
disease depends largely on the type and severity of the disease. Liver disease may arise from
toxic damage( due to alcohol abuse, chemicals and infections), biliary tract obstructions, heart
disease, Wilson’s disease and others.

14.1. Disorders of the Mouth

14.1.1. Cleft Lip and Cleft Palate

Cleft lip (harelip) is a congenital cut on the upper lip. Cleft palate is a congenital deformity
characterized by incomplete closure of the lateral halves of the palate or roof of the mouth.
Children born with cleft will have feeding difficulties, speech, and hearing defects, dental
deterioration, psychological problems and facial disfigurement.

For infants with cleft palate or lips, milk formula can be taken from a medicine dropper or a
feeding bottle equipped with soft nipple with an enlarged hole. Small feedings are given slowly
to the infant in an upright position. The baby should be frequently burped to expel large
amounts of air swallowed. Since acid foods are irritating and cannot be incorporated in the
formula, ascorbic acid supplements should be given. For older infants, solid foods are mixed
with milk and given by bottle with large nipple holes.

Good nutrition status is a must before surgical repair is planned. The infant or child is usually
fed a fluid or semifluid diet using a medicine dropper or a spoon. Great care must be exercised
to protect the suture line and avoid any strain.

14.1.2. Dental Caries

Dental caries is a chronic infectious disease characterized by a progressive destruction of tooth

substance due to interactions between metabolic products of microorganisms colonizing the
tooth surfaces. Caries arise from four important factors that must be present simultaneously: 1)
a susceptible host or both surface; 2)microorganism, such as Streptococcus mutans in the
oral environment 3) fermentable carbohydrates in the diet , which acts as the substrate for
bacterial fermentation; and 4) time/duration in the mouth for bacteria to metabolize the
fermentable carbohydrate, produce acids and cause a drop in saliva ph (>5.5). Once the pH
reaches this level, oral bacteria can initiate the caries –formation process. When the decay
affects the nerves, pain is inevitable, commonly called toothache.

Primary carbohydrates in the form of sucrose have been shown to be the most harmful in
promoting dental plaque, bacterial growth and carious lesion. Most natural teeth are susceptible
to decay unless preventive measure are instituted, which include proper food choices and
oral hygiene.

Diet therapy. Avoid cariogenic foods that contain fermentable carbohydrates like hard
candies, high sucrose- containing foods and solid sticky foods (cookie, potato chips, and the
likes, crackers, cakes and doughnuts, etc). Such foods when become in contact with
microorganism in the mouth can cause a drop in pH and stimulate the caries process. However,
if cariogenic foods are eaten with foods low in available carbohydrates (e.g. bananas combined
cereal and milk or crackers combined with cheese) the risk of developing caries is reduced.

Encourage positive habits of snacking cariostatic foods (foods that cannot contribute to decay)
such as protein foods, vegetables, fats, and sugarless gums. Avoid the practice of snipping
carbonate beverages over extended periods, snacks frequently and retaining candy, sugar mints
or breath fresheners in the mouth for a long period. Proper oral hygiene and other caries
prevention strategies are give.

Table 14.2. Caries Prevention Guidelines

 Brush at least twice a day, especially after eating meals

 Rinse mouth after eating when brushing is not possible
 Chew sugarless gum for 15-20 minutes after eating
 Floss twice daily
 Use fluoridated toothpaste
 Pair cariogenic foods with cariostatic foods
 Snack on cariostatic and anticariogenic foods e.g. cheese, nuts, popcorn and vegetables
 Limit between-meal eating and drinking of fermentable carbohydrates
 Regular dental check-up

14.1.3. Periodontal Disease

Periodontal disease is an inflammatory disorder of the supporting structure of the teeth that
can result in tooth detachment and loss. Early periodontal disease, may go unrecognized, since
it is often asymptomatic and without clinically obvious signs. As periodontal disease progresses,
it can be detected by gingival exudates associated with discomfort or pain. The disease is
treated by improved oral hygiene and antibiotic therapy if necessary. The amount of refined
carbohydrate in the diet should be reduced and unrefined carbohydrate should be increase as
the condition of the gums improves.
Diet therapy. A well- balance d-diet that provides the necessary nutrients (protein, calcium,
phosphorus, vitamin D, Vitamin C , Vitamin A, and zinc) to help regenerate tissue and maintain
immune response is important in the process of therapy. The diet may need to be modified in
consistency depending on the patient’s tolerance. When dietary intake is enough, oral
supplements should be recommended. To prevent plaque formation, provide a diet plan that
controls the timing and frequency f meals and snacks. Inclusion of high detergent foods( firm
and fresh fruits and vegetables) is encouraged.

14.2. Disorders of the Esophagus

14.2.1. Achalasia

Achalasia is a neuromuscular disorder characterized by esophageal motility where the lower

esophageal sphincter (LES) fails to relax normally after swallowing so that the food can enter
the stomach. The loss or absence of ganglion cells is believed to be the cause. Dysphagia,
vomiting and weight loss are some of the symptoms of achalasia.

Diet Therapy. To facilitate swallowing and to meet nutritional requirement, only liquid foods
plus supplementary foods are given. Bland foods are provided avoiding excessively hot or cold
drinks to prevent irritation or pain. Avoid acid juices, alcohol, fatty foods and chocolates. Tube
feeding is given if the patients is severely malnourished or unable to consume adequate meals
orally. The risk of pulmonary aspiration is so great that is usually better to wait until dilatation
or surgical therapy has been performed before trying to increase oral intake.

14.2.2. Esophagitis

This is an acute or chronic inflammation of the esophageal wall. The classical symptom is
substernal pain during swallowing. Heartburn is also a chief compliant. Most cases of chronic
esophagitis are attributed to a sliding hernia that permits the reflux of gastric juice into the
esophagus. Mucosal erosions and narrowing of the lumen occur. The disorder occurs most
frequently in persons with high gastric acidity, many of whom have a history of duodenal ulcer.

Diet Therapy. The goals are: to prevent pain and irritation of the inflamed esophageal
mucosa, to avoid reflux of food bolus into the esophagus and to reduce the erosive capacity of
the gastric secretion. Dysphagia diets are recommended. Avoid foods with an acid pH (citrus
fruits, tomatoes, soft drinks, etc) if these cause pain and discomfort during inflammation
periods. Large fatty meals, spices and fibrous foods may also cause irritation. Weight loss has
not been found to reduce reflux symptoms but tight- fitting clothing should not be worn by
overweight/ obese persons. Chocolates, alcohol and caffeine-containing beverages reduce the
LES pressure which encourages reflux of gastric contents and therefore may need to be
eliminated.

14.2.3 Gastroesophageal Reflux Disease and Hiatal Hernia

A common disorder affecting the esophagus is the herniation (out pouching) of a portion of the
stomach into the chest through the hiatus of the diaphragm. Hiatal hernia occurs most
frequently in person over 45 years of age, in persons stocky build and in overweight individuals.
Loss of muscle tone weakens the specific muscle around the diaphragm and increase in
abdominal pressure helps push the stomach through the diaphragm. Symptoms occur when the
herniated portion is irritated or impaired or is large enough to affect the organs. Substernal
pain, heartburn, belching or hiccupping occurs after meals or while lying down.

Gastroesophageal reflux disease (GERD) is a condition in which partially- digested food in the
stomach backs up into the esophagus. GERD is a term recognized for conditions commonly
called acid indigestion, heartburn and reflux esophagitis. Heartburn or acid indigestion which is
pleasant burning sensation under the breastbone that usually occurs after a meal is actually one
symptom of GERD. Most individuals with GERD also have hiatal hernia, which makes it easier
for stomach contents to reflux into the esophagus. The main problem is a defective valve found
between the end of the esophagus that opens and closes to regulate the passage of food bolus
to the stomach.

Diet Therapy. The goals of nutrition care are the same as those given earlier for esophagitis:
to prevent reflux, to neutralize gastric acidity and to eliminate foods that irritate the esophagus.

Table 14.3. The Management of Hiatus Hernia and GERD

 Measures which may help
 Eating small, frequent meals
composed of soft foods (in acute
episodes)
 Remaining in upright position for two
hours after meals
 Losing weight, if overweight to help
relieve pressure on the diaphragm
 Propping up the bed by approximately
4 inches,e.g. a household brick under
 Taking all medicine regular as
prescribed by the doctor.
Things to avoid
 Smoking(nicotine weakens LES)
 Eating larger meals (especially fatty
meals) for several hours before
bedtime.
 Eating foods that decrease LES( foods
with extreme temperature, highly
spiced foods, chocolates,
decaffeinated and regular coffee,
onions, garlic, alcohol,etc)
 Eating foods that may irritate the
esophagus- citrus juices, tomatoes
and tomato sauce.
 Tight – fitting clothes

14.3. Disorder of the Stomach

A review of the anatomy and physiology of the stomach gives the rational for the guidelines for
diet therapy of the selected disorders discussed below.

14.3.1. Gastritis

Gastritis is an acute or chronic inflammation of the mucous membrane of the stomach

resulting in tissue damage and erosion, which expose the underlying cells to gastric secretion
and pathogens. The common complaints are: anorexia, nausea, vomiting, malaise, belching
(gas) a feeling of fullness and epigastric pain. Occasionally, fever and diarrhea may be present.
Bacterial or viral infection and stress are among the causative factors of gastritis. Helicobacter
pylori infection has been specifically identified as a primary contributory cause. Acid provoking
and irritating agents include heavy smoking, alcohol use, caffeine, improper diet such as spicy,
greasy foods.

Diet Therapy. Because gastritis is mainly due to H. pylori infection and use of NSAIDs dietary
management plays only a supportive role in the treatment. Only minor modifications are
needed which aimed at providing comfort and reducing gastric acid production to allow healing
of erosion.

In acute gastritis, it may be necessary to withhold food for 24 hours to allow the stomach to
rest. Initiate oral diet the following day beginning with clear liquids, then full liquids to soft diet
s per individual tolerance. Emphasize a nutritionally adequate diet once the patient tolerates
regular foods. Omit only those food items that result in stomach discomfort which is highly case
to case basis. Patients with chronic gastritis require folate and vitamin B12 supplementation.

In the light of new research findings on diet and gastritis, the following must be discussed
during patient education:
1. Milk and cream; as a treatment component of gastritis and ulcer, is no longer considered
beneficial. Milk as a protein food, has temporary neutralizing effect on gastric acid, but
they also stimulate secretion of gastrin and pepsin.
2. Alcohol( from any source) may cause superficial mucosal damage and therefore, from a
practical perspective, should be avoided by the patient with chronic gastritis.
3. The pH of food prior to ingestion is not likely to cause tissue damage or appreciably
interfere with healing. Thus, fruit juices and soft drinks are not omitted from the diet
unless the patient recognizes it as a source if discomfort.
4. Coffee (regular and decafe), red and black pepper and large intake of chili pepper must
be avoided. These items are strong irritants to mucosal cells.
5. Studies on the appropriate meal frequency are conflicting. However, it is better to
consume three meals per day to prevent an increase in acid production. In addition,
patients should refrain from eating large meals before bedtime.
14.3.2. Peptic Ulcer Disease (PUD)
Researchers suggest that the bacterium Helicobacter pylori are responsible for the
majority of ulcer. H. pylori weaken the protective mucous coating of the stomach and
duodenum, which allows acid to get through the sensitive lining beneath. H, pylori are
present in feces and transmission is probably person to person by the fecal oral route.
This organism is also linked with increased of gastric ulcer. Long- term use of non-
steroidal anti-inflammatory drugs (NSAIDs) is also strongly associated. Poor nutrition,
smoking, alcohol abuse, stress and heredity are predisposing factors to PUD.
Diet Therapy. While an ulcer is bleeding, no food is allowed; instead the patient may
be given intravenous feedings of dextrose and amino acids. As the condition improve,
the patient progresses from a full liquid to a regular diet with the omission of irritants
based on individual tolerance. A prudent diet is recommended. The traditional
dietary treatment of ulcer such as bland diets, heavy emphasis on milk products and
frequent, small meals, has been set aside.
14.3.3. Stomach Ulcer
Causative factors include: chronic pylori infection, excessive alcohol intake and high
consumption of smoked, cured foods. For the latter, nitrosamines have been implicated.
With cited evidence that mortality from gastric cancer tends to be higher in areas where
the nitrate content of the water and the soil, is high.
Diet Therapy. If the disease is not too far advanced (before metastasis has occurred) a
gastrectomy either partial or total is done. After a resection has been performed, the
postoperative dietary regimen is used. Small, frequent meals are given for those
patients who develop the dumping syndrome. Foods should be high in protein
moderately low in fat and low in carbohydrate.
The patient with advanced, non-operable cancer should receive a diet adjusted to
provide comfort. His food preferences, unless definitely harmful, usually are grated. In
the later stages of the disease the patient may tolerate only a liquid diet and it may be
necessary to resort to parenteral fluids or transfusions. Anorexia is almost always
present from the early stage throughout the entire course. The patient who is
encourage to select his own menu and who suggests foods which are appealing usually
ingest more than when he is not involved in the selection or when force applied.
14.4.1. Lactose Intolerance
Lactose intolerance is caused by a deficiency of lactase; the enzyme needed for
digesting the sugar in milk. Undigested lactose remains in the gut and acts osmotically
to draw water into the intestines. Lactose also serves as a substrate for bacterial
fermentation, which produces short chair fatty acids, CO2 and hydrogen gas. A glass of
milk is sufficient to cause bloating, flatulence, cramps, and diarrhea.
Lactose intolerance may be primarily or secondary. Primary lactose intolerance includes
congenital lactase deficiency and adult lactase deficiency. The latter is quite common in
Asians and many non-white and ethnic populations, including Blacks, Orientals, Jews,
Mexicans and American Indians. Secondary lactose intolerance arise from other disease
conditions affecting the intestinal mucosa (e.g. acute enteritis, celiac sprue) and can
occur after small bowel or gastric surgery and after periods of disease of intestinal
tract(e.g. starvation or prolonged TPN). This lactose intolerance is transient and
disappears when the disease is resolved. Most lactose-intolerant individuals usually have
no difficulty handling small amounts of lactose.
Diet Therapy. A lactose restricted diet is a difficult diet since lactose is a hidden
ingredient in many foods and drugs. Restriction is also highly individualized because the
amount of lactose allowed depends on the person’s tolerance.
Milk, milk solids, lactose, whey and casein are best avoided. Many commercially
prepared milk formulas that are lactose-free are readily available. People with lactose
intolerance can cause commercial enzyme preparation (e.g. Lactaid) to manage
digestion of milk. Most persons tolerate cottage cheese, aged cheddar cheese and
fermented milk products like yogurt.
14.4.2. Diarrhea
Diarrhea refers to the passage of stools of liquid to semi-solid consistency at frequent
intervals along the digestive tract, effectively preventing complete digestion and
absorption. Diarrhea is not a disease itself but a symptom of a variety of diseases or
infection. In diarrhea, fluids are not absorbed as the intestinal contents move quickly
through the GI tract and this is added to the food residue.
The most common categories of diarrhea are acute (less than two weeks duration) and
chronic (longer than two weeks duration). Acute diarrhea is caused by viral, bacterial, or
protozoan infections; by intention or as side effect of medication; or by altered dietary
intake. Chronic diarrhea is a cause for concern. It can result from other disorders like
malabsorption or protein energy malnutrition, or medical treatments (radiation
therapy/drugs).The person with chronic diarrhea can become dehydrated, having lost
large amounts of water and electrolytes.
Diet Therapy. NPO for 12 hours with IVF and electrolytes. Oral fluids may be started
as soon as allowed. With intractable diarrhea, TPN may be prescribed. Losses f Na+, K+
and other electrolytes may account for the profound weakness associated with severe
diarrhea. Potassium loss, in particular is detrimental as K is necessary for normal muscle
 tone of the GI tract. Anorexia, vomiting, listlessness and muscle weakness may occur
unless losses are replaced by liberal intake of fluids as fruit juices that are high in K.
Broths and electrolyte solution are good replacement therapy for Na+ and K+ lost.
Avoid harsh fibers. Pectin from applesauce or a supplement and small amounts of
other hydrophilic fiber may help in controlling diarrhea.
Vitamin deficiencies frequently see in chronic diarrheas are related to the decreased
intake of vitamin and the increased requirements because of losses in the stools. A
temporary reduction in the synthesis of some B complex vitamins also occurs when
antibiotic therapy is used. Vitamin B12 and niacin deficiency have been observed in
various diarrheas. Folate supplementation may be useful for acute diarrhea, possibly
because it accelerates the normal regeneration of damaged mucosal epithelial cells. Iron
deficiency is a common finding in patients with chronic diarrhea owing to the increased
losses of iron in the feces, the occasional blood losses and the reduced intake of iron-
rich foods because of fear that these foods may aggravate an existing lesion.
The World Health Organization recommends an oral rehydration formula that can be
prepared cheaply at home for moderate to severe dehydration following diarrhea. The
formula consists of: ¾ tsp table salt, 1 tsp baking soda, 1 cup orange juice, 4 tbsp
sugar and 1 liter (1.05 quarts) of clean water. A local oral rehydration solution (Oresol)
is also available in health centers.
14.4.3. Constipation
Three types of constipation are generally recognized namely: atonic; spastic; and
obstructive constipation.
Atonic constipation is sometimes called the “lazy bowel” constipation because of loss
of rectal sensibility; the rectum is full of feces but the urge to defecate is lacking. The
feces are large and hard. This type of constipation is often observed in older people
whose body processes are slowing down. It also occurs in obesity, accompanying fevers,
following surgery and during pregnancy. Inadequate diet, irregular meals, insufficient
liquids, dietary fiber and failure to establish a regular time for defecation are the most
frequent causes of atonic constipation.
Spastic constipation is caused by an overstimulation of the intestinal nerve endings
which results in irregular contractions of the bowel. Evidence suggests that there is
excessive or uncoordinated sigmoidal mobility and loss of rectal sensibility. It is
accompanied by abdominal pain and sometimes nausea, excessive gas and bloating.
The stools are usually dry, hard and small. Mucus may be found in the stool. Attacks are
usually associated with an emotional upset or a long period of stress.
Contributing causes of spastic constipation are varied and include excessive use of cathartics,
laxatives and tobacco, eating very coarse foods, drinking too much tea, coffee and alcohol,
stressful and emotional disturbance, previous GI illness, antibiotic therapy, enteric infections,
poor hygiene and poor habits in sleep, rest, fluid intake and evacuation.
In obstructive constipation, an obstruction or closure hinders the passage of intestinal residue.
The obstruction may be complete or partial. Adhesions, cancer, a tumor or an impaction
usually causes the obstruction. Surgical treatment is frequently indicated to remove the
obstruction.
Diet Therapy. Atonic and spastic constipations require a high fiber diet with liberal fluid
intakes. However, in acute attacks of spastic constipation, a low fiber diet is most beneficial.
A diet consisting of 20-35g/ day of dietary fiber is recommended. The consumption of more
than 40 g of dietary fiber has no additional benefit and may cause intolerance. The
combination of soluble fibers and insoluble fibers ( e.g. cellulose with pectin) is recommended
as a superior bulk- forming laxative. Both types of fiber contribute to increases fecal bulking
through absorption of water and by the addition of indigestible material. Gas produced during
fermentation of soluble fiber contributes to moving fecal material through the colon. Fiber can
be added to the diet by emphasizing whole grain breads and cereals, fruits and vegetables ,
dreid beans and peas and nuts. Cereal fiber is the preferred fiber for increased stool weight.
Wheat bran can be used to increase the fiber content of the diet significantly. A rounded
teaspoon of unprocessed bran contains 2.4 grams of fiber. It can be sprinkled on cereals,
salads and many other food items or added to beverages. Bran should be used in moderation.
Excessive amounts may irritate a sensitive alimentary tract and large quantities may cause an
intestinal block.
Fluid intake should also be increased. Without sufficient water, cellulose tends to produce dry
stools. Prunes and prune juice contain laxative ( dihydroxyphenyl isatin) and may also be
useful. Regular exercise and a consistent eating and drinking schedule can also be helpful.
Dietary measures should primarily form of treatment and laxatives should be used only as
an adjunct to dietary therapy where there are complicating factors. Prolonged or constant
use of laxatives can actually lead to chronic constipation because the colon losses its ability
to respond to natural stimulation. The lining of the intestine becomes irritated and muscular
reflexes diminish.
For obstructive constipation, alow residue diet is given in the amount related to the size of
the obstruction. If the obstruction is very extensive, a liquid diet may be necessary.In such
cases, the liquids should provide ample nutrients and include such foods as cream, malted
milk, oil, sugar, and fruit juices, Vitamin concentrates are used as supplements. Sometimes
it may be more desirable to administer nutrient and fluids parenterally. Regardless f the
type of diet, attention should be directed toward ensuring sufficient calories, proteins,
electrolytes, and vitamins and fluids. All nutrients may be provided by intravenous
hyperalimentation when the patient is unable to ingest food orally.
The post operative diet should be fiber- free for a period, after which, a soft diet is usually
ordered.
14.4.4. Celiac Disease
Celiac disease is multisystem disorder with an impact on almost any organ system.
Manifestations are protean, including diarrhea, constipation, malaise, gastrointestinal
symptoms, osteoporosis and anemia. Peripheral neuropathy or ataxia is common. The
duodenal biopsy is still the gold standard in diagnosis. Positive serological tests (usually the
tissue transglutaminase antibodies) result in endoscopic duodenal biopsies that reveal
varying degrees of villous atrophy and intraepithelial lymphocytosis.
Diet Therapy. Treatment is successful in alleviating symptoms in 70% of patients within 2
weeks, but requires a lifelong commitment from the patient with the assistance of the
gastroenterologist and dietitian to a gluten- free diet. This diet avoids most grain, pasta,
cereal, and many processed foods particularly those that contain wheat (including spelt,
triticale and kamut) ,rye, barley, and possibly oats. Despite these restrictions people with
celiac disease can eat varied, well- balanced diet including bread and pasta. Instead of
wheat flour, use potato, rice, soy, or bean flour. Gluten- free bread, pasta and other
products are available from specialty food companies.

14.4.5. Crohn’s Disease (Regional Enteritis, Granulomatous Colitis)

Crohn’s disease or regional enteritis is an inflammation or irritation involving chiefly the
terminal ileum but may also affect other parts of the GIT) accompanied by crack- like ulcers
and granulomas. It is believe to be hereditary, although recent studies suggest that high
intakes of animal protein and polyunsaturated fatty acids PUFAs ) and low intake of omega
-3 fatty acids may contribute to its development. Crohn’s disease may result from many
disorders, food and chemical poisoning, the consumption of ingestible material or
overeating. However, in most cases, bacterial, invasion causes the disease and in the
advanced state is known as bacillary dysentery.
The condition is characterized by hyperplasia (enlargement due to cell increase) of the
lymphatic, which eventually interferes with the blood supply of the mucosa for that section
of the intestinal tract which is affected. This in turn gives rise to edema and ulceration,
scarring of the mucosa, thickening of the intestinal wall with narrowing of the lumen of the
bowel and obstruction. The disease may be confined to one segment or involve multiple
segments with normal areas in between.
The disease may be self- limited and will eventually be cured, but it often recurs.
Inflammation and scarring may narrow the intestinal lumen, sometimes causing obstruction.
Corticosteroids and immunosuppressive agents and antibacterial drugs (sulfasalazine) are
given to treat the disease. The diseased portion of the bowel must be surgically removed
but even after surgery, the disease flares up in other areas of the bowel. The disease is
highly unpredictable and a relapse may occur.

Characteristic symptoms include cramping abdominal pain, diarrhea, weight loss, fever,
weakness and anorexia. The mucus is present in the stools and frequently, blood and pus
also. Fat in the stools (steatorrhea) may be a factor. At times the discharge may be firm,
dry and shiny. At other times, the character of the stool may be watery. Systemic
complications, malnutrition and fistula formation are common. Anemia may be present due
to blood loss and to poor absorption or iron and vitamin B12. The clinical manifestations of
Crohn’s disease in Filipino patients observed were similar but less severe from those
reported in Caucasians.
Diet Therapy. The diet should be high in caloric value, liberal in animal proteins and rich in
vitamins and minerals particularly Vitamin A, B1, B2, B6, folate, calcium, and zinc. Fiber is
restricted in symptomatic active disease. However, fiber modification does not control
disease activity. In regional enteritis with malabsorption steatorrhea, sometimes severe
restriction (10% of calories) is necessary. Improvement may be manifested by the use of
medium chain triglycerides. Ideally, a loss of stool fat should be kept below 10 g daily. In
case of prolonged diarrhea, foods high in potassium should be given.
Complete parenteral feeding has been recommended by some to rest the bowel during
attacks. But hydrolyzed and elemental diets have been used successfully during acute
periods of Crohn’s disease to provide nutrition without the need for TPN. These hydrolyzed
formulas are easily absorbed in the upper small intestine; they also allow the bowel to rest.
Tubefeeding however can be used if the person cannot tolerate the formula orally although
formulas cab safely be administered at full strength in many people with Crohn’s disease.
If lactose intolerance develops, milk and milk products are eliminated. Supplemental
vitamin- mineral preparations are frequently prescribed. A nutrient –rich, well-balanced diet
should be provided and nutrition status frequently reassessed.