Medical Nutrition Therapy for

Upper Gastrointestinal Tract

Disorders
Lecture 3
 Introduction
• Digestive disorders are among the most common problems in health care
• Between 60 and 70 million people are affected by all digestive diseases,
with more than 50 million ambulatory care visits made annually in the
United States alone.
• More than 20 million diagnostic and surgical procedures involving the
gastrointestinal (GI) tract are performed each year (CDC, 2014).
 ASSESSMENT PARAMETERS
Components of a comprehensive nutrition assessment of patients with GI
disorders include
• The clinical examination
• Evaluation of anthropometrics
• Biochemical markers
• Patient’s nutrition history
A detailed nutrition history includes
• The typical dietary intake
• Changes in appetite
• Food allergies and intolerances
• Mastication and swallowing ability
• GI symptoms such as nausea, vomiting, diarrhea, constipation, and the
use of dietary supplements
 Gastrointestinal track
• The gastrointestinal tract is involved in transforming the food eaten into
energy to meet the body’s needs for its sustenance and function.
• Anything that affects its function disturbs this process and leads to
disease
 Parts of gastrointestinal track
The gastrointestinal tract consists of
• Esophagus (food tube)
• Stomach (mixes food and forms chyme)
• Small intestine (small diameter tube 6 meter long, consisting of the
duodenum, the jejunum and the ileum)
• Large intestine (large diameter tube which includes cecum, colon, rectum
and anal canal).
 Functions of gastrointestinal system
• Mix the food with enzymes produced in different parts of the
gastrointestinal track to break the complex foods to simpler forms of food
(digestion)
• Propel the food mixture through mouth, esophagus, stomach, duodenum,
small and large intestines to the anus
• Absorb the various nutrients into the blood especially from small intestine
and outer parts.
 Functions
• The food is grounded in the stomach into tiny particles.
• The stomach secretes mucous to protect the lining of the gastrointestinal tract.
• In addition it also secretes hydrochloric acid and several enzymes and readies
the food for digestion by changing it into semifluid chyme
• The pancreas secrete pancreatic juice into the duodenum to facilitate the
digestion of the food in the small intestine.
• Food products carried by blood vessels from the walls of the digestive tube are
delivered to the liver, the largest organ in the digestive system
 Dietary factors
The dietary factors associated with ailments of the gastrointestinal tract
(G.I.) are:
• Acidity
• inadequate fiber
• fat
• substances such as gluten in wheat
• lactose
 Factors That Affect Gastric Acidity
Food and Gastric Acidity :
• Foods normally have a pH of 5 to 7
• pH of acid (hydrochloric) secreted in gastric juices in the stomach is less
than 2
• The pH of citrus fruits and other acid tasting foods is about 3.5 or more
• Therefore, no food is acid enough to change the ph. of the stomach
contents
Stimulants
• Stimulants increase the production of gastric acid
• Hence these need to be avoided by persons suffering from acidity
• The stimulants to be avoided include tea, coffee, alcohol, tobacco, meat
extracts in soups and gravies and spices – chilli powder, black pepper,
mustard seeds.
Increase gastric acidity
Cephalic Phase of Digestion
• Thought, taste, smell of food, and chewing and swallowing initiate vagal
stimulation of the parietal cells in the fundic mucosa, resulting in secretion
of gastric acid.
Gastric Phase of Digestion
Effect of food in the stomach:
• Distention of the fundus stimulates the parietal cells to produce acid.
Increased alkalinity of antrum causes the release of gastrin, which
stimulates gastric acid secretion.
• Distention of the antrum causes release of gastrin
• Substances in certain foods and digestive products increase acidity (e.g.,
coffee, both with or without caffeine; alcohol; polypeptides and amino
acids [products of protein digestion]).
Decrease Gastric Acidity
Gastric Phase of Digestion
• Acidification of the antrum reduces gastrin release and thus gastric acid
secretion.
• Food, especially protein, has an initial buffering effect.
Intestinal Phase of Digestion
• Fat, acid, and protein in the small intestine stimulate release of one or more
gastrointestinal hormones that inhibit gastric acid secretion.
 Esophagus

• Esophagus is a muscular tube 25 cm in length and basically helps in

transporting the food from the mouth to stomach.
• As the bolus of food is moved voluntarily from the mouth to the pharynx,
the upper esophageal sphincter relaxes, the food enters esophagus and
subsequently the lower esophageal sphincter (LES) relaxes to receive the
food bolus.
• With the help of peristaltic waves, the bolus of food is moved into the
stomach.
The normal esophagus has a multitiered defense system that prevents
tissue damage from exposure to gastric contents, including;
• LES contraction
• Normal gastric motility
• Esophageal mucus
• Tight cellular junctions
• Cellular ph. regulators.
Achalasia is characterized by a failure of esophageal neurons, resulting in a
loss of ability to relax the LES and have normal peristalsis.
 Esophagitis
Esophagitis
• an acute/ chronic inflammation of the esophageal wall.
• occurs in the lower esophagus as a result of the irritating effect of acidic
gastric reflux on the esophageal mucosa
 Types
1.Reflux Esophagitis
• Reflux esophagitis occurs when gastroesophageal reflux disease (GERD),
a condition that arises when acidic stomach substances like acids
regurgitate into the esophageal tube, irritates and inflames the esophagus.
• When people have suffered from GERD for many years, they may
develop Barrett’s esophagus (BE), which in rare cases can develop into
esophageal cancer.
The severity of the esophagitis resulting from esophageal reflux is
determined by the
• Content of gastric reflux
• Mucosal resistance
• Clearing rate of esophagus
Content of gastric reflux may include
partly digested food, pepsin, acid and possibly bile and at times pancreatic
enzymes.
It is probably this combination, which causes mucosal damage, Symptoms
develop when reflux becomes frequent and mucosa of esophagus` becomes
sensitive to the reflux contents.
2.Drug-Induced Esophagitis
• Certain medications taken without adequate water can stay in the
esophageal tube for too much time and cause drug-induced esophagitis.
• Pills that are too big for people to swallow without problems can irritate
the esophageal wall, and residue that comes from various kinds of
medications remains in the esophagus.
• The most troublesome of these medications are bone loss minimizers,
anti-inflammatory drugs, antibiotics, potassium chloride, and pain
relievers.
3.Infectious Esophagitis
• Viruses such as the herpes simplex virus, parasites, bacteria, or fungi can
cause infectious esophagitis, a rare condition. It can be exacerbated by a
weak immune system due to medications or disease conditions. People with
lymphoma, cancer, leukemia, HIV, AIDS, or diabetes are more likely to
contract this condition
4.Eosinophilic Esophagitis
• An overabundance of eosinophils, which are specialized white blood cells in
the esophagus, causes eosinophilic esophagitis as the body overreacts to
allergens.
 Risk factors
• GERD or gastroesophageal reflux disease
• Vomiting
• Surgery
• Medications such as aspirin and other anti-inflammatory drugs
• Taking a large pill with too little water or just before bedtime
• Swallowing a toxic substance
• Hernias
• Radiation treatment for cancer
• Certain foods like fatty meals, chocolate, coffee, alcohol, spicy food,
citrus juices lower the sphincter pressure (also hormone mediated)
• Food allergies
• Infections
 Complications
The complications involved in the disorder
• stenosis and esophageal ulcer.
• Significant gastritis in the herniated portion of the stomach may cause
occult (hidden or minute amounts) bleeding and anemia.
 Esophagitis Diagnosis

After thorough physical examination and reviewed medical history, there are several tests
that can be used to diagnose esophagitis. These include:
• Upper endoscopy. A test in which a long, flexible lighted tube, called an endoscope, is
used to view the esophagus.
• Biopsy. During this test, a small sample of the esophageal tissue is removed and then sent
to a laboratory to be examined under a microscope.
• Upper GI series (or barium swallow). During this procedure, X-rays are taken of the
esophagus after drinking a barium solution. Barium coats the lining of the esophagus and
shows up white on an X-ray. This characteristic enables doctors to view certain
abnormalities of the esophagus.
 Nutrition Management Goals
The objectives of nutritional care include the following:
• Prevention of irritation of the inflamed esophageal mucosa(in the acute
phase)
• Prevention of esophageal reflux
• To decrease the acidity of the gastric juice.
• It is evident from these objectives that there is no significant change in
the nutrient requirements of the patient. We however need to make several
qualitative changes in the diet and feeding pattern.
 Dietary Management
In acute phase, the dietary factors to be kept in mind are:
• Liquid diet; small and frequent meals.
• Less abrasion to the esophagus thus avoiding orange juice and other citrus
• tomato products because of their acidity.
• Spices like chili powder, black pepper to be avoided
In chronic phase, following factors must be considered as
well:
• Efforts must be taken to increase LES pressure.
• Meals/foods high in protein increase sphincter pressure and reduce the likelihood of
reflux and heartburn.
• Avoiding foods that are known to cause heartburn and decrease LES pressure like
chocolate, alcohol, caffeine containing beverages, coffee, cold drink, fatty foods and
increased fat intake.
• Timing of the meals is very important especially before the afternoon nap and evening.
• The patients should consume nothing except water 3 hours before lying down.
• This in turn ensures an almost empty stomach with less likelihood of reflux on lying
down.
• Avoid lying down, bending or straining immediately after eating.
• Reduce weight so that abdominal pressure is decreased