Gastrointestinal Disorders

Definitions

• Endoscopy: A medical procedure used to examine the body’s digestive system. During the procedure a thin, long, and flexible tube is inserted through the mouth or other body holes so that the inside of the digestive system can be viewed by the examiner on a TV monitor. 
• Steatorrhea: When fat is present in feces.
• Bacterial translocation: When bacteria move across the intestinal membrane and into the circulatory, lymphatic system, or other body tissues.
• Ileus: Partial or complete bowel obstruction

Pathophysiology

What laboratory values would most likely be changed in a patient with dehydration due to severe diarrhea?

BUN; Sodium; Potassium; Chloride; Serum Osmolality; Albumin

For each of the following disorders, describe the etiology, clinical symptoms, medical management, and diet therapy:

Hiatal hernia

• Etiology: An increase in intra-abdominal pressure, weakness muscle tissue, and injury to the stomach can cause a Hiatal Hernia.
• Clinical symptoms: The symptoms experienced by a person with Hiatal Hernia are similar to those of a person with GERD. These include dysphagia, heartburn, nausea, chest pain, and belching.
• Medical management: Medical management is similar to that of GERD. This includes medication with antacids, foaming agents, H2 blockers, proton pump inhibitors, and prokinetics. Surgery can also be performed. Surgery includes retracting the hernia and repairing any hole in the diaphragm. A procedure called fundoplication can also be performed.
• Diet therapy: Diet therapy includes reducing gastric acidity and avoiding food that can lower the lower esophageal sphincter pressure.

Gastroesophogeal reflux disease (GERD)

• Etiology: In GERD atmospheric pressure in the stomach becomes greater in the stomach than in the esophagus. This can be caused by several different factors including a hiatal hernia, cigarette smoking, medications, consumption of specific foods or medications, and increased secretion of hormones such as gastrin, estrogen, and progesterone.
• Clinical symptoms: Dysphagia, heartburn, nausea, chest pain, and belching
• Medical management: Pharmacologic treatment includes use of the following: antacids, foaming agents, H2 blockers, proton pump inhibitors, and prokinetics. A surgery known as Fundoplication can also be performed to strengthen the lower esophageal sphincter and thus aid in prevention of reflux. 
• Diet therapy: Diet therapy includes reducing gastric acidity and avoiding food that can lower the lower esophageal sphincter pressure.

Diabetic gastroparesis

• Etiology: The cause is not entirely understood however it is believed that damage to the vagus nerve occurs as a result of diabetes and leads to gastroparesis.  
• Clinical symptoms: Bloating, anorexia, vomiting, decreased appetite, nausea, feeling full despite not having consumed much food, weight loss, erratic blood glucose control.
• Medical management: Medication to treat gastroparesis includes control of blood glucose via insulin.
• Diet therapy: Consuming foods low in fat, consuming small frequent meals throughout the day, consuming liquid meals, and consuming foods low in fiber.

Crohn’s disease

• Etiology: The cause of Crohn’s disease is not known however it is believed that there are several contributing factors including genetics, smoking, infectious agents, and intestinal flora.
• Clinical symptoms: Abdominal pain, cramping, diarrhea, and tenesmus. 
• Medical management: Treatment for patients with Crohn’s disease includes treatment with antibiotics, immunosuppressive medications, immunomodulators, biologic therapies, and surgical intervention. 
• Diet therapy:  Diets will need to be individualized based on the patient however caffeine should be avoided and foods that produce gas should be limited. A healthy well balanced diet should be consumed and foods that cause irritation should be avoided during flare ups.

Drug Therapy

Discuss the use of the following drugs; include classification, mechanism of action, indications for use, and nutrient/drug interactions.

Reglan

• Classification: Prokinetic agent
• Mechanism of action: Increases muscle contractions in the upper GI by binding to Dopamine D2 receptors.
• Indications for use: Used to slow stomach emptying and sometimes used to empty the stomach before surgery. 
• Nutrient/drug interactions: Alcohol may increase the effects of Reglan on the central nervous system. Sugar levels may also be affected.

Flagyl

• Classification: Antibiotic
• Mechanism of action: Enters bacteria and kills their DNA.
• Indications for use: Bacteria infections of the stomach and respiratory tract. 
• Nutrient/drug interactions: Anorexia, dry mouth, metallic taste, nausea, vomiting, diarrhea, constipation. Avoid alcohol.

Immodium

• Classification: Antidiarrheal opiate
• Mechanism of action: Inhibits acetylcholine and slows peristalsis.
• Indications for use: Diarrhea
• Nutrient/drug interactions: Dry mouth, nausea, vomiting, abdominal pail, bloating, and constipation. Electrolytes may be affected by diarrhea.

Lactulose

• Classification: Sugar
• Mechanism of action: Breaks down in the large intestine and draws in water and softens the stool.
• Indications for use: Increases ammonia level.
• Nutrient/drug interactions: Increases absorption of calcium and magnesium. Decreases NH3.

Solu-Medrol

• Classification: Glucocorticoid
• Mechanism of action:  Stimulates the synthesis of proteins involved in anti-inflammatory processes. Mimics the action of cortisol. 
• Indications for use: Severe allergic conditions, endocrine disorders, dermatologic diseases, and gastrointestinal diseases.
• Nutrient/drug interactions: Increases sodium and glucose and decreases potassium and calcium levels in the blood. Caffeine and grapefruit should be avoided.

Nutritional Management

Describe the nutritional management of the following problems:

• Diarrhea: Patients should be introduced to foods to stimulate the gastrointestinal tract. Oral rehydration solutions can be used to assist the patient in obtaining proper fluid and electrolyte balance. Also, solid foods can be introduced with a low-residue diet beginning with starches and slowly adding foods as they are tolerated. Probiotics may also be used. 
• Constipation: Increase fiber intake. It is recommended that a person consume about 20-35 grams of dietary fiber every day in a ration of 3:1 for insoluble to soluble fiber. Patients should also consume an adequate amount of water. Additionally, probiotic and prebiotic has recently been recommended for treatment.
• Dumping syndrome: Avoid simple sugars in order to prevent hyperosmolality and hypoglycemia and consuming a balanced diet that is slightly higher in protein and fat. Meals should be consumed as several small meals throughout the day and liquid should be consumed between meals instead of during meals.
• Early satiety: Limit fat intake, consume small frequent meals, and possibly consume a liquid diet. 
• Lactose intolerance: Avoid consumption of dairy products including but not limited to milk, yogurt, and cheese.

Describe the role of pro-biotics in the management of GI disorders.

More research is still necessary in order to fully understand the role probiotics play in managing GI disorders. However, according to the National Center for Complementary and Alternative Medicine current understanding of probiotics does show that they play a role in treating diarrhea, irritable bowel syndrome, pouchitis, and they shorten the length of an intestinal infections. Probiotics may have a protective effect in treating these conditions due to their ability to suppress the action of harmful microorganisms that upset the natural balance of the gastrointestinal tract. 

Click here to view the Gastrointestinal Disorder chart review.

INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: GI Disorders

CHARTING TYPE: Not specified 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

Beyond GERD and other medical complications the patient had inflammation in her throat caused by a throat incision. During our initial meeting she mentioned that she “chokes” on food occasionally, but that it was “not a problem.” The patient then stated firmly that she did no want to be switched to a mechanically altered diet. Her statement about occasional choking was an obvious flag for a speech consult. 

Mr. Harris was the preceptor I worked with on completing this initial assessment. He has a very straightforward charting style and prefers to keep everything short and simple. He also prefers to lay out his assessments in a way that places all decisions in the hands of the MD. Coler-Goldwater uses forms for completing nutrition assessments which can be somewhat limiting, however, Mr. Harris recommended that I select that the diet consistency was appropriate, indicate in the intervention section that I recommend an evaluation for dysphagia, and in the nutritional status/comments section state that I will communicate with the MD regarding a change in diet consistency. This was done as opposed to selecting that the current diet was not appropriate for chewing and swallowing.

INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

This patient was not receptive at first to the idea of a change in the consistency of her diet. She was worried that the food would not be appetizing. However, after describing the importance of a switch to a mechanical soft diet and reassurance that her food would be chopped and not pureed the patient was more receptive to the change in her diet consistency.
Although the patient stated she had not had any recent problems with GERD, during our initial meeting we discussed GERD and its complications. We discussed some possible changes she could implement immediately to prevent reflux including not lying down or bending over after eating. The patient was receptive to these suggestions.

WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

I was unable to follow up with the patient because the change happened at the end of my rotation and I was no longer working with the same RD to determine if a choking problem was still occurring. However, my recommendations were picked up by the physician and immediate changes occurred. The MD switched the diet to a mechanical soft diet to prevent choking and ordered a speech consult.