MNT II: Exam 1 (Upper Gastrointestinal (GI) Disorders) Flashcards by Kyle Monticone

Barium swallow- drink barium and have an x ray taken

Endoscopy- swallow a lighted tube with a camera so MD can look at GI tract

aids in the diagnosis of Upper Gastrointestinal (GI) disorders

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Any problem swallowing food, beverages, or medications

Dysphagia

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anorexia and weight loss
food sticking in the throat
choking on food, liquid or saliva
Coughing or discomfort in the throat or chest when swallowing
heartburn or acid reflux
the patient finds fluids and/or solids difficult to swallow

Signs and Symptoms of Dysphagia

part 1

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symptoms indicating aspiration, such as recurrent chest infection
Need for repeated swallowing
Drooling or rocking the tongue
Pockets of food pooling in the mouth or throat
Difficulty chewing
Gurgling or wet voice quality
Hoarse breathing

Signs and Symptoms of Dysphagia

part 2

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Bedside Swallow Evaluation 
Usually a Speech &amp; Language Pathologist will carry this out
A. important considerations
1. Oral mechanism exam
2. Mental status exam 
Can stay alert for 30 min
3. Activities of daily living
4. Medical diagnosis

B. if patient shows adequate skills, various food consistencies are presented for a swallow test
Liquid, Paste, Puree, Solid

(Diagnosis of Dysphagia)

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Food or beverages enter the respiratory tract
Can cause immediate respiratory distress, block the airway, or lead to aspiration pneumonia
May occur only with certain consistency foods or all foods

Aspiration

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VISCOSITY = resistance to flow or the rate of flow per unit force units= centipose (cP)
COHESIVENESS= degree to which a food deforms instead of shears when compressed
ADHESIVENESS= the attraction between a food and another surface

Terms for Dysphagia

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Smooth pureed foods, cohesive, no lumps, homogenous
Pudding like
No jello, fruited yogurt, peanut butter, scrambled eggs

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 1- DYSPHAGIA PUREED

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Moist soft textured foods with some cohesion (easily form a bolus)
Tender ground or finely diced meats, soft tender cooked vegetables, soft fruit
No bread, dry cake, rice, cheese cubes, corn, peas, pineapple

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 2- DYSPHAGIA MECHANICALLY ALTERED

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Nearly regular diet- no hard, crunchy, very dry, or sticky (adhesive) foods

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 3- DYSPHAGIA ADVANCED

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Regular diet
www.beckydorner.com
specific info and tips on diet

NATIONAL DYSPHAGIA DIET(NDD)

LEVEL 4- REGULAR DIET

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Thin liquids are usually the most difficult for the patient to swallow and present the highest risk of aspiration so many patients will be required to drink thickened liquids
1-50 cP

NDD TERMS FOR VISCOSITY LABELS FOR LIQUIDS

Dysphagia

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NECTAR-LIKE consistency of thicker fruit juices like apricot nectar
51-350cP
HONEY-LIKE
351-1750 cP 
SPOON-THICK 
like pudding
>1750 cP 
Prethickened liquids at nectar and honey consistency are available commercially
Water, juices
Tea, coffee, hot choc
milk

Dysphagia

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THICKENERS ARE AVAILABLE TO ADD TO LIQUIDS
Some are fortified with nutrients
Resource thickenup 
Thickit 
Thick & easy
nutrathik

Dysphagia

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an esophageal motility disorder characterized by failure of a LES to relax and the absence of esophageal peristalsis
This causes a bag like distension of the esophagus
Caused by defective nerves or maybe a virus

Achalasia

ESOPHAGEAL AND LOWER ESOPHAGEAL SPINCTER (LES)

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Dysphagia for solids and liquids
Weight loss/ malnutrition
Substernal chest pain
Fullness in the chest
Nausea & vomiting
Regurgitation and burning

Signs and Symptoms of Achalasia

ESOPHAGEAL AND LOWER ESOPHAGEAL SPINCTER (LES)

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Will not alter disorder but may help lessen discomfort
May need dysphagia diet
Frequent small feedings and eat slowly
Dietary fat may help relax the LES so include fat in feedings
Avoid extremes of temperature
Avoid foods that cause discomfort such as spicy, hot, acid, or very fibrous foods
Similar recommendations for esophageal strictures

Medical Nutritional Therapy for Achalasia

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Weakened esophageal wall causing a pouch in the esophagus

Signs & Symptoms
Dysphagia
Fetid breath
GERD

MANAGEMENT
surgical removal

ESOPHAGEAL (Zenker) DIVERTICULUM

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Low LES pressure results in a lack of adequate LES closure and back flow of acidic gastric contents into the esophagus

Unlike the stomach the esophagus is very sensitive to acid

Long term chronic GERD can lead to esophagitis or Barrett’s esophagus which may increase risk of esophageal cancer especially in genetically susceptible individuals

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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Pyrosis (heart burn)
Dysphagia
Pulmonary symptoms/aspiration
Chest pain
Burning throat
bitter or sour taste of the acid in the back of the throat

SIGNS & SYMPTOMS of GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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A. avoid factors that may lower LES pressure and increase those that make it higher
B. decrease gastric acidity
C. surgery fundoplication

MANAGEMENT of GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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High fat foods, Alcohol, Coffee/caffeine, Chocolate, Smoking
Peppermint/spearmint
Acid foods like citrus or tomatoes
Hot spicy foods, mustard, Pepper, Red wine, Carbonated beverages
Meds such as: Estrogen, Progesterone, Valium, L-dopa, narcotics

A. FACTORS THAT MAY DECREASE LES PRESSURE or IRRITATE THE ESOPHAGUS

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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High protein intake
Metoclopramide (reglan)-speed gastric emptying

Other
Avoid obesity and overeating
Do not recline during or after (2-3 hrs) meals
Avoid large fluid intake with meals
Avoid constipation

FACTORS THAT MAY INCREASE LES PRESSURE or SPEED GASTRIC EMPTYING

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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OVER THE COUNTER MEDS

Histamine receptor blockers
nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac)

Antacids
Mylanta, Maalox,Tums, or Rolaids etc

proton pump inhibitors(PPI’s)
Prescription meds
esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec)

B. Decrease gastric acid

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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Any of these meds (previous flashcard) may have side effects (which are reviewed in the food drug interaction section of you notes) for example Antacids may decrease absorption of iron, thiamin, phosphorus, and vitamin A PPI's and Hist blockers may cause a decrease in vitamin B-12 absorption Lower stomach acid may decrease calcium, magnesium, and iron absorption

B. Decrease gastric acid GASTROESOPHAGEAL REFLUX DISEASE (GERD)

LINX Reflux Management System (Torax Medical Inc) Magnetic sphincter augmentation (MSA) implantable device for treatment of GERD refractory to drug therapy Restore sphincter like function May cause dysphagia Nissen fundoplication May be done endoscopically (transoral endoscopic fundiplication)- lessens reflux

C. Surgery GASTROESOPHAGEAL REFLUX DISEASE (GERD)

The stomach protrudes up through the diaphragm where the esophagus enters the diaphragm and up into the thoracic cavity May have no symptoms or have symptoms similar to GERD ulceration of the herniated stomach with resultant bleeding and anemia, obstruction, torsion, gangrene, and perforation may occur gastric volvulus with strangulation which usually occurs post-prandially is a surgical emergency if the stomach cannot be decompressed it is life threatening

Hiatal Hernias

chest pain, retching but unable to vomit, and inability to pass a nasogastric tube indicate gastric volvulus

Borchardt's triad

Borchardt's triad: chest pain, retching but unable to vomit, and inability to pass a nasogastric tube indicate gastric volvulus Often requires emergency surgery MANAGEMENT Same as for GERD Surgery may be needed

Hiatal Hernias

Inflammation of the esophagus | May be acute or chronic

Esophagitis

Symptoms similar to heartburn, cough, dysphagia, hoarseness, sore throat Infections like candida albicans, HIV, Epstein Barr virus, CMV, TB etc Trauma Bulimia/frequent vomiting Chemotherapy or radiation exposure as in cancer therapy

Esophagitis

``` Drug side effect Ingestion of caustic materials Crohn's disease Graph vs host disease eosinophilic (may be related to food allergies) Alcohol or smoking other ```

Esophagitis

dysphagia, upper esophageal webs, difficulty swallowing and iron deficiency anemia, glossitis, koilonychia (spoon nails),pallor treat with iron supplements

Plummer-Vinson syndrome ESOPHAGITIS

May lead to Barrett's esophagus which may increase risk of esophageal cancer May lead to Mallory Weiss Syndrome (tears in the esophagus with bleeding) which in a few cases require surgical repair ESOPHAGEAL VARICES

ESOPHAGITIS

MANAGEMENT Treat condition causing it if possible Correct iron deficiency in Plummer-Vinson syndrome Otherwise treatment is similar to GERD

ESOPHAGITIS

Etiology: Increased blood pressure in the portal vein caused by liver disease Can lead to increased pressure and dilation of veins in the stomach and esophagus A major upper GI bleed will cause hematemesis (vomiting blood) or melena (black, tarry stool) May result in shock and death If it happens enough, you can become anemic

ESOPHAGEAL VARICES ESOPHAGITIS

When the route of the blood is blocked due to congestion in the liver, pressure increases and the blood tries to find a new way back to the heart It starts bypassing the liver creating small blood vessels called varices Varices are small and delicate and there is a significant risk of internal bleeding when or if the varices may rupture Portal hypertension Results in esophageal varices

ESOPHAGEAL VARICES ESOPHAGITIS

Most often squamous cell carcinoma or adenocarcinoma Risk is increased by tobacco or alcohol use, Barrett's esophagus, other irritant exposure, viruses, high meat & low F & V intake

Esophageal Cancer

STAGES I (localized)-IV(metastisized) ``` SIGNS & SYMPTOMS Difficult or painful swallowing Severe weight loss Pain in the throat or back, behind the breastbone or between the shoulder blades Hoarseness or chronic cough Vomiting Coughing up blood ```

Esophageal Cancer

MANAGEMENT Esophagectomy-removes the tumor along with all or a portion of the esophagus, nearby lymph nodes, and other tissue in the area The remaining healthy part of the esophagus may be anastamosed to the stomach (B) or a plastic tube or part of the intestine may be used to replace the esophagus (D & E) May need radiation and/or chemotherapy and /or laser therapy

Esophageal Cancer

ESOPHAGEAL REPLACEMENT SURGERY If there is no esophagus, the patient must have a gastrostomy tube or jejunostomy tube for feeding and is not able to eat So replacement surgery is an option to restore a more normal function part of the colon or SI or a tube may be with to replace the esophagus

Esophageal Cancer

ESOPHAGEAL REPLACEMENT SURGERY Often a jejunostomy tube is placed at the time of the surgery and the patient is weaned from tube feeding to oral food intake in frequent small feedings This may take weeks Liquid supplements may be helpful Patients may experience dysphagia,some lactose intolerance, GERD, poor taste, or bad tastes

Esophageal Cancer

nausea, retching, & emesis

3 components of Vomiting

Nausea- unpleasant sensation that you feel sick to your stomach which often precedes vomiting Retching- "dry heaves" and spasms in the upper GI tract, may have gagging Emesis- the act of vomiting or forceful removal of gastric contents up and out of the mouth, "throwing up"

Nausea and Vomiting

CAUSES Viruses, bacteria, motion sickness, morning sickness, diabetic ketoacidosis, PUD, brain tumors, Meniere's disease, bowel obstruction, chemotherapy and other medications etc Psychogenic- food aversions, self induced- manually or with ipecac, erotic

Nausea and Vomiting

POSSIBLE CONSEQUENCES Usually none unless vomiting is very severe or prolonged or the patient is at high risk of aspiration Can lead to sodium and/or potassium depletion , dehydration, alkalosis Black or coffee ground vomit or bright red blood in the vomit- go to ER Repeated vomiting can cause tears in the esophagus, esophagitis, tooth deterioration etc

Nausea and Vomiting

MANAGEMENT Some Antiemetic Meds include: Antivert (Meclizine) and bonine (Cyclizine)- antihistamines Phenergan (promethazine)

Nausea and Vomiting

HG is intractable nausea & vomiting (N&V) during pregnancy @2% of pregnancies It is a conditions that makes a pregnancy in the high risk category

HYPEREMESIS GRAVIDARUM (HG)

ETIOLOGY Not clear but may be related to: hormonal changes, allergies or immunological factors, metabolic abnormalities, psychosomatic as in AN/bulimia, genetic incompatibilities, GERD, Helicobacter pylori, stomach abnormalities, vitamin deficiencies such as B-6 or Mg ?????

HYPEREMESIS GRAVIDARUM (HG)

Signs and Symptoms Severe N&V, dehydration, electrolyte depletion, ketosis, weight loss or poor weight gain, poor oral intake and appetite, multiply nutritional deficiencies, ptyalism (excessive salivation), esophagitis, esophageal tears, liver damage, kidney damage, encephalopathy, brain or retinal hemorrhage, injury or death of mother or baby

HYPEREMESIS GRAVIDARUM (HG)

give anti-emetics that are safe for pregnancy, restore fluid and electrolyte balance and nutritional status If anti-emetics don't work, the patient will need either jejunostomy feedings or TPN until normal oral intake can be maintained It may be weeks to months in some cases Good outcome for mother & baby as long as it is adequately treated

HYPEREMESIS GRAVIDARUM (HG)

Inflammation of the stomach lining

Gastritis

May be caused by bacteria, viruses, alcohol, allergies, autimmune reactions as in pernicious anemia, medications, chemical damage, bile reflux, Crohn's, radiation gastritis, GVHD, Menetrier's disease hyperplastic hypersecretory gastropathy) etc HELICOBACTER PYLORI IS A VERY COMMON CAUSE

Gastritis

SIGNS & SYMPTOMS Burning sensation, pain, nausea & vomiting, burping, bloating, red or coffee ground vomit, melena (black stool due to blood), anorexia, weight loss, diarrhea

Gastritis

MANAGEMENT Give antibiotics if gastritis is bacterial Avoid meds etc that irritate the stomach If pernicious anemia, give high dose oral or IM vitamin B-12 In Menetrier's disease or hypertrophic gastritis, a high protein diet (20% kcals) is recommended as albumin is low

Gastritis

Mucosal break in the stomach or duodenum | @15 % gastric (in the stomach) and 85 % in the duodenum

Peptic Ulcer Disease (PUD)

``` Possible Causes Helicobacter pylori- most common NSAIDs, aspirin, Alcohol Gastrinoma (Zollinger-Ellison syndrome) Severe stress (eg, trauma, burns), Curling ulcers Bile reflux Pancreatic enzyme reflux Radiation Staphylococcus aureus exotoxin Bacterial or viral infection ```

Peptic Ulcer Disease (PUD)

SIGNS AND SYMPTOMS Gastric: pain ½ -1 hr after eating which is not relieved by food intake, vomiting, hematemesis (vomiting bright red blood), gastric cancer-rare, weight loss Duodenal: pain 2-3 hrs after eating that is lessened by food intake, pain at night, vomiting-rare, melena ( dark to black tar like stools), weight gain

Peptic Ulcer Disease (PUD)

DIAGNOSIS Gastroscopy/endoscopy 1) View GI with a lighted scope and take pictures or videos Barium Swallow/upper GI series 1) Drink chalky liquid and get X-rayed 2) Generally NPO overnight as the stomach should be empty for either procedure

Peptic Ulcer Disease (PUD)

MANAGEMENT Stop taking nsaids and aspirin and any other meds as directed by MD Stop smoking Take meds for the ulcer as directed by MD which may include: Take therapy (flagyl, tetracycline, & pepto bismol, proton pump inhibitor) if helicobacter test is positive proton pump inhibitors-esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), Dexlansoprazole (Dexilant)or rabeprozole (Aciphex)

Peptic Ulcer Disease (PUD)

MANAGEMENT Carafate (Sucralfate) - coats ulcer and decreases its exposure to acid and pepsin OVER THE COUNTER MEDS- less effective Histamine receptor blockers nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac) Antacids Mylanta, Maalox,Tums, or Rolaids etc Gaviscon- foams and decreases acid reflux into the esophagus

Peptic Ulcer Disease (PUD)

ADJUNCTIVE MNT Diet does not cause and can not cure an ulcer Avoid irritant and acid production stimulants as for GERD Avoid eating within 3 hrs of bedtime Avoid skipping meals or eating very large meals Check for anemia especially if pt has had hemetemesis or melena- may need iron RARE, LAST RESORT IF MEDS DO NOT WORK , ULCER PERFORATES or HEMORRHAGES IS SURGERY

Peptic Ulcer Disease (PUD)

VAGOTOMY 1) Cut the vagus nerve to decrease stimulation 2) Not very effective Antrectomy or partial gastrectomy The lower half of the stomach that makes most of the acid is removed with a Billroth 1, II, or a Roux-en-Y gastrojejunostomy Pyloroplasty Opening up the valve at the outlet of the stomach to speed gastric emptying

Peptic Ulcer Disease (PUD)

TOTAL GASTRECTOMY Entire stomach is removed and esophagus is anastomosed to the duodenum PARTIAL GASTRECTOMY a portion of the stomach is surgically removed and the remainder must be reattached to the bowel BILLROTH I- joining the upper stomach back to the duodenum is called a or gastroduodenostomy. BILLROTH II-Joining the upper stomach with the jejunum and creating a "y" with the bile drainage and the duodenum forming the second branch of the "y."

Peptic Ulcer Disease (PUD)

Tumors of the delta cells in the islets of Langerhans in the pancreas (or sometimes at other sites like lymph nodes or duodenum and may others) that produce gastrin and cause the parietal cells in the stomach to over secrete acid Tumors may be cancerous or benign

Zollinger-Ellison Syndrome

``` SIGNS & SYMPTOMS Ulcers in the stomach and/or duodenum Pain Secretory diarrhea Diarrhea, steatorrhea, malabsorption (due to inactivation of pancreatic enzymes by the excess acid) Weight loss/poor appetite/malnutrition Vomiting blood ```

Zollinger-Ellison Syndrome

MANAGEMENT Surgical removal of tumors Proton pump inhibitors If these do not work, a surgical resection or total gastrectomy is needed

Zollinger-Ellison Syndrome

MNT POST GASTRECTOMY Do a complete nutritional assessment prior to surgery If pt has PEM, try to start improving nutritional status prior to surgery Pt will usually need TPN or jejunostomy feeding after surgery Will need to be NPO the night before surgery

Gastric Cancer

Generally the larger the portion of the stomach removed the more difficult recovery will be for the pt For a total gastrectomy due to cancer or Zollinger-Ellison, it is best to have a surgical jejunostomy inserted at the time of surgery as it will be a slow process for the patient to ease back into being able to eat a normal amount Early post-op nutrition may be given via the J tube Start trying PO intake of small amounts of water then noncarbonated sugar free or diluted clear juices progress slowly as per patient tolerance Progress to soft bland foods in at least 6 small feedings per day

Gastric Cancer

Monitor protein and kcal intake , plasma proteins and wt- supplements or feeding via J tube Generally, drink liquids before or after meals, eat slowly, chew all foods thoroughly If steatorrhea develops, decrease fat intake, try MCT oil, pancreatic enzyme capsule may be helpful, give water miscible forms or larger doses of fat soluble vitamins if the condition is chronic As many or all of the cell that produce gastric intrinsic factor are removed in the surgery B-12** absorption will be lessened Large doses PO (500 to 2000 mg/day) or IM vitamin B-12 will be needed to prevent macrocytic/megaloblastic** anemia

Gastric Cancer

Remember folate will also treat the anemia, but will not prevent nerve damage from cobalamin deficiency so it is critical that the pt get adequate B-12** IRON DEFICIENCY* may occur due to blood loss from bleeding prior to and during surgery 1) Microcytic anemia is most often due to iron deficiency 2) Plasma iron and ferritin will be low and TIBC will be elevated in iron deficiency CALCIUM AND VITAMIN D malabsorption may result in osteomalacia Check plasma 25-OH vitamin D levels

Gastric Cancer

Plasma calcium levels are not usually a good indicators of calcium status and a bone density test is needed to detect osteomalacia Give calcium and vitamin D supplements daily Risk of BEZOAR (fibrous blockages) in the GI tract is increase May need to avoid high intake of very fibrous foods such as: oranges, coconut, persimmons, berries, green beans, figs, apples, celery, psyllium, sauerkraut, Brussel sprouts, potato peels, legumes to decrease risk of a phytobezoar

Gastric Cancer

This is a risk of ________ syndrome with Gastric Cancer.

Dumping Syndrome

Early dumping is caused by the high osmolarity of simple carbohydrates entering rapidly into the SI and rapid distension of the SI by too much chyme entering too fast Late dumping is due to reactive hypoglycemia where BG rises high quickly followed by an over response with too much insulin production which then leads to hypoglycemia

Dumping Syndrome

SIGNS & SYMPTOMS flushing, sweating, syncope (fainting), abdominal fullness, diarrhea, nausea & vomiting, weakness, tachycardia, hunger, tremors, anxiety

Dumping Syndrome

MANAGEMENT Don't drink fluids with meals Recline after eating Small frequent feedings Cut down on rapid acting CHO's if they cause distress Try new foods in small amounts and one at a time to assess tolerance, try again tolerance may improve over time Really hot or cold liquids bother some people

Dumping Syndrome

MNT II: Exam 1 (Upper Gastrointestinal (GI) Disorders) Flashcards

(76 cards)