Lower GI Flashcards
(146 cards)
1
Q
define the lower GI tract
A
the portion of the ailmentary canal including the jejunem and ileum of the small intestine as well as the large intestine
2
Q
in ml what is the normal daily volume of gas?
A
around 200 ml
3
Q
what is gas/ flatulence derived from?
A
swallowed air
bacterial fermentation in the intestinal tract
4
Q
name the intestinal gases
A
CO2, O2, N2, H2, and sometimes CH4
5
Q
amount of air consumed increases with…
A
- eating or drinking too fast
- smoking
- chewing gum
- sucking on hard candy
- using a straw
- drinking carbonated drinks
- wearing loose-fitting dentures
6
Q
what factors alter the symptoms of intestinal gas?
A
- decreased motility
- aerophagia (swallowed air)
- dietary components
- certain GI disorders
7
Q
normally the _ _ has fewer bacteria than the colon
A
small intestine
8
Q
why might someone have the inability to move normal amounts of gas?
A
inactivity
constipation
intestinal dysmotility
partial bowel obstruction
9
Q
MNT for gas and flatulence
A
recommend a food diary to track habits and symptoms to help identify the specific foods causing gas.
ask the client if they are chewing their food well
ask the clients if they are eating slowly
ask the client if they are eating large amounts of raw foods
ask the client if they are eating in stressful environments
10
Q
what foods increase gas production?
A
beans
veggies (broccoli, cauliflower, cabbage, brussel sprouts, onions, mushrooms, artichokes, asparagus)
fruits (apples pears, peaches)
sodas; drinks with HFCS; fruit drinks especially apple and pear juice
milk and ilk products
packaged foods containing small amounts of lactose
sugar-free candies and gums containing sugar alcohol
11
Q
what demographic has a higher prevalence of constipation?
A
- adult females
- older age
- high BMI
- low socioeconomic status
12
Q
define constipation
A
Defined as difficulty with defecation characterized by abnormal frequency or dyschezia (painful/ hard/ incomplete evacuation)
13
Q
normal bowel movement frequency ranges from _ x/day to _ x/week
A
3, 3
14
Q
stool weight as little as _g daily is considered normal in healthy children and adults
A
200g
15
Q
causes of constipation
A
inadequate fibre intake (primary cause)
physical inactivity
postponing defacation
colonic inertia
most neurologic diseases
IBS
narcotic use
16
Q
what are the 2 types of constipation? explain them
A
- Normal transit constipation (AKA functional constipation) (most common)
- Passes through the colon at a rate of ~5 days (i.e., often in the normal range)
- Pts report hard stools and/or perceived difficulty with defecation
. May experience bloating and abdominal pain
- Typically responds to dietary fibre alone or with addition of an osmotic agent (e.g., lactulose), or - Slow transit constipation
- infrequent BMs (<1/wk)
- Frequently, do not feel the urge to defecate
- May c/o bloating & abdominal discomfort
- Slowing of movement through the intestine results in ↓ water content in stool
- Most common tx is an aggressive laxative regime
- Select pts (w/ severe slow transit constipation) may respond well to surgical procedures such as subtotal colectomy and ileorectal anastamosis
17
Q
Rome III Diagnostic Criteria for Functional Constipation
A
Symptom onset @ least 6-months pre-diagnosis
Symptoms for the last 3 months
1. Must include >2 of (for >25% of defecations)
a. straining
b. Lumpy or hard stools (Bristol stool scale 1 or 2)
c. Sensation of incomplete evacuation
d. Sensation of anorectal obstruction/blockage
e. Manual maneuvers (i.e., digital evacuation, support of the pelvic floor)
f. AND <3 defecations/wk
2. Loose stools rarely present without use of laxatives
3. Insufficient criteria for IBS
18
Q
anorectal dysfunction results from
A
- Pelvic floor muscle laxity
- Impaired rectal sensation
- ↓ luminal pressure in the anal canal
19
Q
secondary constipation common causes and other indicators
A
Lack of dietary fibre
Inactivity
Low fibre intake
medications
Lifestyle
mechanical blockages (e.g., from adhesions or strictures)
Psychogenic factors (e.g., depression, eating disorder, dementia)
20
Q
what is neurogenic bowel
A
bowel dysfunction caused by nerve malfunction after spinal cord injury or nerve disease
two main types:
Reflex (spastic) bowel
Flaccid bowel (not contracting at all)
21
Q
1st approach to treat mild, functional constipation is to ensure
A
Adequate dietary fibre
Adequate fluid intake
Exercise
heeding the urge to defecate
22
Q
what are stool softeners?
A
Anionic surfactants with an emulsifying property that ↑ water content in stool to make BMs easier to pass
23
Q
what are osmotic agents
A
Contain poorly absorbed or nonabsorbable sugars; work by pulling fluid into the intestinal lumen
24
Q
what are stimulant laxatives
A
- ↑ peristaltic contraction and bowel motility
- Act to prevent water absorption
25
constipation can be related to
- Inadequate fibre intake
- Inadequate fluid intake
- Side effects of medication
- Inactivity
- Disordered bowel motility
26
Careful hx and physical exam followed by parent/child education, behavioural & nutritional intervention, and appropriate use of laxatives often leads to dramatic improvement
27
DRI for fibre
14g/1000 kcal
(25g/day for adult women & 38g/day for adult men)
28
MNT recommendations for constipation in healthy people
- consumption of adequate fluids with adequate fibre to soften stools and make them easier to pass
- consumption of adequate dietary fibre - soluble and insoluble to increase colonic fecal fluid, microbial mass, stool weight and frequency and rate of colonic transit
29
explain the difference between soluble dietary fibre and insoluble dietary fibre
soluble: forms a gel, acting to slow digestion. does not have laxative effect
Insoluble: absorbs water to add bulk to stool; accelerates fecal transit and consists of:
- cellulose
- hemicellulose
- pectins
- gums
- lignin
- starchy materials
- oligosaccharides partially resistant to digestive enzymes
30
fibre amounts consumed over _ g/day are not necessary and may increased abdominal distention and excessive flatulence
50
31
does cooking destroy fibre?
no, but may change the structure
32
4 guidelines for high fibre diets
1. increase consumption of whole-grain breads, cereals, and other products to 6-11 servings per day
2. increase consumption of vegetables, legumes, fruits, nuts and edible seeds to 5-8 servings/day
3. consume high-fibre cereals, granolas and legumes to bring fibre intake to 25g in women and 38g/day in men
4. **increase consumption of fluids to a minimum of 2 L /day**
33
increasing dietary fibre is unlikely to help those with:
.
.
.
.
.
- serious dysmotility syndromes
- neuromuscular disorders
- chronic opiod use
- pelvic floor disorders
- other serious GI disease
34
what is diarrhea as defined by WHO?
the passage of more than 3 loose or liquid stools/day
35
when does diarrhea occur?
- accelerated transit of intestinal contents through the SI
- decreased enzymativ digestion of foodstuffs
- decreased absorption of fluids and nutrients
- increased secretion of fluids into the GI tract
- exudative losses (oozing of fluid of other materials from cells and tissues due to inflammation)
36
what may cause diarrhea?
- inflammatory disease
- viral, fungal or bacterial infection
- medications
- overconsumption of sugars or other osmotic substances
- allergic response to food
- damaged mucosal absorptive surface
37
since diarrhea is a symptom and not a diagnosis, the inital priority is to....
identify and treat the underlying problem
38
after you have identified and treated the underlying problem causing diarrhea what should be the next priority?
manage and replacement of fluids and electrolytes
| If cases are severe, restoring fluids and electrolytes should come 1st
39
best treatment for refractory C.Difficile infection is to employ _ _ transplant
fecal microbiota
40
what types of fluids can be used in MNT for diarrhea?
oral rehydration solutions
soups and broths
vegetable juices
isotonic liquids (milk, diluted juice, etc)
41
# MNT for diarrhea
Some clinicians recommend a progression of starchy CHO & low-fat meats, followed by small amounts of fruits and veg, followed by _
fats
42
_ alcohols, lactose, fructose, and large amounts of sucrose may worsen osmotic diarrheas
sugar
43
Diarrhea related to colonic inflammation is associated with _ nutrient absorption
good
| most nutrients are absorbed in the small intestine
44
Fibrous material tends to slow gastric emptying, moderate overall GI transit and pull water into the _ of the intestine
lumen
45
# MNT for diarrhea
Nutrient deficiencies can cause mucosal changes which contributes to _
malabsorption
46
Food in the _ is needed to restore the compromised GI tract after disease & periods of fasting
lumen
47
Early refeeding reduces stool output & _ duration of illness
shortens
48
# MNT for diarrhea
Micronutrient replacement/ supplementation may be useful for acute diarrhea, likely because it accelerates normal regeneration of ...
damaged mucosal epithelial cells
49
Acute diarrhea is most dangerous in _ & _ who are easily dehydrated by large fluid losses
infants & kids
50
# MNT for diarrhea in infants and children
Standard oral rehydration solutions recommended by WHO contain a _% concentration of glucose (13.5g/L), 75 mEq/L Na
1.35%
51
A substantial proportion of 9-20 month old children can maintain adequate intake when offered either a _ or _ diet continuously during bouts of acute diarrhea
liquid or semisolid
52
# GI Strictures & Obstruction
Specific pts are more prone to obstruction, including those with
Gastroparesis
Adhesions
hernia
Metastatic cancers
Dysmotility
Volvulus
53
# GI Stricture & Obstruction
Symptoms of obstruction
Bloating
Abdominal distention
Pain
Nausea
Vomiting
54
Recommend to pts prone to obstruction to
chew food thoroughly
Avoid excessive fibre intake
55
Initial tx of total obstruction consists of
- Aggressive fluid resuscitation
- Nasogastric decompression (e.g., NG to suction)
- Administration of analgesics and antiemetics
56
RDs must work with the pt & physician to determine the nature, site & _ of the obstruction in order to individualize nutrition therapy
duration
57
# celiac disease
peak in diagnosis occurs between _ - _ yrs
40 - 60
58
Presentation of celiac in childhood includes
Diarrhea
Steatorrhea (fat in stool)
Poor weight gain
59
what is celiac frequently misdiagnosed as?
IBS, lactase deficiency, gallbladder disease or other disorders not necessarily involving the GI tract
60
less classic GI symptoms of celiac disease
Anemia
Generalized fatigue
Weight loss or failure to thrive
Osteoporosis
Vitamin or mineral deficiency
GI malignancy (rare)
Itchy skin rash (dermatitis herpetiformis)
61
explain gluten sensitivity vs gluten intolerance
**Gluten sensitivity** is used to describe nonspecific symptoms, without the immune response characteristic of celiac disease or the intestinal damage
**Gluten intolerance** (AKA nonceliac gluten sensitivity) is diagnosed in those with symptoms who may or may not have Celiac disease
62
Pts experiencing gluten intolerance or sensitivity symptoms should be advised _ adopting a gluten-free diet without having had a workup to exclude or confirm a Celiac diagnosis
against
63
Celiac disease primarily affects the _ and _ section of the small bowel
proximal and middle
64
# celiac disease
Diagnosis is made from a combination of
- Clinical
- Laboratory (i.e., antibody screening)
- Histologic
Evaluations
65
what is considered the gold standard for celiac diagnosis?
biopsy of the small intestine
66
if positive for celiac disease what will the biopsy show?
villous atrophy
Increased intraepithelial lymphocytes
crypt cell hyperplasia
67
elevated blood levels of what antibodies are found in people with celiac disease
Anti-tissue transglutaminase (tTG IgA test)
Antigliadin IgG
Antigliadin IgA
68
# celiac disease
Initial evaluation of blood tests should be completed _ the pt eliminates gluten from their diet
before
69
what is the only known treatment for Celiac disease
Lifelong, strict adherence to a gluten-free diet
70
# celiac disease
Symptoms have typically abated within _ to _ weeks of starting a gluten-free diet
2-8
71
# celiac disease
what nutrients should be evaluated in newly diagnosed patients
ferritin, folate, Vitamin B12 and 25-OH Vit. D
| commonly malabsorbed in celiac patients
72
celiac patients should be assessed for nutrient _ before intiating supplementation
deficiency
73
Pts with malabsorption may benefit from a bone density scan to assess for osteopenia or _
osteoporosis
74
_ and _ intolerance sometimes occur secondary to Celiac disease
Lactose and fructose
75
Upon celiac diagnosis, the individual and their family should be taught (by an RD) about
-label reading
-Safe food additives
-Food preparation
-Sources of cross-contamination (e.g., toaster, condiment jars, bulk bins, buffets)
-hidden sources of gluten (e.g., medications, communion wafers)
76
what does a workup for celiac disease ensure?
1. Any underlying medical condition is detected (for which a gluten-free diet may not be the treatment)
2. It is not more difficult to diagnose Celiac disease (which may be the case after the pt has followed a gluten-free diet for months or years)
3. People aren’t unnecessarily restricting their diet and/or spending money unnecessarily
77
what is tropical sprue
Acquired diarrheal syndrome with malabsorption that occurs in many tropical areas
78
tropical sprue symptoms
Diarrhea
Malabsorption
Anorexia
Abdominal distention
Nutritional deficiency as evidenced by night blindness, glossitis, stomatitis, cheilosis, pallor, edema
Anemia may result from iron, folic acid, and Vit. B12 deficiencies
79
is tropical sprue diarrhea infectious?
yes
80
tropical sprue syndrome may include?
- bacterial overgrowth
- changes in GI _
- _ changes in the GI tract
motility
cellulary
81
gastric mucosa from tropical sprue are atrophied and inflamed, with diminshed secretion of _ and _ factor
HCl and intrinsic factor
82
MNT for tropical sprue includes:
restoration and maintenance of fluids, electrolytes, macronutrients and micronutrients and introduction of a diet that is appropriate for the extent of malabsorption
83
what 2 nutrients may need to be supplemented for tropical sprue if deficiency is identified
B12 and folate
84
what is lactose intolerance
Syndrome of diarrhea, abdominal pain, flatulence or bloating occurring after lactose consumption
85
seconday lactose intolerance can develop as a consequence of:
.
.
.
.
- infection of the small intestine
- inflammatory disorders
- HIV
- malnutrition
86
High concentrations of lactase are present in the _ _ of all newborn mammals
small bowel
87
Lactose malabsorption is diagnosed by:
Abnormal hydrogen breath test
Abnormal lactose tolerance test
88
MNT for lactose intolerance
Requires dietary change
- Symptoms are alleviated by reduced consumption of lactose-containing foods
Persons avoiding dairy products may need Ca and Vit D supplements or must be careful to consume nondairy sources of these nutrients
A complete lactose-free diet is not necessary – most can consume some lactose (up to 12 g/day) without major symptoms
89
Many with intolerance can adapt to and tolerate >_ g lactose per day, when introduced gradually, in increments, over several weeks
12
90
3 main forms of dietary fructose
Monosaccharide
Disaccharide sucrose (fructose + glucose)
In chains as fructans
91
The human small intestine (SI) has a limited ability to absorb _
fructose
92
glucose absorption stimulates pathways for _ absorption
fructose
93
what are the 2 major forms of IBD
- crohns disease
- ulcerative colitis (UC)
94
when does onset of IBD most often occur?
15-30 years of age
95
what clinical characteristics are shared between crohns and UC?
Diarrhea
Fever
Weight loss
Anemia
Food intolerances
Malnutrition
growth failure
extraintestinal manifestations
- Arthritic
- Dermatologic
- Hepatic
96
whats the difference between Crohn's and UC?
Ulcerative colitis is limited to the colon while Crohn's disease can occur anywhere between the mouth and the anus
In Crohn’s segments of inflamed bowel can be separated by healthy segments
In UC, disease process is continuous
All layers of mucosa are affected in Crohn’s disease (transmural)
In UC, disease is limited to the mucosa
97
In both forms of IBD, risk of _ ↑ with duration of disease
malignancy
98
what are the major environmental factors of IBD?
Resident & transient microorganisms in the GI tract
Dietary components
99
Crohn’s can affect any part of the GI tract but ~50-60% of cases involve the distal _ & _
ileum & colon
100
Crohn's is characterized by:
Abscesses
Fistulas
Fibrosis
Submucosal thickening
Localized strictures
Narrowed segments of bowel
Partial or complete obstruction of the intestinal lumen
101
# IBD
Features of the inflammatory response
↑ cytokines
↑ acute-phase proteins
↑ GI permeability
↑ proteases
↑ oxygen radicals
↑ leukotrienes
Can result in GI tissue damage
102
how does diet trigger IBD relapse?
affects the type & relative composition of resident microflora
Nutrients such as dietary fats or Vit. D can affect the intensity of the inflammatory response
103
Malnutrition can affect the function & effectiveness of mucosal, cellular and _ _
immune barriers
104
Problems experienced by those with IBD
Partial GI obstruction
Malabsorption
Diarrhea
Altered GI transit
Increased secretions (exudate)
Food aversions
105
# IBD
goals of medical management
To induce & maintain remission
To improve nutrition status
- Treatment of GI manifestations appear to correct most extraintestinal features of the disease (i.e., arthritic, dermatologic, hepatic)
106
what are the most effective medical agents for IBD?
Corticosteroids
Antiinflammatory agents (e.g., mesalamine)
Immunosuppressive agents (e.g. cyclosporine)
Monoclonal tumor necrosis-factor antagonists (anti-TNF)
Antibiotics (e.g., ciprofloxacin)
Agents that inactivate one of the primary inflammatory cytokines (e.g. infliximab)
107
In Crohn’s, surgery may be necessary to repair _ or remove portions of the bowel
strictures
108
in extreme cases for crohns surgery, patients may have extensive or multiple resections, resulting in _ - _ syndrome and dependence on PN
short-bowel
109
what is the primary goal of MNT for IBD?
To restore and maintain the nutrition status of the individual
110
Persons with IBD may have intermittent ‘flares’ of their disease characterized by...
partial obstruction, nausea, abdominal pain, diarrhea
111
# slide 82
is there a single regimen for IBD that decreases symptoms or flare-ups?
no
112
EN is not as effective as _ in inducing remission in adults with Crohn’s
corticosteroids
113
For children, _ is more effective and should be considered primary therapy
EN
114
mplete bowel rest using PN is not necessarily required but might be used in those with inadequate functioning bowel for _ - _ weeks pre-surgery in malnourished patients
1-2
115
# MNT for IBD
If EN is not an immediate option, _ remains a better option (for pts with persistent bowel obstruction, fistulas & major GI resections resulting in short-bowel syndrome) than prolonging time without adequate nutrition support
PN
116
should protein needs be increased in MNT for IBD?
Needs may be ↑, depending on severity and stage of disease & restoration requirements
**1.3-1.5 g/kg per day** is recommended to maintain positive nitrogen balance in those with ACTIVE IBD
117
diarrhea can aggravate the loss of which nutrients?
Zinc, potassium, and selenium
118
Those on intermittent corticosteroid therapy may require supplemental _ and _
Ca and Vit D
| Monitor Vit. D levels and bone density routinely
119
If the pt has:
- rapid intestinal transit
- Extensive bowel resection
- Extensive small bowel disease
Then, absorption may be compromised meaning that excessive intake of:
Lactose
fructose
Sorbitol
120
Those with strictures or partial bowel obstruction benefit from a reduction in _ _ or limited food particle size
dietary fiber
121
If fat maldigestion is likely ,supplementation with _ may be useful in adding calories and serving as a vehicle for fat-soluble nutrients
MCTs
122
what is pouchitis?
inflammation of the illiel pouch after surgery
123
Regular intake of _ foods such as oligosaccharides, fermentable fibres and resistant starches can beneficially affect the gut microbiota
prebiotic
124
what is microscopic colitis
inflammation that is not visible by inspection of the colon during colonoscopy
- Apparent only when the colon lining is biopsied and examined under a microscope
- Pts may have diarrhea for months or yrs before a diagnosis is made
- cause is unknown
125
what are the 2 types of microscopic colitis?
**Lymphocytic colitis**
- Accumulation of lymphocytes within the lining of the colon
**Collagenous colitis**
- Layer of collagen just below the lining in addition to accumulated lymphocytes
- More common among females ♀️
Some believe these simply represent two stages of the same disease
126
symptoms of microscopic colitis
chronic, watery diarrhea
Mild abdominal cramps
Pain
>30% of patients report weight loss
127
what should be the aim in MNT for microscopic colitis?
Maintain weight & nutrition status
Avoid symptom exacerbation
Maintain hydration
128
what is irritable bowel syndrome (IBS)?
unexplained abdominal discomfort or pain
Associated with changes in bowel habits
Other symptoms:
Gas
bloating
Diarrhea
Constipation
↑ GI distress associated with psychosocial distress
129
why is IBS classified as a functional diagnosis because:
.
.
.
Tests show no diagnostic abnormalities, so
Diagnosis depends on symptoms
No specific marker or test is diagnostic
130
Rome IV criteria for IBS
Recurrent abdominal pain, on average, at least 1 day/wk in the last three months, associated with >2 of these criteria (with symptom onset @ least 6 months before diagnosis)
1. Related to defecation
2. Associated with a change in frequency of stool
3. Associated with a change in form (appearance) of stool
131
list the 4 subtypes of IBS
**IBS with predominant constipation (IBS-C)**
**IBS with predominant diarrhea (IBS-D)**
- Pts have less than 25% of stool with constipation and
**Mixed IBS (IBS-M)**
- Mix of hard and loose stools
**Unsubtyped IBS**
- Bowel habits cant be categorized into one of the other categories
132
what Factors are presumed to play a role in IBS etiology
Nervous system alterations
Gut flora alterations
Genetics
Psychosocial stress
133
medical management of IBS
1st step includes validating the reality of pt complaints & establishing an effective clinician-patient relationship
Tailor care to help the patient manage the symptoms and factors that trigger them
- Nutrition therapy using the FODMAP elimination diet should be a primary consideration
Drug therapy is aimed at management of symptoms
Treatment is determined by the predominant bowel pattern and the symptoms that most disrupt the patient’s quality of life
134
what are the goals of MNT for IBS?
Ensure adequate nutrient intake
Explain potential roles of foods in management of symptoms
135
what is the first line of therapy for IBS?
implementation of a FODMAP elimination diet OR low FODMAP diet
136
explain the initial steps in a nutrition appointment for MNT for IBS
- Review current medications (all – not just those prescribed for treatment of IBS)
- Review GI symptoms:
duration
severity
frequency
- Asses nutritional status and food intake
- Assess weight changes
- Review supplement intake (vitamins, minerals, fats, pre- & probiotics, herbals)
- Review use of mind-body therapies (& results)
137
Low FODMAP limits food that contain:
lactose
fructose
fructo-oligosaccharides (fructans)
galacto-oligosaccharides (galactans)
polyols/ sugar alcohols
138
_FODMAPs are poorly absorbed in the _ _, are highly osmotic & are rapidly fermented by bacteria in the large intestine, resulting in gas, pain & _ in sensitive individuals
small intestine
diarrhea
139
explain the FODMAPs eating plan
Examination of the pt’s current diet should be completed before an elimination phase
- A trial elimination should last (max) 6 weeks and should involve removal of all FODMAPs from the diet
- The challenge phase begins with slow, controlled reintroduction of 1 FODMAPs diet category at a time
140
what is the goal of low FODMAP eating plan?
Goal is to create a diet that includes FODMAPs at the most tolerable intake level
141
142
Nutritional deficiencies that can arise on a low FODMAP diet include:
Folate
Thiamin
B6
Fibre (from limiting cereals and breads)
Vit. D
Calcium
143
what is diverticulosis?
the formation of sac-like **outpouchings **or pockets within the colon that form when colonic mucosa and submucosa herniate through weakened areas in the muscle
More common with age – particularly in age >60 years
144
what is diverticulitis?
a complication of diverticulosis caused by **inflammation** of >1 diverticulum
145
Cause of diverticulosis is unclear,
Proposed factors increasing risk include
Low-fibre diets
Decreased levels of serotonin
Obesity
High intake of red meat and fat
Vit. D deficiency
Lack of exercise
smoking
Certain medication (e.g., NSAIDs and steroids)
146
# slide 106
