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GASTROINTESTINAL DISEASES
PART-1
Upper Gastrointestinal diseases
– Behavioral modification
Avoid :
Eating within 3-4 hours of retiring
Lying down after meals
Tight-fitting garments
Cigarette smoking
GASTRITIS & PEPTIC ULCERS
– Result when infection, chemical or neural abn disrupt mucosal integrity of the
stomach
– Common cause : Helicobacter pylori (gram-negative bacteria)
– H.pylori induce inflammation from innate & systemic immune response
– other form of gastritis :
Chronic use of ASPIRIN or NSAIDs, steroids, alcohol, erosive substances,
tobacco, etc
Manifest : nausea, vomiting, malaise, anorexia, hemorrhage and epigastric pain
Prolong gastritis : atrophy and loss of stomach parietal cells, loss of secretion of
HCl (achlorhydria) and intrinsic factor (pernicious anemia)
Chronic reduction of gastric secretion of HCl reduce absorption of nutrients :
B12, calcium, and nonheme iron increase incidence of bone fracture,
intestinal infection (front barrier to microbial invasion)
PEPTIC ULCERS
Occur anywhere in the gaster First few cm of the duodenal bulb (below
Most along the lesser curvatura pylorus)
Associated w/ gastritis, inflammatory
involvement of parietal cells (acid prod.),
athropy of acid and pepsin prod.cells in
advancing age
Relativity low acid output Increased acid scretion (nocturnal acid
secretion)
Anthral hypomotility, gastric stasis, increased
duodenal reflux
Hemorrhage and mortality are higher than
duodenal ulcers
MNT – Gastritis impaired intrinsic factor and decreased vit B12 malabsorption
– Low acid state reduced absorption of iron and calcium
– Eradication of H.pylori
– Protein temporarily buffer gastric secretion, but also stimulate secretion :
gastrin, acid and pepsin
– Orange juice pH 3,2 – 3,6, soft drink : pH 2,8 – 3,5
– Acidic food from fruit juice and soft drink not likely causes peptic ulcers
– Alcohol large amount can cause superficial mucosal damage and worsen
peptic ulcers
– Coffee and caffeine stimulate acid secretion
– Spices ( chili, cayenne, black peppers) increase acid secretion, erosion,
inflammation of the mucosal lining and altered GI permeability or motility
– Probiotics eradicated H.pylori
– Omega3 dan 6 anti inflammatory, cryptoprotective of the GI mucosa
GASTRIC CARCINOMA
– Slow manifest, frequently overlooked until it is too late
for a cure
– Clinical symptoms : loss of appetite, loss of BW,
abdominal pain, nausea, vomiting, anemia and abdominal
mass
– Studies :
– (Lynch et al 2005) other factors may increase the risk :
chronic infect. H.pylori, smoking, intake highly salted,
pickled foods or inadequate micronutrients
– Lead to malnutrition cause of excessive blood and protein
losses
– Surgery : partial or total resection of the gaster
(gastrectomy) malnutrition
MNT
– Determined by the location of the cancer, nature function and stage
– Gastrectomy : difficulties w nutrition after surgery
– Inoperable cancer : diet is adjusted to the patients tolerances, preferences and
comfort.
– Advanced stage : if unable to tolerate oral feeding, consider to alternate route such as
gastric or intestinal feeding tube, or PN
GASTRIC SURGERY
INDICATIONS :
– Ulcer diasease,
– Malignancy, Jojuoum
Afferen! loop
– Weight loss Billroth I Billrolh LI Partial gastric resection
gaslroduodenostomy gastroJeju™>Stomy
(bariatric) Los$ ou,,_,g than s.qu.1no. such aa stoolorrhoo.
Wllh Billroth II. waoght I06s. dumping. Smell poucti
11<>1iwtmg.
ana ollen with tho Bill101ti
mon, '>ae1ertOI II
oYerg,owtn.
p,ocedwe Chen "'1h Blliro.:h I.
oocur
Enlargement ol Jejunum
pylorlo spNncter
Combination of :
- Colonic
structure, Hard fecal
motilility,
genetics
- Lifelong low
Intra colonic
fiber intake
pressure
Herniation to
the weaker
segment of
the colon
25 % diverticulosis develop diverticulitis
Complications: range from painless- mild bleeding
Inflammatory Respon~
• Diarrhea
• Weight Joss
• Poor growth
• Hyperhomocysteinemla
• Partial GI obstructions
Ulcerative versu Crohn's Disease
Colitis s Ulcerative Crohn's Disease
Presentation
Colltls Perianal disease, abdominal pain (65%), mass m
Bloody diarrhea abdomen
Gross Pathology Rectum always involved Rectum may not be involved
Moves connnuously, proximallyfrom Can occur anywhere along gastrointestinal tract
recrum Not continuous: "skip lesions"
Thin wall Thick wall Strictures
Few stnctures common Cobblestone
Diffuse ulceration appearance Granulomas
Histopathology o granulomas lvioreinfla1111nation
Low inflammanon Shallow ulcers
Deeper ulcers (hence named ulcerative) Fibrosis
Pseudopolyps
Abscesses 111 crypts
Extramtesnnal Marufestanons clerosmg cholangms Erythema nodoswn
Pyoderma gangrenosum Migratory polyarthritis Crohn's Disease
Gallstones
Complications _, Toxic megacolon l\Ialabsorption
Cancer Cancer
Ulcerative Colitis Strictures and fistulas are very rare "'rr1ctures or fistulas
Perianal disease
Diet enviromental factor trigger relapses of IBD
Malnutrition
Dietary lipid
Food allergies, intolerance
Sucrose intake, low intake fiber, red meat and alcohol, altered omega6/3 ratio
Diet & spesific nutrients supportive role in maintaining nutrition status,limiting exacerbation
Energy requirement : not greatly increased (unless weight gain is desired)
Protein : may incrased depends on the severity & stage of the disease
Protein losses occur in inflamed and ulcerated intestinal mucosa to maintain positif nitrogen
balance : 1,3-1,5g/kgbw/day
Vit: folate, B6 & B12, also mineral and trace elements (Zinc, potasium,and selenium)
Probiotics
Possible Intestinal Causes of the Irritable Bowel Syndrome Altered
C
colonic motility
Chronic or acute inflammation
lschemia
Alterations in ion channels
Sodium ,--. - Bloating and
Medications Type 2 chloride (CIC-2) Excess production of
intestinal gases distention
Trauma Guanylate cyclase C (GCC)
Chronic or acute infections (H2, CO,. CH,)
Food-mediated (e.g.,
Bacteria (e.g., spirochetes) fructans, gluten)
Viruses Mutated ion
I
Disaccha ridase deficiency
Changes in
Parasites gut flora
1. Diarrhea predominant
to dorsal root ganglia
hard to pass Upstream signaling to
2. Constipation predominant
Abdominal pain,
185-Diarrhea (IBS·D) diarrhea, or constipation
Food moves too
3. mixed
tquickly th bowel.
hrough
This causes watery
MNT goals: adequate nutrient intake, modified diet for the spesific IBS pattern,
potential role of food for managements symptoms
Diarrhea predominant IBS Food may be poorly tolerated : fat, caffeine, lactose,
fructose, sorbitol & alcohol
Constipation-predominant IBS recommendation foods: insoluble fiber (psylium,
wheat bran) & adequate fluid are recommended
Food with fiber prebiotic food maintain healthy microflora
Probiotics significant improvement in abdominal pain, bloating & distension
Low FODMAPs diet low in fermentable oligo-, di-, monosaccharides and polyols.
FODMAPs poorly absorbed in small intestine, highly osmotic and rapidly
fermented by bacteria
Entire colon, colon, rectum and anus must be removed
Some cases, a temporary opening healing distal parts of the intestinal tract
allow surgery
Odorous food : legumes, onions, garlic, cabbage, eggs, fish.
Persistent odor poor stoma hygiene stoma complication (bacteria overgrowth
in the ileum)
Normal output from ileum-colon : ± 750 -1500mL (intact GIT)
Ileostomy : adaptation 1-2 weeks
Depends on resektion, ileostomy
ENTEROCUTANEOUS FISTULAE (ECF)
Parenteral Nutrition
Depend on case severity
High output and proximal fistula TPN decrease GI secretion 30-50%
Nowadays : PN and EN combination good outcome
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