Upper GI

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Upper GI

• NFSC 370 - Clinical Nutrition
• McCafferty

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Anatomy Review

• Mouth
• Salivary glands
• Food chewed and mixed w/saliva. Bolus is moved
  toward pharynx and swallowing is stimulated
• Esophagus Extends from pharynx to stomach
• Protected by mucus
• Empty and collapsed at rest

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• Esophagus is maintained empty by 2 sphincters
• UES - Upper Esophageal Sphincter first 2-3 cm
  of the esophagus. Thickening of circular muscle
  layer which allows food to move from the mouth to
  the esophagus
• LES - Lower Esophageal Sphincter (AKA Cardiac
  sphincter) Between esophagus and stomach.
• No structural difference (no thickening) but
  high intraluminal pressure that keeps it closed
  until food needs to be dumped into the stomach.
  This prevents gastric reflux.

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• Stomach
• Upper portion (fundus/orad region) Storage
  occurs here. Little muscle tone so it can bulge
  outward active relaxation. Little contractile
  activity.
• Lower portion (body, antrum) Mixing moves
  contents toward antrum. With each wave, a few ml
  of chyme move into duodenum, but most is pushed
  back for more mixing w/gastric secretion
  (retropulsion).
• As the stomach empties, contractions begin
  further up the body to bring down stomach
  contents.
• Pyloric Sphincter connects stomach to duodenum

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• Small Intestine (duodenum, jejunum, ileum) bulk
  of nutrient absorption
• structural folds in lining (less in ileum),
  including villi and microvilli (brush border)
• ileocecal sphincter (ileocecal valve) connects
  s.i. to large intestine.
• Large Intestine (colon) bulk of fluid and
  electrolyte absorption
• Rectum/Anus holding/excretion of fecal matter.

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LES
Pyloric sphincter
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Disorders of the Mouth and Esophagus

• Difficulties Chewing (masticating) can lead to
  wt. loss and compromised nutritional status.
• Depending on the problem (individualized!) soft
  or pureed foods may be used. (remember this is
  just a regular diet thats mechanically
  modified).
• keep as wide a variety of foods as possible, and
  use appropriate temperatures/variety of colors

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• Conditions that may interfere w/chewing and
  swallowing
• 1. Mouth ulcers (2 viruses, drugs, radiation
  therapy)

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• 2. Inadequate Saliva Production
• Encourage good oral hygiene Encourage sucking on
  sugarless candy/chewing sugarless gum

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Difficulties Swallowing DYSPHAGIA

• Causes
• Diagnosis ____________________________, x-ray,
  measurement of UES pressure, fluoroscopy.

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• Dangerous and often undiagnosed
• food gets stuck in my throat

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• Watch for
• aspiration
• food caught in trachea/lungs ?
• Silent aspiration

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Nutrition Therapy

• Individualized according to pt.s particular
  swallowing problem
• Mechanical soft solids and smooth or thickened
  liquids are easiest to handle
• Tube feedings may be necessary
• TF into stomach still risks aspiration pneumonia
• Safer

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Nutrition Therapy

• Monitor patient for

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Disorders of the Esophagus and Stomach

• Indigestion and Reflux Esophagitis (GERD)
• Indigestion (dyspepsia) vague term for
  epigastric pain, fullness, early satiety,
  belching, hiccups, heartburn and regurgitation of
  stomach acid into the esophagus.

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• Recurrent acid reflux ?irritation of esophageal
  mucosa ?
• Severe inflammation may cause

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• Causes

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• Nutrition Therapy
• Alleviate reflux and irritation by
• CAPA-free diet (peptic ulcer diet)
• Foods that decrease LES pressure or increase acid
  secretion

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• Small meals w/ fluids between meals
• Eat slowly, relax, chew food thoroughly
• Elevate head of bed and/or refrain from lying
  down after eating.
• Avoid tight clothing that increases abdominal
  pressure.

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• Drug Therapy
• Antacids
• Antiulcer agents
• Cholinergics

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Hiatal Hernia

• Protrusion of stomach into the chest cavity
  through the esophageal hiatus of the diaphragm
• Normally, the LES sits right in the hiatus of the
  diaphragm and is reinforced by it.

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• Cause hiatus weakens allowing a portion of the
  stomach to protrude above the diaphragm.
• Most common sliding hiatal hernia.
• Pressure generated by the hernia is sufficient to
  force acidic stomach contents into the esophagus.
• Nutrition Therapy
• Same as for reflux esophagitis.

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Gastritis

• Inflammation of the stomach mucosa
• pain, n/v.
• Acute Gastritis
• asprin/alcohol use, food allergies, food
  poisoning, radiation therapy, metabolic stress,
  bacterial infection
• n/v

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• Chronic Gastritis (atrophic gastritis)
• May be associated w/ chronic disease or no known
  etiology.

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Peptic Ulcer Disease (PUD)

• Erosion of cells of the top layer of mucosa
  (gastric, duodenal, esophageal).
• Underlying layers exposed to stomach
  acid/peptidases.
• If ?
• If ?

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• Causes
• Disorders that cause excessive gastric acid
  production (less common)
• Zollinger-Ellison syndrome tumor in pancreas
  secretes excessive amts. of gastrin, causing
  hypersecretion of gastric acid, ? ulcers

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• Nutrition Therapy
• Minimizing pain/irritation, promoting healing.

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• Drugs
• decrease gastric secretions or otherwise protect
  mucosa from further erosion.

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• Gastric Surgery
• Gastrectomy

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• Pyloroplasty

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• Gastric partitioning

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• Gastric Bypass

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• Nutritional consequences
• If duodenum is bypassed
• ? absorption of
• Patients are required to take nutritional
  supplements that usually prevent these
  deficiencies.
• Dumping Syndrome
• Mr. C had extensive gastric resection 1 wk ago,
  and has just begun to eat solids. About 15
  minutes after eating he begins to feel weak and
  dizzy. He looks pale, his heart beats rapidly,
  and he breaks out into a sweat. Shortly
  thereafter, he develops diarrhea. What has
  happened?

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• Pylorus removed
• Partially digested food is dumped into the
  jejunum
• Fluid from body (capillaries) enters jejunum
• Result

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• The pt. may experience the same symptoms again a
  few hours later why?
• Most people who experience dumping gradually
  adapt to a fairly regular diet.

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• Nutrition Therapy The Post-Gastrectomy Diet
• NPO post-surgically for several days.
• Advanced to liquids, then solids.
• High protein, moderate fat
• ADAT (close monitoring of tolerances)
• Monitor fluid and lytes/hydration

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• Gastric bypass patients
• 1 week
• 2 weeks
• 2 weeks
• 2 weeks

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Nutrition-related Gastrectomy Complications

• Weight loss, malabsorption, nutrient
  deficiencies.
• Limited intake 2? early satiety, post-surgical
  pain, dumping
• Reflux esophagitis
• Prot and fat malabsorption
• Normally, food entering the duodenum triggers the
  release of hormones such as CCK?secretion of
  digestive enzymes bile.
• Duodenum bypassed fat DA interrupted.
• Accelerated transit of food ? ?absorption

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• Anemia Fe-deficiency common after gastric
  surgery. (may take time to show up)

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• B12 def from ? IF prod?
• Bone disease